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April2011 Vol.48 Issue:      2 Table of Contents
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Carotid Intima-Media Thickness: A predictor of Atherosclerotic Burden in Type 2 Diabetes Mellitus

Mohamed Saad1, Shereen Zakarya1, Mohammad Abu-Hegazy1,

Maha El Shafaee2, Ahmad  Abdelkhalek3

 

Departments of Neurology1, Internal Medicine2, Radiology3, Mansoura University; Egypt

 



ABSTRACT

Background: The most important risk factor of ischemic stroke is Diabetes Mellitus (DM) which is associated with accelerated atherosclerosis. Patients with type 2 DM have greater risk of carotid artery intima-media thickness which is important cause of cerebral ischemia. Objective: This study assessed the possible use of common carotid artery intima-medial thickness and plaque as a marker of atherosclerosis in patients with type 2 DM. Methods: This prospective study was conducted on 127 patients with type 2 DM, divided into 2 groups. Group 1: 111 patients with chronic ischemic cerebral symptoms and group 2: 16 patients with acute ischemic stroke. Both groups underwent full neurological examination, laboratory tests, brain magnetic resonance imaging (MRI) and carotid ultrasonography. Results: There was significantly increased prevalence of most risk factors [age, duration of DM, smoking, ischemic heart disease and higher values of hemoglobin A1c (HbA1c)] in group 2 than group 1 patients. Mean common carotid artery intima-medial thickness( >1.5 mm) and numbers of carotid plaques were significantly greater in group 2 patients compared to group I. Brain MRI in group 1  was  normal in  17  patients, showed chronic ischemia in 39 cases,  lacunar  infarctions  in 53  but all cases of group 2 showed acute ischemic stroke. Conclusion: Increased common carotid artery intima-media thickness and plaques score were correlated with acute ischemic stroke in patients with type2 diabetes mellitus. [Egypt J Neurol Psychiat Neurosurg.  2011; 48(2): 103-110]

 

Key Words: Carotid Artery; Intima-media thickness; Type 2 DM

 

Correspondence to Mohammad Abu-Hegazy, 195-B El-Gomhoria St., Mansoura, Egypt.

Tel: +20103900790.  Email: mhegazy@mans.edu.eg





INTRODUCTION

 

Cerebrovascular disease and the issues related to it (transient ischemic attacks, stroke and vascular dementia) are increasing overtime particularly with increasing age1,2,3 and are expected to reach fourth place in order of disability by 20204. In most of ischemic strokes the underlying pathophysiology is atherosclerosis. The risk factors for stroke are modifiable and non modifiable. The modifiable risk factors are mostly related to atherosclerotic burden and include diabetes, hypertension, smoking and hyperlipidaemia5,6. The most important risk factor is diabetes mellitus which is associated with accelerated atherosclerosis due to increased frequency of dyslipidemia, hyperglycemia, obesity, hypertension and associated nephropathy7. High resolution B mode imaging of the carotid artery intima-media (IMT) has been shown to reflect histopathologically verified atherosclerosis and is therefore widely used to detect and quantify non invasive measurement of atherosclerosis8. Atherosclerotic plaques and carotid vessel stenosis are reported to be independent predictors of cerebrovascular accidents9. Several studies have also established strong correlation between common carotid artery IMT with all types of ischemic stroke, carotid plaque and cardiovascular deaths10.

 

The assessment of carotid atherosclerosis by ultrasonographic measurements of carotid IMT thickness took over as being the marker of atherosclerosis11,12. It was suggested by the international atherosclerosis project that atherosclerotic process occurs at the same time in the carotid, the cerebral and the coronary arteries13,14. Different groups have performed measurement at different sites at carotid artery and it has been shown that IMT of common carotid artery (CCA) is a good predictor of stroke incidence whereas internal carotid artery (ICA) IMT measurement has a great power of prediction for myocardial infarction13.

This prospective study aimed to assess the role of carotid Doppler ultrasonography in prediction of atherosclerotic burden in type 2 DM.

 

PATIENTS AND METHODS

 

A total of 127 patients with type 2 diabetes mellitus were studied (67 males, 60 females). Their age ranged from 43 to 77 with mean age (57.9±7.83). Excluded from the study were patients with type I diabetes mellitus and those with secondary diabetes. Patients were divided into 2 groups:  Group 1, one hundred and eleven patients with type 2 diabetes mellitus with symptoms of vertebrobasilar insufficiency such as vertigo (as a control group) and Group 2, sixteen patients with type 2 DM with first time acute ischemic stroke. A stroke was defined as rapidly developing signs of focal or global disturbance of cerebral function lasting more than 24 hours with no apparent cause other than vascular. Both groups underwent careful history taking (age, sex, history of smoking, duration of DM), full neurological examination, body mass index (BMI), laboratory investigations (Hb A1c, triglyceride, total cholesterol, high density lipoprotein (HDL) & low density lipoprotein (LDL) cholesterol), carotid Doppler ultrasonography, brain magnetic resonance imaging (MRI) studies, as well as electrocardiography (ECG) and  cardiac  echo in some selected cases.

 

MRI Studies:

MRI diffusion-weighted, T1- and T2-weighted, and fluid-attenuated inversion recovery (FLAIR) were obtained with a 1.5 T Gyroscan Intera System (Philips, Bothell, Wash). Patients with acute ischemic stroke underwent brain MR imaging within 2 days from the onset of symptoms. The median time between brain infarction and CCA-IMT evaluation was 8.1 days (range, 1-78) and 7.5 days (range, 0-80) for cases and control groups respectively.

 

Carotid Ultrasonography:

Both CCA-IMT and plaque score were evaluated using high-resolution sonography equipped with a linear transducer at 7.5 MHz in B mode (HDI 5000 SonoCT; Philips). We assessed the presence of plaques in the CCA, bifurcation, ICA, and defined plaques as focal widening of the vessel wall of more than 50% relative to adjacent segments, with protrusion into the lumen, composed of calcified or noncalcified components. Protrusion was visually determined. The total plaque score reflected the total number of sites with plaques and ranged from 0 to 6 (each of the CCAs, bifurcations, and ICAs, bilaterally). Patients with score ≥ 1 were defined as having plaques. We confined IMT measurements to the CCA because of the relatively common occurrence of plaques at the origin of the ICA. To access CCA-IMT, we focused on far-wall IMT, because far-wall measurements are considered more valid than near-wall measurements. IMT of the far-wall was defined as the distance between the leading edge of the lumen-intima interface and the leading edge of the media-adventitia interface. Far-wall IMT of both CCAs was measured at 3 sites (thickest point, and at sites 1 cm upstream and downstream, free from plaque) using Digimatic calipers (Mitutoyo, Kawasaki, Japan) on the longitudinal views. The maximum and mean IMT of the carotid arteries were assessed. The mean CCA-IMT was defined as the mean IMT of the right and left CCAs, calculated from 3 measurements on each side. The maximum CCA-IMT (max CCA-IMT) was defined as the average of the thickest wall of the right and left CCAs. If there was uniform intimal thickening in the CCA, we measured intimal thickness every 1 cm from the bifurcation to the end of the CCA. Then, we made 3 measurements: at the thickest point and 1 cm upstream and downstream. Statistical Analysis: Data was analyzed using SPSS (Statistical Package for Social Sciences) version 15. Qualitative data was presented as number and percent.  Comparison between groups was done by Chi-Square test. P <0.05 was considered to be statistically significant.

 

RESULTS

 

The age, smoking, duration of DM, IHD, and hypertension were significantly higher in the patient than control group (p = 0.038, 0.003, 0.000, 0.02, and 0.001 respectively), whereas, BMI and gender didn’t differ significantly (p=0.32, and 0.40 respectively) (Table 1).

 

Group 2 patients showed significant higher prevalence of high laboratory values of fasting and 2-hour postprandial blood glucose, HbA1c, LDL, TG, micro-albuminuria than the control group (p= 0.017, 0.040, 0.048, 0.043, 0.034, 0.021, and 0.008 respectively). Inversely it showed significant lower prevalence of high HDL values (p= 0.034), however there was no significant prevalence difference between both groups, regarding high or normal total cholesterol levels (p= 0.165) (Table 2).

 

Vertigo (77.5%), face numbness (42.3%), and dysarthria (34.2%) were the most common symptoms in group 1 with vertebrobasilar insufficiency while dysmetria (42.3%, and ataxia (38.7%) were the most common signs (Table 3).

 

There was statistically significant higher incidence of patients with mean IMT more than 1-5 mm in patient group than control group 56.3 vs 16.2% (p=.001). Group 2 also showed higher incidence of patients having carotid artery plaques than group 1 75 vs 18% (p=0.000) (Tables 4 and 5).

 

Brain MRI delineated normal, chronic cerebral ischemia, lacunar infarcts in 17.1, 35.1, 47.8% respectively, while all patients in group 2 (100%) delineated acute cerebral infarction (p=0.000) (Table 6).


Table 1. Patient characteristics.

 

P value

Group 2 (16)

Group 1 (111)

 

%

No

%

No

 

0.038*

12.5

18.8

25.0

43.7

2

3

4

7

22.5

34.2

28.9

14.4

25

38

32

16

 Age: <49

         50-60

         60-70

         >70

0.404

62.5

37.5

10

6

51.4

48.6

57

54

SEX: Male

          Female

 

0.316

 

50

50

 

8

8

 

63.1

36.9

 

70

41

BMI  kg/m2

       <30

       >30

 

 

0.003*

 

-

62.5

37.5

-

 

-

10

6

-

 

43.2

44.1

11.8

.9

 

48

49

13

1

Duration of DM

       <5Years

       6-10 years

       10-15 years

       >15 years

 

0.025*

 

50

50

 

8

8

 

23.4

76.6

 

26

85

IHD

     +

     -

 

0.001*

 

93.8

6.2

 

15

1

 

47.7

52.3

 

53

58

HTN

     +

     -

 

0.000**

 

78.8

21.2

 

11

5

 

24.3

75.7

 

27

84

Smoking

      +

      -

BMI Body mass index, IHD Ischemic heart disease, HTN Hypertension

 

Table 2. Laboratory data in both groups.

 

P Value

Group2 ( 16 )

Group 1 ( 111 )

 

%

No

%

No

 

0.017*

 

18.8

81.2

 

3

13

 

50.5

49.5

 

56

55

FBG

<110

>110

 

0.040*

 

12.5

87.5

 

2

14

 

38.7

61.3

 

43

68

2HPPBG

<146

>140

 

0.048*

 

18.8

81.2

0

 

3

13

0

 

37.8

49.6

12.6

 

42

55

14

HB A1-C

<7-5

7.5-10

>10

 

0.043*

 

37.5

62.5

 

6

10

 

64

36

 

71

40

LDL

<136

>130

 

0.034*

 

18.8

81.2

 

3

13

 

47.7

52.3

 

53

58

HDL

>50

<50

 

0.165

 

25

75

 

4

12

 

43.2

56.8

 

48

63

Total Cholesterol

<200

>130

 

0.021*

 

 

75

25

 

12

4

 

44.1

55.9

 

49

62

TG

<200

>200

 

0.008*

 

50

50

 

8

8

 

19.8

80.2

 

22

89

Micro-albuminuria

`+

  -

2HPPBG 2 Hour post prandial Blood Sugar, FBS Fasting Blood Sugar, LDL Low Density lipoprotein,

HDL High Density Lipoprotein

Table 3. Clinical symptoms in group (1).

 

Symptoms

N

%

Signs

N

%

Vertigo

Dizziness

Face Numbness

Dysarthria

Headache

Nausea, Vomiting

Diplopia

Memory loss

Transient loss of vision

86

25

47

38

38

30

35

20

5

77.5

22.5

42.3

34.2

34.2

27

31.5

18

4.5

Visual field defect

Ataxia

Facial  hypoalgesia

Dysmetria

Nystagmus

Sensory loss

Horner syndrome

Amaurosis fugax

Babinski sign

19

43

11

47

32

26

10

18

30

17.1

38.7

9 .9

42.3

28.8

23 .4

9

16.2

27

            

Table 4. Intima-Media thickness in both groups. 

P value

Group 2 (16 )

Group 1  ( 111 )

 

%

No

%

No

 

0.001*

-

-

18.0

20

Normal

43.7

7

54.1

60

<.8mm

-

-

11.7

13

0.8-1.5mm

56.3

9

16.2

18

>1.5mm

 

 

 

 

 

 

* Significant at p<0.01

 

Table 5. Prevalence of carotid plaques in both groups.

 

P value

Group 2                 (16 )

Group (111)

 

%

No

%

No

0.000*

25

4

82

91

No plaques

75

12

18

20

Plaques

 * Significant at p<0.01

 

Table 6. MRI findings in both groups.

 

P value

Group 2 (16 )

Group 1 (111)

 

%

No

%

No

0.000*

0

0

17.1

19

Normal

0

0

35.1

39

Chronic ischemia

0

0

47.8

53

Lacunar infarction

100

16

0

0

Acute cerebral infarction

* Significant at p<0.01

 

 

Figure 1. Ultrasound of the carotid artery shows increased intimal wall thickness.

  

 

Figure 2. MR Images: FLAIR MR Images show multiple discrete and congruent areas of hyperintense

signals seen scattered in the periventricular regions - sign cope with white matter ischemic changes -.

 

 


DISCUSSION

 

The development of sonography has allowed the non invasive assessment of carotid arteries. The initial manifestation of carotid atherosclerosis is characterized by increase in vascular intimal medial thickness, the progression of which leads to plaque formation and vascular narrowing, increased common carotid artery intimal medial thickness is associated with a high risk of stroke15-18. Touboul et al.18 observed that increased common carotid artery intimal medial thickness is associated with brain infarctions both overall and in the main subtypes also intimal thickness may help to identify patients at high risk for brain infarction.

In this study, it was found that age, duration of diabetes, hypertension and smoking had significant relation with incidence of acute cerebral infarction in type 2 diabetic patients. Same results were reported by Kawamori  et al.19  and Bots et al.20, who concluded  that same risk factors have predisposition to macrovascular complications in type 2 diabetes mellitus especially patients with  thickened intimal medial thickness of common carotid. Also Kong et al.21 concluded in their study  that common carotid artery intimal thickness and ischemic stroke was closely associated with age, male sex and smoking but in our study no relation with male sex, this understandable as protective factor of female gender on premature atherosclerosis.

Blood sugar level had more significant elevation in group 2 patients. This was in agreement with many studies22,23,24 who found that type 2 diabetic patients exhibit a higher degree of early atherosclerosis than normal glucose tolerant subjects matched for age and sex and so more vulnerable to ischemic stroke. It was found that patient group had significantly higher levels of Hb A1c. Similar results were concluded by Wagnknecht et al.22, who found that chronic hyperglycemia was an independent risk factor for carotid atherosclerosis and cerebral ischemia also Kawamori19 reported that diabetes itself might be of crucial importance for the development of atherosclerosis because of the clustering of various interrelated metabolic disturbances as well as hyperglycemia and the cause of atherosclerosis in type 2 diabetes could be sought in the glucose toxicity to the endothelium and glycosylation processes as indicated by higher levels of plasma glucose and HB A1-c in patients with diabetes. The BMI levels showed no statistically significant difference in both groups. This was in agreement with Taniguchi et al.25, who found a strong association of age, duration of DM and raised esterified free fatty acids while no correlation was seen with BMI26,27,28. So high TG, LDL and low HDL are risk factors for atherosclerosis. Some studies24,29 reported similar to the present study that proteinuria and increased CCA-IMT were associated with higher incidence of atherosclerotic cerebral stroke, Another study30 also reported that a slight elevation of albuminuria is a significant determinant of intimal-medial thickness and pulse wave velocity, independent of conventional cerebrovascular risk factors in type2 diabetes mellitus with no clinical nephropathy or any vascular diseases more in patients with acute ischemic stroke when compared with patients without ischemic stroke.

Vertigo, face numbness and dysarthria were the most common presentations in group 1 with vertebrobasilar insufficiency this cope with Troost31 in his study on vertebrobasilar diseases. The mean intimal medial thickness was >1.5mm in 56.3% of patients with acute ischemic stroke while 16.2% in patients with chronic ischemic symptoms while intimal medial thickness was <0.8mm in 54.1% of patients with chronic ischemic symptoms (Group 1) compared to 43.8% in (group 2), this in agreement with some studies32.  There was highly significant correlation between carotid artery plaques and incidence of acute ischemic stroke irrespective of their location (P=0.000) as carotid plaques present in  75% of patients with acute ischemic stroke and 18% of patients with chronic ischemic symptoms. So in neurologically asymptomatic subjects carotid plaques are likely to be both markers of generalized atherosclerosis and sources of emboli this was supported by Kitamura16 who reported that wall thickening of common carotid artery and formation of uncalcified plaque were positively associated with risk of stroke. Another study15 showed that carotid artery plaques were more strongly associated with elevated cerebrovascular risk than diffuse increase in IMT.

Based on theses finding, carotid atherosclerosis even in absence of stenosis appear to be associated with risk of stroke therefore we evaluated the value of common carotid artery intimal medial thickness and plaque score for identifying patients with type2 diabetes mellitus at high risk of cerebral infarction.

 

Conclusion                  

Increased CCA-IMT and plaque score were higher in acute ischemic stroke patients with type2 diabetes mellitus (the greater CCA-IMT and plaque score in patients with type II DM, the more risk of acute ischemic stroke). This seems to be induced by cerebrovascular risk factors prevalent in patients with diabetes, therefore CCA-IMT and plaque score in patients with type2 diabetes mellitus can be considered intermediate factors in the causal pathway between cerebrovascular risk factors and ischemic stroke and strict control of these risk factors together with monitoring of CCA-IMT and carotid plaque may play an important role in decreasing the incidence of acute ischemic stroke.

 

[Disclosure: Authors report no conflict of interest]

 

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الملخص العربى

 

تمثل أمراض الشرايين المخية أكثر أسباب الموت فى معظم دول العالم ولذلك كان التعرف على الخلل المرضى وعوامل الخطر فى أمراض شرايين المخ يساعد على إختيار العلاج المناسب وتحسن النتائج على إختيار العلاج أنة من الممكن استخدام قياس سمك الطبقة الداخلية والوسطى للشريان السباتى للعنق فى مرضى الداء السكرى من النوع الثانى كعلامة مبكرة لحدوث تصلب شرايين العنق وهذا الاكتشاف قد يساعد على العلاج والوقاية السليمة وقد اشتملت هذه الدراسة على مجموعتين من المرضى

المجموعة الأولى: اشتملت هذه المجموعة على مرض الداء السكرى 111 مريضا يعانون من قصور الشرايين الدماغية ولكنهم لم يصابوا بالسكتة الدماغية الكاملة

المجموعة الثانية: اشتملت على 16 مريض من مرضى الداء السكرى أصيبوا بالسكتة الدماغية الكاملة وقد خضع كلا من المجموعتين للفحوصات الآتية:

معرفة التاريخ المرضى بدقة مع فحص كامل للجهاز العصبي-التحاليل الروتينية وتشمل نسبة السكر الصائم وبعد الإفطار بساعتين ونسبة الكولستيرول فى الدم (الدهون عالية الكثافة ومنخفضة الكثافة) ونسبة الجليسريدات الثلاثية نسبة البروتين فى البول - أشعة الرنين المغناطيسى للمخ - فحص الشرايين العنقية بجهاز الدوبلكس

النتائج :

النتائج الإكلينيكية لقد كان لتقدم عمر المريض, ارتفاع نسبة السكر بالدم وارتفاع ضغط الدم ووجود قصور الشرايين التاجية والتدخين من أكثر عوامل الخطر الإكلينيكية شيوعا لحدوث السكتة الدماغية الكاملة فى مرض الداء السكرى. أيضا زيادة الكولستيرول والجلسيريدات الثلاثية يؤدى أكثر إلى زيادة الإصابة بالسكتة الدماغية الكاملة.

وكذلك متوسط سمك الطبقة الداخلية والوسطى للشرايين العنقى أعطى قياس أعلى فى مرضى المجموعة الثانية الممثلة فى السكتة الدماغية الكاملة

الملاحظة:

تصلب شرايين العنق يعد جزأ من تصلب شرايين الدماغ والقلب لذلك تقاس سمك الطبقة الداخلية والوسطى للشريان السباتى للعنق سيجعل من الممكن التعرف المبكر على الحالات التى سوف تعانى من خطر اعتلال شرايين المخ بالجلطة الحادة أو نوبات القصور المتكررة وذللك سوف يزيد من إمكانية الوقاية الأولية.



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