European Journal of Cardiovascular Medicine

Cerebrovascular accident (CVA) is classically characterized as a neurological deficit attributed to a non-traumatic, focal injury of the central nervous system and typically results in permanent damage by a vascular cause including cerebral infarction, intracerebral hemorrhage, and/or subarachnoid hemorrhage [1]. CVA is classified depending upon its etiology into either ischemic stroke (80%) or hemorrhagic stroke (20%). It is the second leading cause of death worldwide [2]. Carotid intima-media thickness (CIMT) is a noninvasive measure of atherosclerosis burden and is associated with future stroke risk [3]. CIMT is a measurement of the thickness of artery walls, by external ultrasound. Measuring carotid CIMT is gaining acceptance as a non-invasive, inexpensive method to assess the extent of atherosclerosis [4-5]. Patients with carotid stenosis (< 75%), the annual incidence of stroke is 1.3%, while patients with more than 70% carotid artery stenosis have a stroke rate of 28% at 18 months [6]. Carotid artery stenosis can lead to stroke by multiple mechanisms including: embolism, thrombotic occlusion, dissection, or hypoperfusion [7]. Carotid Intima-Media Thickness (CIMT) is an established non-invasive predictor of the incidence of future ischemic stroke, as it accurately predicts the early stages of atherosclerosis and cardiovascular risk [8]. CIMT is safe, reliable, and inexpensively measured. It has recently been seen as a strong predictor of future vascular events such as myocardial infarction and stroke [9]. A positive association exists between CIMT and the risk of subsequent cardiovascular events including stroke, independent of all major risk factors [10].

There are only a few studies showing an association between increased carotid intima media thickness and stroke.

Aim of this study: The primary objective of the study was to evaluate role of CIMT in patients with cerebrovascular accident.

This case control study was conducted in the Department of Radiodiagnosis in a tertiary care hospital; India. The study was conducted over a span of one year.

Inclusion criteria:

●     Patients ≥ 40 years of age with both gender

●     Patients with CVA who underwent carotid Doppler examinations.

Exclusion criteria:

●     Patients <40 years of age

●     Patients having hemorrhagic stroke, evidence of obvious source of cardiac emboli and chronic kidney disease

CVA or ischemic stroke confirmed by computed tomography (CT) Brain.

A total of fifty cases and same number of age matched controls were enrolled in this study. Informed consent was taken

A detailed socio-demographic data, clinical presentation and any history of comorbidities (heart disease, hypertension, diabetes, and smoking) were recorded in all cases and controls. They were subjected to routine investigations, blood sugars and lipid profile. Cases with cardiac symptoms, ECG changes or past history of ischemic heart disease or valvular heart disease were subjected to echocardiogram to rule out cardiac emboli. CIMT was measured by doing carotid Doppler on both the carotid arteries. Imaging of both common carotid arteries up to their bifurcation was done. Intimal plaques were searched. Sites with intimal plaques were avoided during measurement of CIMT.

Statistical analysis: Data were analysed using Epi info software. Mean and standard deviation values were calculating and analysed using Pearson Chi-Square, Fisher's exact test, unpaired t test, one-way ANOVA test. P value less than 0.05 considered statistically significant.

In the present study fifty cases of CVA and fifty healthy controls were analyzed. Male were predominant in each group (62% in cases and 58% in control). Mean age of cases was 60.25 year and that of controls was 59.12 years. Majority of cases were overweight (46%) whereas most of the control was normal weight (52%). Majority of the participants (46% cases & 50% control) belong to middle socio-economic class. There were no significant differences in the base-line characteristics among patients and controls

Table 1: Baseline characteristics of cases and controls

Risk factors like smokers and alcohol intake were more in cases as compared to control. Comorbidities like diabetes, hypertension, dyslipidemia and history of coronary artery disease (CAD) are more common in cases as compared to control. Among cases smokers accounting for 34%, followed by dyslipidemia (30%), diabetes mellitus (26%), hypertension (22%) and CAD accounting for 18% of all risk factors

Table 2: Risk factors and comorbidities among cases and controls

Incidence of increased carotid intima-medial thickness (in both underlined parts) was 32% among Cerebrovascular accident cases

Graph 1: Incidence of increased carotid intima media thickness among CVA patients

Patients with CVA had a significantly higher CIMT as compared to age matched controls in the right and left carotids (p<0.05), but there is no significant difference in CIMT in right and left.

CIMT was also significantly higher among the CVA patients with risk factors like smoking, alcoholism, hypertension, diabetes, dyslipidemia and history of CAD as compared to controls (P<0.05)

Table 3: Correlation between carotid intima-media thickness with Cerebrovascular accident on carotid Doppler

Carotid Intima Media Thickness is a surrogate marker for the early detection of atheromatous changes and is easily accessed by non-invasive B-mode ultrasound. Consideration of both right and left carotids could improve the prediction by assuring the true presence of large parameters [11].A Cerebrovascular disease is the second leading cause of death worldwide. Intima-media thickness (IMT) is a measurement of the thickness of artery walls, usually by external ultrasound.In this study, we evaluated Carotid Intima Media Thickness (CIMT) in patients with CVA.

In our study the majority of the patients were male and mean age of the participants was 60.25 years, similar finding observed by Saxena, et al [12] and Mahajan, et al [13].Sex dimorphisms are important factors that influence the outcomes after ischemic stroke, which include basic health status, cerebrovascular anatomy, hormone levels, and unique factors such as pregnancy and menopause

Prevalence of the thickened CIMT in this study was 32% in CVA patients, consistent with the other studies done by J Walubembe, et al [14] and Song P, et al [15], reported prevalence of thickened CIMT were 31.5% and 27% respectively.

In the present study the CIMT was significantly more in patients with Cerebrovascular accident when compared to controls and this difference persisted across all age groups, in agreement with the R Sahoo, et al [16] and Mukherjee SC [17].

There was a positive correlation between CIMT and cases having ischemic stroke as per the study done by Lorenz M et al [18], which was similar to results obtained in this study.

The baseline characteristics of the cases and control did not significantly different in the current study, concordance with the Relwani PR, et al [19].

We have reported that patients with smoking and alcohol intake had significantly association with the thickened CIMT, our results comparable with Soliman RH et al [20] and Susan D, et al [21].

Our study reported a higher value of CIMT among CVA cases with the co-morbidities (DM, hypertension, Dyslipidemia & CAD), and the difference was statistically significant (p<0.05), similar finding are reported by many other researchers like:Das S, et al [22],Inuwa M, et al [23] and Saha A, et al [24].Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk but also reduces the risk of other cardiovascular diseases

Carotid Intima media thickness with or without any visible plaques is a marker of atherosclerosis and is also a predictor for cerebrovascular accident.The findings highlighted the pivotal role of age, gender, hypertension, diabetes mellitus, smoking influencing the CIMT risk and outcomes in CVA patients. This is a multidisciplinary approach that encompasses both vascular health assessment and CVA management

Conflicts of interest: None

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