Status of carotid intima media thickness (1)
© JAPI • sePtember 2012 • VOL. 60
26
Original Article
Status of Carotid Intima-media Thickness and
Associated Risk Factors in Diabetic, Prediabetic and
Non-Diabetic Acute Stroke
Uday Sankar Ghosh*, Partha Chattopadhyay*, Samar Banerjee**, Madan Karmakar***,
Suchit Majumder****
Abstract
Objective: measure carotid intima-medial thickness (CImt), its variability, risk factors, their correlation, in type
2 diabetic (Dm), pre-diabetic (PDm) and non-diabetic (NDm) acute strokes.
Methods: twenty four Dm and a matched population of 14 patients each of PDm and NDm strokes were studied.
each group was compared as whole and by gender and stroke segregation. study parameters were right and left
CImts (CImtr, CImtL), insulin resistance (Ir), age, bmI and lipids, correlations between CImts and CImts
with risk markers.
Results: CImtr was higher in Dm and PDm compared to NDm, but CImtLs did not differ. CImts were similar
in genders and stroke types of each group. the Ir was significantly high only in Dm. Age and bmI correlations
were predominantly positive and lipids variable except in PDm. Age and Ir had better impacts on CImts in Dm
while bmI was poor. Females and infarcts had a more congruous CImt increment in Dm and PDm but male
and haemorrhage in NDm.
Conclusion: With similar levels of risk markers, their impacts on the CImts are highly variable at various levels
of glycaemia. CImts were similar in the genders and stroke types of each group, irrespective of the glycemic
status. the pre-diabetes group had distinct features.
Introduction
s
troke in diabetes, has a two to four fold increase in its relative
risk compared to non diabetics.1,2 this is evident across
multiple racial and geographic groups.3 there is relative increase
in ischemic stroke; hemorrhagic stroke is probably not increased.4
Atheroma develops faster in diabetes; thickening of the intima
is an early change.5 Carotid intima-media thickness (CImt),
determined non-invasively by high resolution ultrasound (UsG)
imaging, has been widely used as a surrogate for atherosclerosis.6
type 2 diabetes mellitus (t2Dm) patients often have higher
CImt values than the general population. 7 Whether this
elevated CImt predicts future vascular events independent of
conventional vascular risk factors is not clear.8 Incident CImt as
well as its rate of change depends on many factors.9
Increased CImt in t2Dm is associated with known risk
factors like increasing duration, age, male gender, altered
lipids, increased body mass index (bmI), and markers of
inflammation. 10-12 Adverse lipid ratios, smoking, insulin
resistance and homocystienemia have also been positively
correlated with CImt.9-11 In non diabetics, established risk
factors like age, sex, bmI and dyslipidemias are associated with
increased CImt in a graded manner.2
studies are many in relation to coronary vascular disease, but
studies that assess the incident CImt in acute stroke in t2Dm
vis-à-vis other conventional vascular risk markers and compare
with prediabetic and non-diabetic strokes are few.1,6,7,12,13 this
study was planned to assess (1) status of the incident CImts and
conventional risk markers in type 2 diabetic (Dm), prediabetic
(PDm) and non diabetic (NDm) acute strokes (both infarct and
haemorrhage), (2) the relation of the two (right and left) side
CImts and their correlations with the incident risk markers.
Methods
Fig. 1 : Carotid intima-media thickness measurement at the level of
common carotid artery
*
Nrs medical College, Kolkata, West bengal; **VIms, Kolkata, West
bengal, ***bs medical College bankura, ****srichitra Institute ms,
trivandrum
received: 14.02.2011; Accepted: 24.08.2011
Consecutive patients of stroke in known t2Dm patients
(HbA1c > 6.5) were initially enrolled from the in-patient
department of NRS Medical College, who satisfied the inclusion
and exclusion criteria between June 2009 and January 2010.14 An
age, bmI, gender ratio and matched patients NDm (HbA1c < 5.7)
and PDm (impaired fasting glucose and or impaired glucose
tolerance with HbA1c between 5.7 and 6.5) stroke types were
selected of from same inpatient department, between February
2010 and August 2010 for comparing relevant parameters
and act as controls.14 stroke was established according to the
World Health Organisation definition—“a focal neurological
impairment of sudden onset, and lasting more than 24 hours
(or leading to death), and of presumed vascular origin”-- from
the history, clinical signs and Ct scan of brain (establishing
vascular event).
© JAPI • sePtember 2012 • VOL. 60
Fig. 2 : Carotid doppler at the level of carotid bulb
Fig. 3 : Carotid intima-media thickness measurement at the level of
carotid bulb (IMT-BULB)
Parameters studied included – age, gender, bmI, serum
cholesterol (tC), serum triglyceride (tG), LDL-cholesterol
(LD) and non HDL-cholesterol (n-HC), HDL-cholesterol (HD),
Insulin resistance level (Ir) and CImt of the right (CImtr) and
left (CImtL) carotids (Figures 1, 2, 3, 4). Initially the status of
the parameters were compared between the three major (Dm,
PDm, NDm) groups (table 1). then, each major group was
segregated by stroke types (infarct and haemorrhage) and by
gender (tables 2 and 3), and again compared. the CImtr and
CIMTL correlation status and mean difference is depicted in
table 4 and the correlation of the risk factors with the CImts in
tables 5 and 6.
Patients who survived for three days post hospitalisation were
studied as performing the CImt measurements were not possible
before that duration as well as a repeat Ct scan to establish
infarct in certain cases. exclusion criteria included previous
documented vascular event, renal failure, known secondary or
severe hypertension, subarachnoid haemorrhage, intra cranial
arteriovenous malformations, valvular heart disease, AV block,
atrial fibrillation and patients on drugs that might modify the
CImts (statins, aspirin, ACe inhibitors and Angiotensin receptor
blockers).12,13,15 serum for biochemical analysis were collected
after 6-8 hours of fasting (without insulin) after the last feed and
stored if required, as longer fasting and/or delay in therapeutic
interventions was not permitted by the ethical committee.
CImt was measured by high resolution UsG machine (made
by m/s HP make, marketed by Agilent, model Image point HX)
of carotid arteries with the patient in supine position and the
neck being slightly extended and rotated towards the opposite
27
Fig. 4 : Carotid intima-media thickness measurement at the level
of common carotid artery (IMT-CCA) and internal carotid artery
(IMT-ICA)
Table 1 : Comparative analysis of the clinico-biochemical
parameters of diabetic, prediabetic and non diabetic strokes
Stroke Type
Age(yrs)
Dm n=25
PDm n=14
NDm n=14
Dm vs PDm
Dm vs NDm
PDm vs
NDm
stroke type
Dm n=25
PDm n=14
NDm n=14
Dm vs PDm
Dm vs NDm
PDm vs
NDm
stroke type
Dm n=25
PDm n=14
NDm n=14
Dm vs PDm
Dm vs NDm
PDm vs
NDm
BMI (kg/m2)
Infarct %
60.3±10.34
61.4±8.5
60.1±8.7
p=0.75
p=0.97
p=0.72
Sex- Male
(%)
68%
64.3
51.78
p=0.82
p=0.51
p=0.71
25.1±3.9
26.1±3.8
25.8±2.2
p=0.34
p=0.52
p=0.66
60
64.3
57.1
p=0.8
p=0.87
p=0.71
tC(mg/dl)
176.8±26.4
17.2±41.8
187.6±42.6
p=0.62
p=0.35
p=0.33
tG(mg/dl)
154.4±52.7
137.9±43.8
164.5±69
p=0.34
p=0.62
p=0.25
HD(mg/dl)
39.1±7.3
38.2±6.3
45.8±11.8
p=0.72
p=0.04*
p=0.05*
LD(mg/dl)
130.2±25.9
113.9±45.7
120.1±39.9
p=0.17
p=0.35
p=0.71
Ir
3.29±2.2
1.69±1.2
1.04±0.7
p=0.017*
p=0.0007*
p=0.09
n-HC(mg/dl)
137.8±28.6
133±41.3
141.9±46.3
p=0.68
p=0.74
p=0.61
Ctr(mm)
0.88±0.16
0.88±0.17
0.76±0.07
p=0.99
p=0.016*
p=0.04*
CtL(mm)
0.96±0.24
0.87±0.15
0.83±0.1
p=0.24
p=0.07
p=0.42
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic
stroke, yrs- years, bmI- body mass index, tC- total cholesterol,
tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Irinsulin resistance level, n-HC- non HDL cholesterol, Ctr- carotid
intimo-medial thickness of the right side, CtL- carotid intimo-medial
thickness of the left side, vs- versus, p- p value of t test, n- number of
patients, * = significant p value.
side, with 5 -10 mHz linear array transducer.6 All measurements
were performed by manual planometry by a single operator, who
was blinded about the glycemic status of the subjects.
Longitudinal views of the normal carotid walls (both far
and near) demonstrate two nearly parallel echogenic lines,
separated by a hypoechoic to anechoic region. The first echoic
line bordering the vessel lumen represents the lumen-intima
interface; the second echoic line is caused by the mediaadventitia interface. the distance between these two lines
represents the intima-medial thickness of the carotid (CImt).2
© JAPI • sePtember 2012 • VOL. 60
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Table 2: Intra group comparative analysis of the clinico-biochemical parameters of infarct and haemorrhage of the diabetic,
prediabetic and non diabetic strokes
Stroke Type
Dm-I n=15
m:F= 13:2
Dm-H n=10
m:F= 4:6
P value
PDm-I n=9
m:F=6:3
PDm-H n=5
m:F= 3:2
P value
NDm-I n=8
m:F= 4:4
NDm-H n=6
m:F= 4:2
P value
AGE
(yrs)
59.1±8.5
BMI
(kg/m2)
25.5±3.6
TC
(mg/dl)
173.7±23.7
TG
(mg/dl)
137±40.5
HD
(mg/dl)
39.1±8.2
LD
(mg/dl)
129.7±26.7
n-HC
(mg/dl)
134.7±28.1
62±12.3
24.4±4.1
181.5±29.4
180.4±57.9
39.1±5.7
131.1±24.7
0.52
58.3±6.5
0.52
25.2±3.4
0.49
160.4±28.9
0.045*
127.7±42
0.99
38.7±5.7
66.8±8.9
28.4±3.5
190.6±52.9
156.4±40.8
0.08
60.8±9.4
0.15
25.5±1.9
0.23
194.8±27.3
59.3±7.4
26.2±2.4
0.8
0.6
IR
3.2±2
CTR
(mm)
0.93±0.15
CTL
(mm)
0.96±0.32
142.4±28.9
3.4±2.4
0.81±0.14
0.95±0.32
0.89
106.4±43
0.52
121.8±27
0.83
1.8±1.2
0.06
0.84±0.17
0.89
0.86±0.16
37.4±7.2
127.2±47.2
153.2±53.3
1.54±1
0.94±0.16
0.88±0.14
0.3
192.5±71
0.74
45.9±8.9
0.5
126.6±38.1
0.2
148.9±33.9
0.8
0.8±0.4
0.4
0.76±0.07
0.9
0.83±0.1
178.2±55.5
127.2±44.2
45.7±15
111.3±40.4
132.5±57.5
1.4±0.8
0.77±0.08
0.83±0.11
0.5
0.09
0.97
0.5
0.54
0.13
0.9
0.88
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, yrs- years,m- male, F- female, I- infarct, H- haemorrhage, bmI- body mass
index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance level, n-HC- non HDL cholesterol,
Ctr- carotid intimo-medial thickness of the right side, CtL- carotid intimo-medial thickness of the left side, p- p value of t test, n- number of
patients, * = significant p value
Table 3 : Intra group comparative analysis of the clinico-biochemical parameters of males and females of the diabetic,
prediabetic and non diabetic strokes
Stroke Type
AGE
(Yrs)
62.2±8.7
BMI
(kg/m2)
25.9±3.6
TC
(mg/dl)
174.3±26.7
TG
(mg/dl)
153.2±58.5
HD
(mg/dl)
39.8±7.8
LD
(mg/dl)
127.9±22.8
n-HC
(mg/dl)
134.5±28.7
56.1±12.1
23.1±3.7
182.3±24.8
156.9±37.1
37.5±5.8
135.1±30.9
0.18
0.09
0.5
0.88
0.5
PDm-m n=9
I:H= 6:3
PDm-F n=5
I:H= 3:2
P value
63.3±8.7
25.2±3.9
175.4±28.1
143.1±39.7
66.8±8.9
28.4±3.5
190.6±52.9
156.4±40.8
0.27
0.15
0.64
0.6
0.07
0.4
0.83
0.9
0.38
0.85
NDm-m n=8
I:H= 4:4
NDm-F n=6
I:H= 4:2
P value
54.8±4.1
26.5±2.02
172.8±33.4
160.6±56.6
46.3±13.5
109.4±32.8
126.5±37.5
0.91±0.5
0.76±0.07
0.83±0.11
67.3±7.9
24.8±1.97
207.5±45.3
169.7±82.4
45.2±9
134.3±43.7
153.2±53.3
1.54±1
0.94±0.16
0.88±0.14
0.004*
0.17
0.15
0.82
0.88
0.3
0.18
0.43
0.95
0.96
Dm-m n=17
I:H= 13:4
Dm-F n=8
I:H= 2:6
P value
IR
3.3±2.1
CTR
(mm)
0.9±0.17
CTL
(mm)
1.01±0.26
144.8±27.2
3.2±2.4
0.84±0.11
0.85±0.16
0.92
0.53
0.92
0.39
0.13
40.6±5.7
122.3±35.8
134.9±27.2
1.7±1.3
0.91±0.17
0.88±0.14
37.4±7.2
127.2±47.2
153.2±53.3
1.54±1
0.94±0.16
0.88±0.14
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, yrs- years,m- male, F- female, I- infarct, H- haemorrhage, bmI- body mass
index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance level, n-HC- non HDL cholesterol,
Ctr- carotid intimo-medial thickness of the right side, CtL- carotid intimo-medial thickness of the left side, p- p value of t test, n- number of
patients, * = significant p value
the measurements were done in the posterior (far) wall at three
places (i.e. common carotid artery: 20 to 60 mm proximally from
the flow divider; carotid bulb: 0 to 20 mm distally from the flow
divider; and carotid artery bifurcation: 0 to 20 mm proximally
from the flow divider) at zones free of plaques.16 these three
measurements were averaged on either side (left and right
carotid) and the mean values were taken separately for either
side.16,6 the images were digitally captured during the systole of
a single heartbeat (eCG r wave gated) and measurements were
performed offline for each area.16
serum lipids (tC, tG, LD and HD - directly measured and
n-HC calculated) and blood glucose were measured by auto
analyzer and serum insulin by eLIsA (monobind Corporation).
Insulin resistance was assessed by using the previously validated
homeostasis model assessment for insulin resistance, calculated
from the fasting insulin and glucose concentrations according
to the formula: HOmA-Ir = [(insulin × glucose)/22.5].17 HbA1c
was estimated by Boronate affinity chromatography (Bio-Rad
micromat-2). statistical analysis was done by student’s t test
and Pearson’s correlation co-efficient (SPSS Version 14.0). A p
value of ≤ 0.05 was considered significant.
Results
A total of 29 consecutive patients of stroke in known t2Dm
were collected; 4 could not complete the total investigations - the
study was done with 25 patients of t2Dm. In the NDm subgroup
the total number at inclusion was 14 and 17 were found to be
PDm (3 could not complete the study). the Dm strokes had 40%
smokers and the other 2 groups had 37.5% each - all were males
without any significant inter group difference in prevalence.
© JAPI • sePtember 2012 • VOL. 60
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table 1 : the age, bmI, and sex ratio were matched and the
Table 4 : Status of the right and left CIMTs : Level of
correlation and difference in their mean values of each
stroke type and their sub groups
Stroke Type
Dm
PDm
NDm
Dm-I
PDm-I
NDm-I
Dm-H
PDm-H
p -values
r= - 0.03
p=0.89, p(t)=0.18
r=0.27
p=0.24, p(t)=0.9
r=0.38
p=0.18, p(t)=0.07
r=0.57
p=0.02*, p(t)=0.54
r=0.43
p=0.025*, p(t)=0.78
r= -0.1
p=0.81, p(t)=0.13
r= -0.54
p=0.11, p(t)=0.24
r= -0.05
p=0.94, p(t)=0.57
Stroke Type
NDm-H
Dm-m
PDm-m
NDm-m
Dm-F
PDm-F
NDm-F
-
p -values
r=0.87
p=0.02*, p(t)=0.36
r= -0.02
p=0.5, p(t)=0.14
r=0.18
p=0.64, p(t)=0.66
r=0.82
p=0.01*, p(t)=0.18
r=0.25
p=0.55, p(t)=0.87
r=0.46
p=0.01*, p(t)=0.74
r=0.3
p=0.56, p(t)=0.26
-
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic
stroke,m- male, F- female, I- infarct, H- haemorrhage, CImts- carotid
intimo-medial thickness of the right and left sides, p(t)- p value of
t test, r= correlation coefficient, p= p value of the correlation, * =
significant p value
incident lipid parameters differed little among the groups; only
HD was significantly higher in NDM. The mean CIMTR values
were significantly higher in both DM and PDM compared to
NDM; however, DM and PDM did not differ. There was no
difference between the three groups for CIMTL. The IR status
was significantly higher in DM compared to both PDM and
NDM, but NDM and PDM did not differ.
table 2 : In intra group analysis of the parameters between
infarct and haemorrhage none of the parameters differed except
tG which was higher in Dm haemorrhage. In case of infarcts
of all groups both the CImts were higher in Dm compared to
NDM only, though the only the right side was highly significant
(p=0.009) the left only expressed a higher trend (p=0.06). In case
of haemorrhage none of the CIMT values differed for either side
(p value ranged from 0.067 to 0.73).
table 3 : In intra group analysis of the parameters between
males and females the study parameters showed no significant
difference except that the NDM females had higher mean age
compared to their males. though none of the females were
smokers they had a similar CImts as the males. the CImtrs of 3
glycemic varieties of strokes when compared among the males, it
was significantly higher in PDM (p= 0.04) and DM (p=0.05) with
respect to NDM, though the there was no difference between
PDM and DM (p=0.86). The CIMTL values did not differ, p=0.2
(Dm Vs PDm), 0.08(Dm Vs NDm) and 0.5 (PDm Vs NDm). both
the CImts did not vary in case of females of the three glycemic
Table 5 : CIMTR correlations of the risk factors
Types
Dm
PDm
NDm
Dm-m
PDm-m
NDm-m
Dm-F
PDm-F
NDm-F
Dm-I
PDm-I
NDm-I
Dm-H
PDm-H
NDm-H
Age
r= 0.29
p=0.16
r= 0.49
p=0.13
r= 0.13
p=0.7
r= 0.02
p=0.95
r= 0.24
p=0.54
r=-0.04
p=0.9
r= 0.87*
p=0.005
r= 0.71
p=0.18
r= -0.31
p=0.5
r= 0.14
p=0.62
r= 0.45
p=0.2
r= 0.45
p=0.2
r= 0.31
p=0.77
r= 0.24
p=0.7
r= 0.24
p=0.7
BMI
r =0.008
p =0.97
r =0.28
p =0.3
r = 0.3
p =0.3
r=-0.03
p =0.9
r = 0.3
p =0.4
r= 0.33
p=0.43
r=-0.17
p =0.7
r =0.8
p =0.1
r = 0.34
p =0.5
r =0.16
p =0.57
r =0.4
p =0.28
r = 0.26
p =0.52
r =-0.3
p =0.4
r = -0.2
p =0.7
r =0.34
p =0.52
TC
r =0.1
p =0.62
r =0.46
p =0.09
r =-0.28
p =0.34
r =-0.07
p =0.8
r =-0.06
p =0.88
r =-0.34
p =0.42
r =0.85*
p =0.008
r =0.92*
p =0.03
r =-0.29
p =0.57
r =-0.15
p =0.6
r =0.54
p =0.14
r=-0.026
p =0.96
r =0.58
p =0.08
r =0.32
p =0.6
r =-0.4
p =0.38
TG
r =0.1
p =0.63
r =0.5
p =0.07
r =-0.07
p =0.82
r =0.02
p =0.95
r =0.15
p =0.7
r =0.02
p =0.96
r =0.6
p =0.1
r =0.96*
p =0.01
r =-0.16
p =0.77
r =0.32
p =0.25
r =0.83*
p =0.006
r =-0.37
p =0.36
r =0.3
p =0.4
r =-0.27
p =0.66
r =0.54
p =0.27
HD
r= 0.17
p= 0.4
r= 0.14
p=0.63
r=0.49
p=0.07
r= 0.2
p=0.97
r= -0.04
p=0.9
r= 0.36
p=0.38
r= -0.05
p=0.9
r= 0.14
p=0.82
r= 0.78
p=0.07
r=0.35
p=0.2
r= 0.63
p=0.07
r= 0.43
p=0.28
r=-0.2
p=0.6
r= -0.51
p=0.4
r=0.54
p=0.26
LD
r =0.13
p =0.54
r =0.42
p =0.14
r=-0.42
p =0.13
r =0.09
p =0.7
r=-0.03
p =0.93
r =-0.4
p =0.32
r =0.33
p =0.43
r =0.85
p =0.07
r =-0.57
p =0.3
r =0.06
p =0.8
r =0.27
p =0.48
r =-0.26
p =0.54
r =0.31
p =0.4
r =0.57
p =0.3
r=-0.61
p =0.2
n-HC
r =0.05
p =0.81
r =0.4
p =0.1
r =-0.38
p =0.18
r =-0.1
p =0.7
r =-0.05
p =0.9
r =-0.43
p =0.29
r =0.78*
p =0.02
r =0.9*
p =0.037
r =-0.4
p =0.4
r =-0.23
p =0.4
r =0.4
p =0.2
r =-0.13
p =0.76
r =0.63*
p =0.05
r =0.39
p =0.52
r =-0.57
p =0.24
IR
r= 0.11
p=0.59
r= -0.1
p=0.65
r= -0.34
p=0.25
r= -0.08
p=0.75
r= -0.31
p=0.43
r= -0.24
p=0.59
r= 0.68
p=0.06
r= 0.23
p=0.71
r= -0.47
p=0.35
r= 0.14
p=0.62
r= -0.07
p=0.87
r= -0.08
p=0.82
r=0.14
p=0.7
r= -0.23
p=0.87
r= -0.4
p=0.38
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, CImtr- CImt of the right side, yrs- years,m- male, F- female, I- infarct,
H- haemorrhage, bmI- body mass index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance
level, n-HC- non HDL cholesterol, CIMT- carotid intimo-medial thickness, r= correlation coefficient, p= p value of the correlation, * = significant p
value
© JAPI • sePtember 2012 • VOL. 60
30
Table 6 : CIMTL correlations of the risk factors
Types
Dm
PDm
NDm
Dm-m
PDm-m
NDm-m
Dm-F
PDm-F
NDm-F
Dm-I
PDm-I
NDm-I
Dm-H
PDm-H
NDm-H
Age
r=0.33
p=0.1
r= -0.02
p=0.95
r= -0.16
p=0.6
r= 0.45
p=0.07
r= -0.38
p=0.32
r= -0.25
p=0.6
r= -0.11
p=0.8
r=0.65
p=0.24
r= -0.2
p=0.7
r=0. 56*
p=0.03
r= -0.17
p=0.7
r= 0.15
p=0.7
r= 0.18
p=0.54
r= 0.16
p=0.8
r= -0.18
p=0.7
BMI
r = 0.25
p =0.24
r = 0.34
p =0.24
r = 0.2
p =0.5
r =0.19
p =0.48
r = 0.25
p =0.53
r =0.34
p =0.43
r =0.08
p =0.86
r =0.08
p =0.87
r = 0.1
p =0.8
r = 0.03
p =0.9
r = 0.1
p =0.8
r =0.36
p =0.38
r = 0.4
p =0.25
r =0.87
p =0.06
r = 0.11
p =0.83
TC
r =-0.2
p =0.3
r =0.78*
p =0.001
r =-0.29
p =0.32
r =-0.31
p =0.2
r =0.7*
p =0.055
r =-0.38
p =0.35
r =0.2
p =0.58
r =-0.24
p =0.65
r =0.88*
p =0.002
r =-0.98*
p =0.02
r =0.88*
p =0.002
r =0.22
p =0.6
r =-0.001
p =0.99
r =0.86
p =0.06
r =-0.61
p =0.2
TG
r =0.02
p =0.93
r =0.67*
p =0.009
r =0.25
p =0.4
r =0.05
p =0.86
r =0.42
p =0.26
r =-0.11
p =0.8
r =-0.05
p =0.9
r =0.63
p =0.18
r =0.6
p =0.09
r =-0.13
p =0.64
r =0.6
p =0.09
r =0.3
p =0.47
r =0.12
p =.74
r =0.9*
p =0.04
r =0.21
p =0.69
HD
r =0.07
p=0.7
r =0.2
p=0.48
r = 0.013
p=0.97
r = 0.16
p=0.54
r = 0.18
p=0.65
r =0.34
p=0.41
r = -0.57
p=0.14
r = -0.72
p=0.11
r = 0.32
p=0.4
r =0.21
p=0.40
r =0.32
p=0.4
r = -0.67
p=0.07
r =-0.05
p=0.89
r =0.03
p=0.96
r = 0.47
p=0.35
LD
r =-0.01
p =0.96
r =0.79*
p =0.001
r =-0.18
p =0.54
r =-0.09
p =0.7
r =0.84*
p =0.003
r =-0.45
p =0.27
r =0.35
p =0.4
r =0.1
p =0.8
r =0.82*
p =0.006
r =-0.04
p =0.9
r =0.82*
p =0.006
r =0.26
p =0.53
r =0.01
p =0.97
r =0.8
p =0.12
r =-0.68
p =0.13
n-HC
r =-0.2
p =0.29
r =0.75*
p =0.002
r =-0.27
p =0.36
r =-0.33
p =0.2
r =0.69*
p =0.04
r =-0.46
p =0.25
r =0.34
p =0.42
r =-0.09
p =0.87
r =0.87*
p =0.002
r =-0.6
p =0.03
r =0.87*
p =0.002
r =0.35
p =0.39
r =0.01
p =0.98
r =0.85
p =0.07
r =-0.71
p =0.1
IR
r= 0.43*
p=0.03
r= 0.33
p=0.42
r= -0.42
p=0.13
r= 0.39
p=0.23
r= 0.48
p=0.19
r= -0.58
p=0.14
r= 0.68
p=0.06
r= 0.02
p=0.97
r= -0.34
p=0.51
r= 0.16
p=0.57
r= 0.46
p=0.22
r= 0.13
p=0.76
r= 0.63*
p=0.05
r= 0.01
p=0.98
r= -0.8
p=0.06
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, yrs- years CImtL- CImt of the right side,m- male, F- female, I- infarct, Hhaemorrhage, bmI- body mass index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance level,
n-HC- non HDL cholesterol, CIMT- carotid intimo-medial thickness, r= correlation coefficient, p= p value of the correlation, * = significant p value
varieties of stroke (CImtr p value was = 0.84, 0.21, 0.53 and
CImtL p value was = 0.92, 0.79 and 0.72 respectively for Dm Vs
NDm, Dm Vs PDm and PDm Vs NDm).
table 4 : the mean values of the right and left CImt did not
differ amongst the 3 groups as well as their stroke types and
gender types. However there was significant variation in their
correlations. the right – left correlation was worst in Dm and
best in NDM. It was significantly positive in cases of DM infarcts,
PDm infarcts and females, and NDm males and haemorrhage.
table 5 and 6 : Age had predominantly positive correlation
for the right side, being significant only in DM females; it was
more variable for the left side and significantly positive in DM
infarcts only. bmI correlated positively in nearly all groups of
both the sides but was weakest in Dm for the right side and best
in PDM haemorrhage for the left side, but none were significant.
the Ir correlations were predominantly negative for the right
side and none were significant; it was predominantly positive for
the left side being significant only in DM and DM haemorrhage
subgroup.
Correlations of total cholesterol were variable and
predominantly negative for both the CIMT, being significantly
positive in females of Dm, total PDm and PDm infarcts for
CImtr, and total PDm, infarcts of Dm and PDm for CImtL.
triglyceride levels predominantly had a positive correlation for
both CImts, especially in females and infarcts of PDm for the
right side, and PDm and its haemorrhage subgroup for the left.
LDL had a variable correlation with both side CImts but it was
significantly positive in total PDM, PDM males and infarct and
NDm females for the left side only. the HDL cholesterol had a
predominantly positive correlation with both the sides but was
never significant. For n-HC the relations were predominantly
variable for both CIMTs though it was significantly positive in
the females of Dm and PDm and haemorrhage subgroup of
Dm on the right side and PDm group and its male and infarct
subgroups, as well as Dm infarcts and NDm females for the
left side.
Discussion
the common non-invasive markers of sub-clinical and
clinical atherosclerosis include AbPI (ankle brachial pressure
index), CIMT, and AoIMT (aortic intimo medial thickness), flow
mediated brachial artery dilatation and the number and volume
of carotid plaques.18 A CImt of less than 0.55 mm and AoImt
of less than 3 mm have been found to be excellent markers of
the absence of macrovascular abnormalities, especially coronary
artery disease. 18 Higher CImt is more commonly associated with
diabetic strokes, irrespective of the gender and stroke type.19
the status in patients of pre-diabetes is not very conclusive.20
In general, due to anatomic reasons, the left side is known to
suffer more shear stress and so it is more likely to have a higher
CImt than the right.21,8 CImts at all arterial sites may predict
future vascular events to almost the same level.15 However, each
site may have a different progression profile, so a composite of
3 sites was used in our study.22
© JAPI • sePtember 2012 • VOL. 60
In our study, CIMTs of all varieties of stroke were significantly
higher than non –stroke historical controls.7,15 In the three groups
of patients, incidents CImts were higher in Dm strokes, though
predominantly on one side. Predominance of CImtr in Dm was
probably related to the stroke side circulation (more patients in
our study population had a stroke in the right side circulation,
especially in Dm).8 the right and left CImt correlation was most
variable in Dm - possibly signifying a more altered vascular
anatomical remodelling in Dm. Insulin resistance was the only
risk marker that was significantly increased in DM and also
expressed better correlation with the incident CIMTs though
more on one side (left); the relation was least congruous in
non-diabetic strokes. 23, 11 the age of the patient also had a
better correlation with the CIMT status in diabetics (left side)
than the others.24 the Ir level and age of the patient probably
plays some role in CImt status modulation in Dm, while it of
lesser significance in PDM and NDM. 11 the incident lipids were
similar in the three groups; however they correlated best with
the CImt status only in PDm.20 bmI had a positive relation with
the CImts in all, but it was worst in Dm (the right side); its role
in Dm may be questionable.9,10
In intra group analysis of Dm strokes, though females were
non-smokers and hemorrhagic stroke is supposed to have a
different mechanism, they had similar CIMTs and IR status as
males and infarcts. the CImt increments were more uniform
and better related to the IR status in the females while it was age
in males; more so, for the left side.25,24 the bmI may have some
impact in infarcts only.11 Females are probably more predisposed
to have a higher CImt once they are in the post menopausal
state where the usual protection related to female gender is lost.9
there was a poor relation of the CImts in hemorrhage (though
females predominated) but it was better in infarcts indicating a
more uniform vascular remodelling in them; however, the CImt
versus IR correlations were better in hemorrhagic stroke (left
side). the correlation of age was positive in both stroke types but
it was better in cases of infarct (left side).9 the lipid correlations of
the CIMTs were highly variable but were better in females and in
case of hemorrhagic stroke.23 though the mean age, CImts, bmI,
lipids and IR status varied little between the stroke types and
the genders, there was significant variability in their individual
relation with the CImt status as well as the congruity of the
two side CImts, being more congruous in females and infarct.
In intra group analysis of NDm strokes, the mean study
parameters did not vary between the genders as well as the
stroke types. Females were non-smokers and of a significantly
higher mean age, but they had similar CImts as males. Ir status
correlations were poor in the genders and stroke types except
in haemorrhage for CImtL. the uniformity of the right-left
CIMTs were significant in males and haemorrhage than infarct
and females, this was in absolute contrast to both Dm and PDm
strokes.15,16 In contrast to Dm and PDm, incident Ir status and
age had little relation with CIMTs.8,9 the lipid correlations of
CImts were worst compared to both Dm and PDm.8,9 the bmI
correlations were better than both DM and PDM. The CIMTs in
non-diabetics are probably more associated with the tensile wall
stress than altered intimo-endothelial vascular physiology; Ir,
age and lipids play little role, BMI may be more important.26,21
In intra group analysis of PDm strokes, there was no
difference in the mean study parameters between the genders
and stroke types. the right and left side CImt correlation was
significantly positive in females. Like the DM strokes, females
and haemorrhage had a similar CImt as males and infarct
respectively. similar to the Dm strokes, females and infarcts
31
had a more uniform two side CImt status. the Ir and age had
better relations with CIMTs in females compared to DM. Relation
of Ir status with the CImts were variable in the stroke types,
being better for the left side in both. Impact of age was variable
in infarct but better in haemorrhage. The CIMT correlations and
the IR with CIMT relations in the males were better than in DM,
and the impact of age less pronounced except in females. the
correlations of lipid status with the CIMTs were significantly
better in females and infarct than in DM; BMI also had a better
association than in Dm but for the right side only.1,19
At the time of stroke the CImts were higher in Dm and PDm
than NDm but were predominantly one sided (not uniform).8,21
the stroke side circulation CImt was most altered in diabetics,
while the incident risk markers often had a better correlation
with the non-stroke side.8,15,16 the CImt status and risk factor
association in pre-diabetics is distinctly different from both
diabetics and non-diabetics. 20 In major groups, especially
NDm, the mean CImt values were slightly higher on the left
side, probably reflecting the physiologic variation.21 Vascular
remodelling, as evidenced by the CImt status, was more
uniform in non-diabetic strokes than in Dm or PDm.27,21 the
significantly raised IR status is probably an important contributor
for the increased CImt status and or its variability in t2Dm.8
Though the mean CIMTs differed little between the genders and
stroke types of all the stroke groups, the right – left CImt level
variability was an important feature and most marked in Dm
and PDm (except in females and infarcts). the Ir correlations
of the CImts were best in Dm, followed by PDm and worst
in NDm; age correlations were similar while bmI associations
were reverse.10
Dyslipidemia was a common association of strokes of all
glycemic statuses, however the lipid correlations of the CImts
varied immensely; it had a consistent relation only in PDm.
Targeting lipids as an intervention tool might be effective only
in pre-diabetics; targeting all the atherosclerosis risk factors
together is probably the option in the others.28,21 In most
subgroups of the patients, non-HDL cholesterol had a negative
correlation (except in PDm) while HDL cholesterol (except in
Dm females and haemorrhage) had a positive relation with the
CImts; this in contrast to conventional thoughts.23
male diabetics and pre-diabetics are more prone to have
higher CImt values than their non-diabetic counterparts
irrespective of the stroke type.25 In females, along with the
conventional risk factors, the post menopausal state is probably
an important contributor for CImt alterations. though t2Dm
is not known to increase the risk of intracerebral parenchymal
haemorrhage and CImt is regarded as a non-invasive marker
of ischemic stroke in diabetics, the CImts were similar in both
infarcts and hemorrhagic strokes.26,4
CImt estimated by 2D UsG does not measure medial and
intimal thickness separately and therefore cannot distinguish
between medial remodelling as a result of an adapted response
to tensile (hypertensive) stress, and intimal thickening which is
primarily indicative of atherosclerosis.29-31 estimation of plaque
number or volume by the 3D USG is probably a better indicator
of the atherosclerosis burden than the CImt at plaque free
zones.32,6 However, diffuse CIMT increments are known to be
predictive for plaque formation.6,17 Genetic or other acquired and
less measured factors might be more important in this regard.3,10
CImt regression might not be a prerequisite for reducing
events in t2Dm as it is only a measure of focal abnormality (not
circumferential) and acute changes like spastic vasoconstriction
© JAPI • sePtember 2012 • VOL. 60
32
or plaque rupture cannot be reflected.3,5,10 There is also significant
variation in the methodology of assessment as well as the values
of CImt.30 Whether CIMT increment is a modifiable risk factor
with improved survival benefit, is still not known.25,33 Larger
studies including less measured risk variables and stroke side
circulation status might be helpful.13,27,30
17.
Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF,
turner rC. Homeostasis model assessment: insulin resistance and
beta-cell function from fasting. Diabetologia 1985;28:412-9.
18.
belhassen L, Carville C, Pelle G, monin JL, teiger e, Duval-moulin
Am et. al. evaluation of carotid artery and aortic intima-media
thickness measurement for exclusion of significant coronary
atherosclerosis in patients scheduled for heart valve surgery. J Am
Coll Cardiol 2002;39:1139-44.
19.
brohall G, Oden A, Fagerberg b: Carotid artery intima-media
thickness in patients with type 2 diabetes mellitus and impaired
glucose tolerance: a systemic review. Diabet Med 2006;23:609-616.
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26
Original Article
Status of Carotid Intima-media Thickness and
Associated Risk Factors in Diabetic, Prediabetic and
Non-Diabetic Acute Stroke
Uday Sankar Ghosh*, Partha Chattopadhyay*, Samar Banerjee**, Madan Karmakar***,
Suchit Majumder****
Abstract
Objective: measure carotid intima-medial thickness (CImt), its variability, risk factors, their correlation, in type
2 diabetic (Dm), pre-diabetic (PDm) and non-diabetic (NDm) acute strokes.
Methods: twenty four Dm and a matched population of 14 patients each of PDm and NDm strokes were studied.
each group was compared as whole and by gender and stroke segregation. study parameters were right and left
CImts (CImtr, CImtL), insulin resistance (Ir), age, bmI and lipids, correlations between CImts and CImts
with risk markers.
Results: CImtr was higher in Dm and PDm compared to NDm, but CImtLs did not differ. CImts were similar
in genders and stroke types of each group. the Ir was significantly high only in Dm. Age and bmI correlations
were predominantly positive and lipids variable except in PDm. Age and Ir had better impacts on CImts in Dm
while bmI was poor. Females and infarcts had a more congruous CImt increment in Dm and PDm but male
and haemorrhage in NDm.
Conclusion: With similar levels of risk markers, their impacts on the CImts are highly variable at various levels
of glycaemia. CImts were similar in the genders and stroke types of each group, irrespective of the glycemic
status. the pre-diabetes group had distinct features.
Introduction
s
troke in diabetes, has a two to four fold increase in its relative
risk compared to non diabetics.1,2 this is evident across
multiple racial and geographic groups.3 there is relative increase
in ischemic stroke; hemorrhagic stroke is probably not increased.4
Atheroma develops faster in diabetes; thickening of the intima
is an early change.5 Carotid intima-media thickness (CImt),
determined non-invasively by high resolution ultrasound (UsG)
imaging, has been widely used as a surrogate for atherosclerosis.6
type 2 diabetes mellitus (t2Dm) patients often have higher
CImt values than the general population. 7 Whether this
elevated CImt predicts future vascular events independent of
conventional vascular risk factors is not clear.8 Incident CImt as
well as its rate of change depends on many factors.9
Increased CImt in t2Dm is associated with known risk
factors like increasing duration, age, male gender, altered
lipids, increased body mass index (bmI), and markers of
inflammation. 10-12 Adverse lipid ratios, smoking, insulin
resistance and homocystienemia have also been positively
correlated with CImt.9-11 In non diabetics, established risk
factors like age, sex, bmI and dyslipidemias are associated with
increased CImt in a graded manner.2
studies are many in relation to coronary vascular disease, but
studies that assess the incident CImt in acute stroke in t2Dm
vis-à-vis other conventional vascular risk markers and compare
with prediabetic and non-diabetic strokes are few.1,6,7,12,13 this
study was planned to assess (1) status of the incident CImts and
conventional risk markers in type 2 diabetic (Dm), prediabetic
(PDm) and non diabetic (NDm) acute strokes (both infarct and
haemorrhage), (2) the relation of the two (right and left) side
CImts and their correlations with the incident risk markers.
Methods
Fig. 1 : Carotid intima-media thickness measurement at the level of
common carotid artery
*
Nrs medical College, Kolkata, West bengal; **VIms, Kolkata, West
bengal, ***bs medical College bankura, ****srichitra Institute ms,
trivandrum
received: 14.02.2011; Accepted: 24.08.2011
Consecutive patients of stroke in known t2Dm patients
(HbA1c > 6.5) were initially enrolled from the in-patient
department of NRS Medical College, who satisfied the inclusion
and exclusion criteria between June 2009 and January 2010.14 An
age, bmI, gender ratio and matched patients NDm (HbA1c < 5.7)
and PDm (impaired fasting glucose and or impaired glucose
tolerance with HbA1c between 5.7 and 6.5) stroke types were
selected of from same inpatient department, between February
2010 and August 2010 for comparing relevant parameters
and act as controls.14 stroke was established according to the
World Health Organisation definition—“a focal neurological
impairment of sudden onset, and lasting more than 24 hours
(or leading to death), and of presumed vascular origin”-- from
the history, clinical signs and Ct scan of brain (establishing
vascular event).
© JAPI • sePtember 2012 • VOL. 60
Fig. 2 : Carotid doppler at the level of carotid bulb
Fig. 3 : Carotid intima-media thickness measurement at the level of
carotid bulb (IMT-BULB)
Parameters studied included – age, gender, bmI, serum
cholesterol (tC), serum triglyceride (tG), LDL-cholesterol
(LD) and non HDL-cholesterol (n-HC), HDL-cholesterol (HD),
Insulin resistance level (Ir) and CImt of the right (CImtr) and
left (CImtL) carotids (Figures 1, 2, 3, 4). Initially the status of
the parameters were compared between the three major (Dm,
PDm, NDm) groups (table 1). then, each major group was
segregated by stroke types (infarct and haemorrhage) and by
gender (tables 2 and 3), and again compared. the CImtr and
CIMTL correlation status and mean difference is depicted in
table 4 and the correlation of the risk factors with the CImts in
tables 5 and 6.
Patients who survived for three days post hospitalisation were
studied as performing the CImt measurements were not possible
before that duration as well as a repeat Ct scan to establish
infarct in certain cases. exclusion criteria included previous
documented vascular event, renal failure, known secondary or
severe hypertension, subarachnoid haemorrhage, intra cranial
arteriovenous malformations, valvular heart disease, AV block,
atrial fibrillation and patients on drugs that might modify the
CImts (statins, aspirin, ACe inhibitors and Angiotensin receptor
blockers).12,13,15 serum for biochemical analysis were collected
after 6-8 hours of fasting (without insulin) after the last feed and
stored if required, as longer fasting and/or delay in therapeutic
interventions was not permitted by the ethical committee.
CImt was measured by high resolution UsG machine (made
by m/s HP make, marketed by Agilent, model Image point HX)
of carotid arteries with the patient in supine position and the
neck being slightly extended and rotated towards the opposite
27
Fig. 4 : Carotid intima-media thickness measurement at the level
of common carotid artery (IMT-CCA) and internal carotid artery
(IMT-ICA)
Table 1 : Comparative analysis of the clinico-biochemical
parameters of diabetic, prediabetic and non diabetic strokes
Stroke Type
Age(yrs)
Dm n=25
PDm n=14
NDm n=14
Dm vs PDm
Dm vs NDm
PDm vs
NDm
stroke type
Dm n=25
PDm n=14
NDm n=14
Dm vs PDm
Dm vs NDm
PDm vs
NDm
stroke type
Dm n=25
PDm n=14
NDm n=14
Dm vs PDm
Dm vs NDm
PDm vs
NDm
BMI (kg/m2)
Infarct %
60.3±10.34
61.4±8.5
60.1±8.7
p=0.75
p=0.97
p=0.72
Sex- Male
(%)
68%
64.3
51.78
p=0.82
p=0.51
p=0.71
25.1±3.9
26.1±3.8
25.8±2.2
p=0.34
p=0.52
p=0.66
60
64.3
57.1
p=0.8
p=0.87
p=0.71
tC(mg/dl)
176.8±26.4
17.2±41.8
187.6±42.6
p=0.62
p=0.35
p=0.33
tG(mg/dl)
154.4±52.7
137.9±43.8
164.5±69
p=0.34
p=0.62
p=0.25
HD(mg/dl)
39.1±7.3
38.2±6.3
45.8±11.8
p=0.72
p=0.04*
p=0.05*
LD(mg/dl)
130.2±25.9
113.9±45.7
120.1±39.9
p=0.17
p=0.35
p=0.71
Ir
3.29±2.2
1.69±1.2
1.04±0.7
p=0.017*
p=0.0007*
p=0.09
n-HC(mg/dl)
137.8±28.6
133±41.3
141.9±46.3
p=0.68
p=0.74
p=0.61
Ctr(mm)
0.88±0.16
0.88±0.17
0.76±0.07
p=0.99
p=0.016*
p=0.04*
CtL(mm)
0.96±0.24
0.87±0.15
0.83±0.1
p=0.24
p=0.07
p=0.42
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic
stroke, yrs- years, bmI- body mass index, tC- total cholesterol,
tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Irinsulin resistance level, n-HC- non HDL cholesterol, Ctr- carotid
intimo-medial thickness of the right side, CtL- carotid intimo-medial
thickness of the left side, vs- versus, p- p value of t test, n- number of
patients, * = significant p value.
side, with 5 -10 mHz linear array transducer.6 All measurements
were performed by manual planometry by a single operator, who
was blinded about the glycemic status of the subjects.
Longitudinal views of the normal carotid walls (both far
and near) demonstrate two nearly parallel echogenic lines,
separated by a hypoechoic to anechoic region. The first echoic
line bordering the vessel lumen represents the lumen-intima
interface; the second echoic line is caused by the mediaadventitia interface. the distance between these two lines
represents the intima-medial thickness of the carotid (CImt).2
© JAPI • sePtember 2012 • VOL. 60
28
Table 2: Intra group comparative analysis of the clinico-biochemical parameters of infarct and haemorrhage of the diabetic,
prediabetic and non diabetic strokes
Stroke Type
Dm-I n=15
m:F= 13:2
Dm-H n=10
m:F= 4:6
P value
PDm-I n=9
m:F=6:3
PDm-H n=5
m:F= 3:2
P value
NDm-I n=8
m:F= 4:4
NDm-H n=6
m:F= 4:2
P value
AGE
(yrs)
59.1±8.5
BMI
(kg/m2)
25.5±3.6
TC
(mg/dl)
173.7±23.7
TG
(mg/dl)
137±40.5
HD
(mg/dl)
39.1±8.2
LD
(mg/dl)
129.7±26.7
n-HC
(mg/dl)
134.7±28.1
62±12.3
24.4±4.1
181.5±29.4
180.4±57.9
39.1±5.7
131.1±24.7
0.52
58.3±6.5
0.52
25.2±3.4
0.49
160.4±28.9
0.045*
127.7±42
0.99
38.7±5.7
66.8±8.9
28.4±3.5
190.6±52.9
156.4±40.8
0.08
60.8±9.4
0.15
25.5±1.9
0.23
194.8±27.3
59.3±7.4
26.2±2.4
0.8
0.6
IR
3.2±2
CTR
(mm)
0.93±0.15
CTL
(mm)
0.96±0.32
142.4±28.9
3.4±2.4
0.81±0.14
0.95±0.32
0.89
106.4±43
0.52
121.8±27
0.83
1.8±1.2
0.06
0.84±0.17
0.89
0.86±0.16
37.4±7.2
127.2±47.2
153.2±53.3
1.54±1
0.94±0.16
0.88±0.14
0.3
192.5±71
0.74
45.9±8.9
0.5
126.6±38.1
0.2
148.9±33.9
0.8
0.8±0.4
0.4
0.76±0.07
0.9
0.83±0.1
178.2±55.5
127.2±44.2
45.7±15
111.3±40.4
132.5±57.5
1.4±0.8
0.77±0.08
0.83±0.11
0.5
0.09
0.97
0.5
0.54
0.13
0.9
0.88
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, yrs- years,m- male, F- female, I- infarct, H- haemorrhage, bmI- body mass
index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance level, n-HC- non HDL cholesterol,
Ctr- carotid intimo-medial thickness of the right side, CtL- carotid intimo-medial thickness of the left side, p- p value of t test, n- number of
patients, * = significant p value
Table 3 : Intra group comparative analysis of the clinico-biochemical parameters of males and females of the diabetic,
prediabetic and non diabetic strokes
Stroke Type
AGE
(Yrs)
62.2±8.7
BMI
(kg/m2)
25.9±3.6
TC
(mg/dl)
174.3±26.7
TG
(mg/dl)
153.2±58.5
HD
(mg/dl)
39.8±7.8
LD
(mg/dl)
127.9±22.8
n-HC
(mg/dl)
134.5±28.7
56.1±12.1
23.1±3.7
182.3±24.8
156.9±37.1
37.5±5.8
135.1±30.9
0.18
0.09
0.5
0.88
0.5
PDm-m n=9
I:H= 6:3
PDm-F n=5
I:H= 3:2
P value
63.3±8.7
25.2±3.9
175.4±28.1
143.1±39.7
66.8±8.9
28.4±3.5
190.6±52.9
156.4±40.8
0.27
0.15
0.64
0.6
0.07
0.4
0.83
0.9
0.38
0.85
NDm-m n=8
I:H= 4:4
NDm-F n=6
I:H= 4:2
P value
54.8±4.1
26.5±2.02
172.8±33.4
160.6±56.6
46.3±13.5
109.4±32.8
126.5±37.5
0.91±0.5
0.76±0.07
0.83±0.11
67.3±7.9
24.8±1.97
207.5±45.3
169.7±82.4
45.2±9
134.3±43.7
153.2±53.3
1.54±1
0.94±0.16
0.88±0.14
0.004*
0.17
0.15
0.82
0.88
0.3
0.18
0.43
0.95
0.96
Dm-m n=17
I:H= 13:4
Dm-F n=8
I:H= 2:6
P value
IR
3.3±2.1
CTR
(mm)
0.9±0.17
CTL
(mm)
1.01±0.26
144.8±27.2
3.2±2.4
0.84±0.11
0.85±0.16
0.92
0.53
0.92
0.39
0.13
40.6±5.7
122.3±35.8
134.9±27.2
1.7±1.3
0.91±0.17
0.88±0.14
37.4±7.2
127.2±47.2
153.2±53.3
1.54±1
0.94±0.16
0.88±0.14
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, yrs- years,m- male, F- female, I- infarct, H- haemorrhage, bmI- body mass
index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance level, n-HC- non HDL cholesterol,
Ctr- carotid intimo-medial thickness of the right side, CtL- carotid intimo-medial thickness of the left side, p- p value of t test, n- number of
patients, * = significant p value
the measurements were done in the posterior (far) wall at three
places (i.e. common carotid artery: 20 to 60 mm proximally from
the flow divider; carotid bulb: 0 to 20 mm distally from the flow
divider; and carotid artery bifurcation: 0 to 20 mm proximally
from the flow divider) at zones free of plaques.16 these three
measurements were averaged on either side (left and right
carotid) and the mean values were taken separately for either
side.16,6 the images were digitally captured during the systole of
a single heartbeat (eCG r wave gated) and measurements were
performed offline for each area.16
serum lipids (tC, tG, LD and HD - directly measured and
n-HC calculated) and blood glucose were measured by auto
analyzer and serum insulin by eLIsA (monobind Corporation).
Insulin resistance was assessed by using the previously validated
homeostasis model assessment for insulin resistance, calculated
from the fasting insulin and glucose concentrations according
to the formula: HOmA-Ir = [(insulin × glucose)/22.5].17 HbA1c
was estimated by Boronate affinity chromatography (Bio-Rad
micromat-2). statistical analysis was done by student’s t test
and Pearson’s correlation co-efficient (SPSS Version 14.0). A p
value of ≤ 0.05 was considered significant.
Results
A total of 29 consecutive patients of stroke in known t2Dm
were collected; 4 could not complete the total investigations - the
study was done with 25 patients of t2Dm. In the NDm subgroup
the total number at inclusion was 14 and 17 were found to be
PDm (3 could not complete the study). the Dm strokes had 40%
smokers and the other 2 groups had 37.5% each - all were males
without any significant inter group difference in prevalence.
© JAPI • sePtember 2012 • VOL. 60
29
table 1 : the age, bmI, and sex ratio were matched and the
Table 4 : Status of the right and left CIMTs : Level of
correlation and difference in their mean values of each
stroke type and their sub groups
Stroke Type
Dm
PDm
NDm
Dm-I
PDm-I
NDm-I
Dm-H
PDm-H
p -values
r= - 0.03
p=0.89, p(t)=0.18
r=0.27
p=0.24, p(t)=0.9
r=0.38
p=0.18, p(t)=0.07
r=0.57
p=0.02*, p(t)=0.54
r=0.43
p=0.025*, p(t)=0.78
r= -0.1
p=0.81, p(t)=0.13
r= -0.54
p=0.11, p(t)=0.24
r= -0.05
p=0.94, p(t)=0.57
Stroke Type
NDm-H
Dm-m
PDm-m
NDm-m
Dm-F
PDm-F
NDm-F
-
p -values
r=0.87
p=0.02*, p(t)=0.36
r= -0.02
p=0.5, p(t)=0.14
r=0.18
p=0.64, p(t)=0.66
r=0.82
p=0.01*, p(t)=0.18
r=0.25
p=0.55, p(t)=0.87
r=0.46
p=0.01*, p(t)=0.74
r=0.3
p=0.56, p(t)=0.26
-
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic
stroke,m- male, F- female, I- infarct, H- haemorrhage, CImts- carotid
intimo-medial thickness of the right and left sides, p(t)- p value of
t test, r= correlation coefficient, p= p value of the correlation, * =
significant p value
incident lipid parameters differed little among the groups; only
HD was significantly higher in NDM. The mean CIMTR values
were significantly higher in both DM and PDM compared to
NDM; however, DM and PDM did not differ. There was no
difference between the three groups for CIMTL. The IR status
was significantly higher in DM compared to both PDM and
NDM, but NDM and PDM did not differ.
table 2 : In intra group analysis of the parameters between
infarct and haemorrhage none of the parameters differed except
tG which was higher in Dm haemorrhage. In case of infarcts
of all groups both the CImts were higher in Dm compared to
NDM only, though the only the right side was highly significant
(p=0.009) the left only expressed a higher trend (p=0.06). In case
of haemorrhage none of the CIMT values differed for either side
(p value ranged from 0.067 to 0.73).
table 3 : In intra group analysis of the parameters between
males and females the study parameters showed no significant
difference except that the NDM females had higher mean age
compared to their males. though none of the females were
smokers they had a similar CImts as the males. the CImtrs of 3
glycemic varieties of strokes when compared among the males, it
was significantly higher in PDM (p= 0.04) and DM (p=0.05) with
respect to NDM, though the there was no difference between
PDM and DM (p=0.86). The CIMTL values did not differ, p=0.2
(Dm Vs PDm), 0.08(Dm Vs NDm) and 0.5 (PDm Vs NDm). both
the CImts did not vary in case of females of the three glycemic
Table 5 : CIMTR correlations of the risk factors
Types
Dm
PDm
NDm
Dm-m
PDm-m
NDm-m
Dm-F
PDm-F
NDm-F
Dm-I
PDm-I
NDm-I
Dm-H
PDm-H
NDm-H
Age
r= 0.29
p=0.16
r= 0.49
p=0.13
r= 0.13
p=0.7
r= 0.02
p=0.95
r= 0.24
p=0.54
r=-0.04
p=0.9
r= 0.87*
p=0.005
r= 0.71
p=0.18
r= -0.31
p=0.5
r= 0.14
p=0.62
r= 0.45
p=0.2
r= 0.45
p=0.2
r= 0.31
p=0.77
r= 0.24
p=0.7
r= 0.24
p=0.7
BMI
r =0.008
p =0.97
r =0.28
p =0.3
r = 0.3
p =0.3
r=-0.03
p =0.9
r = 0.3
p =0.4
r= 0.33
p=0.43
r=-0.17
p =0.7
r =0.8
p =0.1
r = 0.34
p =0.5
r =0.16
p =0.57
r =0.4
p =0.28
r = 0.26
p =0.52
r =-0.3
p =0.4
r = -0.2
p =0.7
r =0.34
p =0.52
TC
r =0.1
p =0.62
r =0.46
p =0.09
r =-0.28
p =0.34
r =-0.07
p =0.8
r =-0.06
p =0.88
r =-0.34
p =0.42
r =0.85*
p =0.008
r =0.92*
p =0.03
r =-0.29
p =0.57
r =-0.15
p =0.6
r =0.54
p =0.14
r=-0.026
p =0.96
r =0.58
p =0.08
r =0.32
p =0.6
r =-0.4
p =0.38
TG
r =0.1
p =0.63
r =0.5
p =0.07
r =-0.07
p =0.82
r =0.02
p =0.95
r =0.15
p =0.7
r =0.02
p =0.96
r =0.6
p =0.1
r =0.96*
p =0.01
r =-0.16
p =0.77
r =0.32
p =0.25
r =0.83*
p =0.006
r =-0.37
p =0.36
r =0.3
p =0.4
r =-0.27
p =0.66
r =0.54
p =0.27
HD
r= 0.17
p= 0.4
r= 0.14
p=0.63
r=0.49
p=0.07
r= 0.2
p=0.97
r= -0.04
p=0.9
r= 0.36
p=0.38
r= -0.05
p=0.9
r= 0.14
p=0.82
r= 0.78
p=0.07
r=0.35
p=0.2
r= 0.63
p=0.07
r= 0.43
p=0.28
r=-0.2
p=0.6
r= -0.51
p=0.4
r=0.54
p=0.26
LD
r =0.13
p =0.54
r =0.42
p =0.14
r=-0.42
p =0.13
r =0.09
p =0.7
r=-0.03
p =0.93
r =-0.4
p =0.32
r =0.33
p =0.43
r =0.85
p =0.07
r =-0.57
p =0.3
r =0.06
p =0.8
r =0.27
p =0.48
r =-0.26
p =0.54
r =0.31
p =0.4
r =0.57
p =0.3
r=-0.61
p =0.2
n-HC
r =0.05
p =0.81
r =0.4
p =0.1
r =-0.38
p =0.18
r =-0.1
p =0.7
r =-0.05
p =0.9
r =-0.43
p =0.29
r =0.78*
p =0.02
r =0.9*
p =0.037
r =-0.4
p =0.4
r =-0.23
p =0.4
r =0.4
p =0.2
r =-0.13
p =0.76
r =0.63*
p =0.05
r =0.39
p =0.52
r =-0.57
p =0.24
IR
r= 0.11
p=0.59
r= -0.1
p=0.65
r= -0.34
p=0.25
r= -0.08
p=0.75
r= -0.31
p=0.43
r= -0.24
p=0.59
r= 0.68
p=0.06
r= 0.23
p=0.71
r= -0.47
p=0.35
r= 0.14
p=0.62
r= -0.07
p=0.87
r= -0.08
p=0.82
r=0.14
p=0.7
r= -0.23
p=0.87
r= -0.4
p=0.38
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, CImtr- CImt of the right side, yrs- years,m- male, F- female, I- infarct,
H- haemorrhage, bmI- body mass index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance
level, n-HC- non HDL cholesterol, CIMT- carotid intimo-medial thickness, r= correlation coefficient, p= p value of the correlation, * = significant p
value
© JAPI • sePtember 2012 • VOL. 60
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Table 6 : CIMTL correlations of the risk factors
Types
Dm
PDm
NDm
Dm-m
PDm-m
NDm-m
Dm-F
PDm-F
NDm-F
Dm-I
PDm-I
NDm-I
Dm-H
PDm-H
NDm-H
Age
r=0.33
p=0.1
r= -0.02
p=0.95
r= -0.16
p=0.6
r= 0.45
p=0.07
r= -0.38
p=0.32
r= -0.25
p=0.6
r= -0.11
p=0.8
r=0.65
p=0.24
r= -0.2
p=0.7
r=0. 56*
p=0.03
r= -0.17
p=0.7
r= 0.15
p=0.7
r= 0.18
p=0.54
r= 0.16
p=0.8
r= -0.18
p=0.7
BMI
r = 0.25
p =0.24
r = 0.34
p =0.24
r = 0.2
p =0.5
r =0.19
p =0.48
r = 0.25
p =0.53
r =0.34
p =0.43
r =0.08
p =0.86
r =0.08
p =0.87
r = 0.1
p =0.8
r = 0.03
p =0.9
r = 0.1
p =0.8
r =0.36
p =0.38
r = 0.4
p =0.25
r =0.87
p =0.06
r = 0.11
p =0.83
TC
r =-0.2
p =0.3
r =0.78*
p =0.001
r =-0.29
p =0.32
r =-0.31
p =0.2
r =0.7*
p =0.055
r =-0.38
p =0.35
r =0.2
p =0.58
r =-0.24
p =0.65
r =0.88*
p =0.002
r =-0.98*
p =0.02
r =0.88*
p =0.002
r =0.22
p =0.6
r =-0.001
p =0.99
r =0.86
p =0.06
r =-0.61
p =0.2
TG
r =0.02
p =0.93
r =0.67*
p =0.009
r =0.25
p =0.4
r =0.05
p =0.86
r =0.42
p =0.26
r =-0.11
p =0.8
r =-0.05
p =0.9
r =0.63
p =0.18
r =0.6
p =0.09
r =-0.13
p =0.64
r =0.6
p =0.09
r =0.3
p =0.47
r =0.12
p =.74
r =0.9*
p =0.04
r =0.21
p =0.69
HD
r =0.07
p=0.7
r =0.2
p=0.48
r = 0.013
p=0.97
r = 0.16
p=0.54
r = 0.18
p=0.65
r =0.34
p=0.41
r = -0.57
p=0.14
r = -0.72
p=0.11
r = 0.32
p=0.4
r =0.21
p=0.40
r =0.32
p=0.4
r = -0.67
p=0.07
r =-0.05
p=0.89
r =0.03
p=0.96
r = 0.47
p=0.35
LD
r =-0.01
p =0.96
r =0.79*
p =0.001
r =-0.18
p =0.54
r =-0.09
p =0.7
r =0.84*
p =0.003
r =-0.45
p =0.27
r =0.35
p =0.4
r =0.1
p =0.8
r =0.82*
p =0.006
r =-0.04
p =0.9
r =0.82*
p =0.006
r =0.26
p =0.53
r =0.01
p =0.97
r =0.8
p =0.12
r =-0.68
p =0.13
n-HC
r =-0.2
p =0.29
r =0.75*
p =0.002
r =-0.27
p =0.36
r =-0.33
p =0.2
r =0.69*
p =0.04
r =-0.46
p =0.25
r =0.34
p =0.42
r =-0.09
p =0.87
r =0.87*
p =0.002
r =-0.6
p =0.03
r =0.87*
p =0.002
r =0.35
p =0.39
r =0.01
p =0.98
r =0.85
p =0.07
r =-0.71
p =0.1
IR
r= 0.43*
p=0.03
r= 0.33
p=0.42
r= -0.42
p=0.13
r= 0.39
p=0.23
r= 0.48
p=0.19
r= -0.58
p=0.14
r= 0.68
p=0.06
r= 0.02
p=0.97
r= -0.34
p=0.51
r= 0.16
p=0.57
r= 0.46
p=0.22
r= 0.13
p=0.76
r= 0.63*
p=0.05
r= 0.01
p=0.98
r= -0.8
p=0.06
Dm- diabetic stroke, PDm prediabetic stroke, NDm- non diabetic stroke, yrs- years CImtL- CImt of the right side,m- male, F- female, I- infarct, Hhaemorrhage, bmI- body mass index, tC- total cholesterol, tG- triglyceride, HD- HDL cholesterol, LD- LDL cholesterol, Ir- insulin resistance level,
n-HC- non HDL cholesterol, CIMT- carotid intimo-medial thickness, r= correlation coefficient, p= p value of the correlation, * = significant p value
varieties of stroke (CImtr p value was = 0.84, 0.21, 0.53 and
CImtL p value was = 0.92, 0.79 and 0.72 respectively for Dm Vs
NDm, Dm Vs PDm and PDm Vs NDm).
table 4 : the mean values of the right and left CImt did not
differ amongst the 3 groups as well as their stroke types and
gender types. However there was significant variation in their
correlations. the right – left correlation was worst in Dm and
best in NDM. It was significantly positive in cases of DM infarcts,
PDm infarcts and females, and NDm males and haemorrhage.
table 5 and 6 : Age had predominantly positive correlation
for the right side, being significant only in DM females; it was
more variable for the left side and significantly positive in DM
infarcts only. bmI correlated positively in nearly all groups of
both the sides but was weakest in Dm for the right side and best
in PDM haemorrhage for the left side, but none were significant.
the Ir correlations were predominantly negative for the right
side and none were significant; it was predominantly positive for
the left side being significant only in DM and DM haemorrhage
subgroup.
Correlations of total cholesterol were variable and
predominantly negative for both the CIMT, being significantly
positive in females of Dm, total PDm and PDm infarcts for
CImtr, and total PDm, infarcts of Dm and PDm for CImtL.
triglyceride levels predominantly had a positive correlation for
both CImts, especially in females and infarcts of PDm for the
right side, and PDm and its haemorrhage subgroup for the left.
LDL had a variable correlation with both side CImts but it was
significantly positive in total PDM, PDM males and infarct and
NDm females for the left side only. the HDL cholesterol had a
predominantly positive correlation with both the sides but was
never significant. For n-HC the relations were predominantly
variable for both CIMTs though it was significantly positive in
the females of Dm and PDm and haemorrhage subgroup of
Dm on the right side and PDm group and its male and infarct
subgroups, as well as Dm infarcts and NDm females for the
left side.
Discussion
the common non-invasive markers of sub-clinical and
clinical atherosclerosis include AbPI (ankle brachial pressure
index), CIMT, and AoIMT (aortic intimo medial thickness), flow
mediated brachial artery dilatation and the number and volume
of carotid plaques.18 A CImt of less than 0.55 mm and AoImt
of less than 3 mm have been found to be excellent markers of
the absence of macrovascular abnormalities, especially coronary
artery disease. 18 Higher CImt is more commonly associated with
diabetic strokes, irrespective of the gender and stroke type.19
the status in patients of pre-diabetes is not very conclusive.20
In general, due to anatomic reasons, the left side is known to
suffer more shear stress and so it is more likely to have a higher
CImt than the right.21,8 CImts at all arterial sites may predict
future vascular events to almost the same level.15 However, each
site may have a different progression profile, so a composite of
3 sites was used in our study.22
© JAPI • sePtember 2012 • VOL. 60
In our study, CIMTs of all varieties of stroke were significantly
higher than non –stroke historical controls.7,15 In the three groups
of patients, incidents CImts were higher in Dm strokes, though
predominantly on one side. Predominance of CImtr in Dm was
probably related to the stroke side circulation (more patients in
our study population had a stroke in the right side circulation,
especially in Dm).8 the right and left CImt correlation was most
variable in Dm - possibly signifying a more altered vascular
anatomical remodelling in Dm. Insulin resistance was the only
risk marker that was significantly increased in DM and also
expressed better correlation with the incident CIMTs though
more on one side (left); the relation was least congruous in
non-diabetic strokes. 23, 11 the age of the patient also had a
better correlation with the CIMT status in diabetics (left side)
than the others.24 the Ir level and age of the patient probably
plays some role in CImt status modulation in Dm, while it of
lesser significance in PDM and NDM. 11 the incident lipids were
similar in the three groups; however they correlated best with
the CImt status only in PDm.20 bmI had a positive relation with
the CImts in all, but it was worst in Dm (the right side); its role
in Dm may be questionable.9,10
In intra group analysis of Dm strokes, though females were
non-smokers and hemorrhagic stroke is supposed to have a
different mechanism, they had similar CIMTs and IR status as
males and infarcts. the CImt increments were more uniform
and better related to the IR status in the females while it was age
in males; more so, for the left side.25,24 the bmI may have some
impact in infarcts only.11 Females are probably more predisposed
to have a higher CImt once they are in the post menopausal
state where the usual protection related to female gender is lost.9
there was a poor relation of the CImts in hemorrhage (though
females predominated) but it was better in infarcts indicating a
more uniform vascular remodelling in them; however, the CImt
versus IR correlations were better in hemorrhagic stroke (left
side). the correlation of age was positive in both stroke types but
it was better in cases of infarct (left side).9 the lipid correlations of
the CIMTs were highly variable but were better in females and in
case of hemorrhagic stroke.23 though the mean age, CImts, bmI,
lipids and IR status varied little between the stroke types and
the genders, there was significant variability in their individual
relation with the CImt status as well as the congruity of the
two side CImts, being more congruous in females and infarct.
In intra group analysis of NDm strokes, the mean study
parameters did not vary between the genders as well as the
stroke types. Females were non-smokers and of a significantly
higher mean age, but they had similar CImts as males. Ir status
correlations were poor in the genders and stroke types except
in haemorrhage for CImtL. the uniformity of the right-left
CIMTs were significant in males and haemorrhage than infarct
and females, this was in absolute contrast to both Dm and PDm
strokes.15,16 In contrast to Dm and PDm, incident Ir status and
age had little relation with CIMTs.8,9 the lipid correlations of
CImts were worst compared to both Dm and PDm.8,9 the bmI
correlations were better than both DM and PDM. The CIMTs in
non-diabetics are probably more associated with the tensile wall
stress than altered intimo-endothelial vascular physiology; Ir,
age and lipids play little role, BMI may be more important.26,21
In intra group analysis of PDm strokes, there was no
difference in the mean study parameters between the genders
and stroke types. the right and left side CImt correlation was
significantly positive in females. Like the DM strokes, females
and haemorrhage had a similar CImt as males and infarct
respectively. similar to the Dm strokes, females and infarcts
31
had a more uniform two side CImt status. the Ir and age had
better relations with CIMTs in females compared to DM. Relation
of Ir status with the CImts were variable in the stroke types,
being better for the left side in both. Impact of age was variable
in infarct but better in haemorrhage. The CIMT correlations and
the IR with CIMT relations in the males were better than in DM,
and the impact of age less pronounced except in females. the
correlations of lipid status with the CIMTs were significantly
better in females and infarct than in DM; BMI also had a better
association than in Dm but for the right side only.1,19
At the time of stroke the CImts were higher in Dm and PDm
than NDm but were predominantly one sided (not uniform).8,21
the stroke side circulation CImt was most altered in diabetics,
while the incident risk markers often had a better correlation
with the non-stroke side.8,15,16 the CImt status and risk factor
association in pre-diabetics is distinctly different from both
diabetics and non-diabetics. 20 In major groups, especially
NDm, the mean CImt values were slightly higher on the left
side, probably reflecting the physiologic variation.21 Vascular
remodelling, as evidenced by the CImt status, was more
uniform in non-diabetic strokes than in Dm or PDm.27,21 the
significantly raised IR status is probably an important contributor
for the increased CImt status and or its variability in t2Dm.8
Though the mean CIMTs differed little between the genders and
stroke types of all the stroke groups, the right – left CImt level
variability was an important feature and most marked in Dm
and PDm (except in females and infarcts). the Ir correlations
of the CImts were best in Dm, followed by PDm and worst
in NDm; age correlations were similar while bmI associations
were reverse.10
Dyslipidemia was a common association of strokes of all
glycemic statuses, however the lipid correlations of the CImts
varied immensely; it had a consistent relation only in PDm.
Targeting lipids as an intervention tool might be effective only
in pre-diabetics; targeting all the atherosclerosis risk factors
together is probably the option in the others.28,21 In most
subgroups of the patients, non-HDL cholesterol had a negative
correlation (except in PDm) while HDL cholesterol (except in
Dm females and haemorrhage) had a positive relation with the
CImts; this in contrast to conventional thoughts.23
male diabetics and pre-diabetics are more prone to have
higher CImt values than their non-diabetic counterparts
irrespective of the stroke type.25 In females, along with the
conventional risk factors, the post menopausal state is probably
an important contributor for CImt alterations. though t2Dm
is not known to increase the risk of intracerebral parenchymal
haemorrhage and CImt is regarded as a non-invasive marker
of ischemic stroke in diabetics, the CImts were similar in both
infarcts and hemorrhagic strokes.26,4
CImt estimated by 2D UsG does not measure medial and
intimal thickness separately and therefore cannot distinguish
between medial remodelling as a result of an adapted response
to tensile (hypertensive) stress, and intimal thickening which is
primarily indicative of atherosclerosis.29-31 estimation of plaque
number or volume by the 3D USG is probably a better indicator
of the atherosclerosis burden than the CImt at plaque free
zones.32,6 However, diffuse CIMT increments are known to be
predictive for plaque formation.6,17 Genetic or other acquired and
less measured factors might be more important in this regard.3,10
CImt regression might not be a prerequisite for reducing
events in t2Dm as it is only a measure of focal abnormality (not
circumferential) and acute changes like spastic vasoconstriction
© JAPI • sePtember 2012 • VOL. 60
32
or plaque rupture cannot be reflected.3,5,10 There is also significant
variation in the methodology of assessment as well as the values
of CImt.30 Whether CIMT increment is a modifiable risk factor
with improved survival benefit, is still not known.25,33 Larger
studies including less measured risk variables and stroke side
circulation status might be helpful.13,27,30
17.
Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF,
turner rC. Homeostasis model assessment: insulin resistance and
beta-cell function from fasting. Diabetologia 1985;28:412-9.
18.
belhassen L, Carville C, Pelle G, monin JL, teiger e, Duval-moulin
Am et. al. evaluation of carotid artery and aortic intima-media
thickness measurement for exclusion of significant coronary
atherosclerosis in patients scheduled for heart valve surgery. J Am
Coll Cardiol 2002;39:1139-44.
19.
brohall G, Oden A, Fagerberg b: Carotid artery intima-media
thickness in patients with type 2 diabetes mellitus and impaired
glucose tolerance: a systemic review. Diabet Med 2006;23:609-616.
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