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International Journal of ChemTech Research CODEN (USA): IJCRGG, ISSN: 0974-4290, ISSN(Online):2455-9555 Vol.10 No.3, pp 465-470, 2017
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Cerebral Computed Tomography CT angiography findings in Iraqi patients presenting with stroke
Fizel Abbas Himyari1, Wisam Saeed Taj-Aldeen*1, Zaid Hadi Al Kfaji 1
1Associate Professor of Neurology and Interventional Neuroradiology, University of Babylon-College of Medicine, Babylon city –Iraq
Abstract : Background: Variance in the distribution of cerebral atherosclerosis in different races is thought to be a result of differences in vascular risk factor profiles, lifestyles, and genetic susceptibility.
Aim of study: Aimed to investigate the risk factor stratification of intra and extra cranial vascular stenoses in Iraqi patients with different distributions of cervicocerebral lesions.
Patients and Methods: A prospective study enrolled 54 patients with acute stroke ,they were in Babylon-Iraq during a period between December 2014 and Oct. 2016.They were divided in to two groups according to the type of stoke (ischemic and non ischemic or haemorrhagic) then the ischemic group divided in to two groups according to the site of stenosis of cervicocerebral arteries ( extracranial and intracranial) ,then comparison of age , gender, risk factors and severity with site of lesions was done between the extracranial and intracranial groups. All the Patients underwent multi-slice CT angiography of cartid and cerebral arteries using a 64-slice helical CT, lesions ≥ 50% stenosis were considered significant. Patients with clear embolic source has been excluded from the study. P-value < 0.05 had statistical significance.
Results: This study had enrolled 54 patients with acute stroke the mean of their ages is 49.1± 16 years 34 patients(62.9%) were male, 20 patients(37.1%) were female ,47 patients(87%) were diabetics, 42 patients(77.7%) were hypertensive, and 37 patients(68.5%) were smokers . Forty four patients(81.5%) with ischemic stroke and 10 patients(18.5%) with non ischemic stroke. DM, hypertension and smoking are proved statistically as risk factors in Iraqi patients with ischemic stroke. Thirty eight patient(86%) of ischemic group have cervicocerebral lesions from which 26 patients(59%) extracranial and 12 patients(27%) intracranial p value <0.05, from those(ischemic group) 10 patients(22.7%) with extracranial significant stenosis and 4 patients (9%) with intracranial significant stenosis T value 1.5667, p value 0.04.There is no difference in risk factors between intracranial and extracranial lesions.
Discussion and conclusion: This study proves that Iraqi peoples are susceptible to develop stroke whether ischemic or hemorrhagic at ages younger than other Asian peoples and European peoples which may be related to racial cause or related to Iraqi dietary habit which is high salt and high fat in addition to Iraqi sedentary lifestyle , also this study prove that diabetes mellitus, hypertension and smoking are risk factors to ischemic stroke, and extracranial cervicocerebral arterial stenosis are more common than intracranial lesions. So we recommend Iraqi people to give special attention to low salt low fat diet with regular sport and smoking cessation with good control of DM and hypertension.
Key words: Cerebral Computed Tomography, CT angiography, stroke, Iraqi patients.
Introduction :
Racial differences in location of lesions in cerebrovascular occlusive disease have been reported between white, black, Japanese, and Chinese persons(1-8). Variance in the distribution of cerebral atherosclerosis
in different races is thought to be a result of differences in vascular risk factor profiles, lifestyles, and genetic susceptibility(9-11). Improving our understanding of the risk factors contributing to cervicocerebral lesios in Asians with ischemic stroke is critical for the development and implementation of appropriate treatment strategies. While several vascular risk factors have been identified in cervicocerebral stenosis(9,12-14.) these risk factors have varied among studies, possibly due to differences in study populations and methodologies.
Aim of the study:
We aimed to investigate the risk factor stratification of intra and extra cranial vascular stenoses in Iraqi patients with different distributions of cervicocerebral lesions.
Patients and method :
This is a prospective study enrolled 54 patients with acute stroke they were selected from those who underwent carotid and cerebral CT angiography at the radiology unit of Shaheed Al-Mehrab cardiac center in Babylon-Iraq during a period between December 2014 and Oct. 2016.They were divided in to two groups according to the type of stoke (ischemic and non ischemic or haemorrhagic ) then the ischemic group divided in to two groups according to the site of stenosis of cervicocerebral arteries ( extracranial and intracranial). Comparison of age , gender, risk factors and severity with site of lesions was done between the extracranial and intracranial groups. Detailed history and thorough physical examination had been performed for each patient included in this study, and all Patients underwent multi-slice CT angiography of carotid and cerebral arteries using a 64-slice helical CT, lesions ≥ 50% stenosis were considered significant(15-20). Patients with clear embolic source has been excluded from the study.
Statistical analysis had been done using student's t-test. P-value less than 0.05 had statistical significance.
Results:
This study had enrolled 54 patients with acute stroke the mean of their ages is 49.1± 16 years 34 patients(62.9%) were male, 20 patients(37.1%) were female ,47 patients(87%) were diabetics, 42 patients(77.7%) were hypertensive, and 37 patients(68.5%) were smokers .as shown in table1. Forty four patients(81.5%) with ischemic stroke and 10 patients(18.5%) with non ischemic stroke as in figure1.
Table 1:Characteristics of total number of stoke patients involved in the study.
Character |
Total number |
Age, mean ± SD ( year) |
gender |
Risk factors |
|||
male |
female |
DM |
Hypertension |
smokers |
|||
Number |
54 |
49.1 ± 16 |
34 |
20 |
47 |
42 |
37 |
Percent % |
100 % |
|
62.9% |
37.1 % |
87 % |
77.7 % |
68.5 % |
And by comparing the ages, gender, and risk factors(DM , hypertension and smoking) of ischemic and non ischemic group the statistical analysis shows that there is significant difference as shown in table 2.
Table 2:comparison of characteristics of ischemic and non ischemic group.
Type of stroke |
Age ( y) mean± SD |
Gender |
DM |
Hypertension |
smokers |
|
male |
female |
|||||
ischemic |
52.8±13 |
29(66%) |
15 (34%) |
39 (88%) |
37(84%) |
33(75%) |
Non ischemic |
32.8±18 |
5(50%) |
5(50%) |
8(80%) |
4(40%) |
5(50%) |
P value |
P value < 0.05 |
Thirty eight patient(86%) of ischemic group have cervicocerebral lesions from which 26 patients(59%) extracranial and 12 patients(27%) intracranial p value <0.05(significant) as shown in table3, from those(ischemic group) 10 patients(22.7%) with extracranial significant stenosis and 4 patients (9%) with intracranial significant stenosis T value 1.5667, p value 0.04 (statistically significant)as shown in table 4.
Table 3: Distribution of cervicocerebral arterial lesions according to site and significance in ischemic stroke patients:
location |
Left significant |
Left non significant |
Right significant |
Right non significant |
Bilateral significant |
Bilateral non sig. |
Total |
Extra- cranial |
4 |
4 |
4 |
7 |
2 |
5 |
26(59%) |
Intra-cranial |
0 |
0 |
2 |
3 |
2 |
5 |
12(27%) |
Total |
4 |
4 |
6 |
10 |
2 |
5 |
38(86%) |
P value <0.05 |
Table 4:Distribution of cervicocerebral arterial significant lesions* in ischemic stroke patients:
location |
Left cervicocerebral |
Right cervicocerebral |
Bilateral |
total |
extracranial |
4 |
4 |
2 |
10 (22.7%) |
intracranial |
0 |
2 |
2 |
4(9 %) |
T value 1.5667 p value 0.04 |
*Significant lesion ≥50% stenosis (15-20)
By comparing the characteristics of stroke patients with extracranial and intracranial lesions there are no statistically significant differences between the two groups regarding their ages, gender, hypertension, diabetes or smoking as shown in table 5.
Table 5:Comparison between the characteristics of patients with extracranial and intracranial significant lesions:
Character |
Age ( y) mean± SD |
Gender |
DM |
Hypertension |
smokers |
|
male |
female |
|||||
Extra-cranial |
58.9±4.9 |
6(60%) |
4(40%) |
9(90%) |
9 (90%) |
8( 80%) |
Intra-cranial |
59.7±5.5 |
3(75%) |
1(25%) |
4(100%) |
3(75%) |
3(75%) |
P value is non significant to all risk factors |
Discussion:
The spatial resolution of CT is continuously improving, resulting in a current 64-slice multi-detector CT. Recently, the dual-source multi-detector CT (DSCT) was released, further improving the temporal resolution. Studies evaluating the accuracy of DSCT in the detection of significant stenosis shows high sensitivity and specificity on a per segment, vessel, or patient level.(21) .Many studies shows the CT angiography results are comparable to MR angiography results(22). So we depended on the results of CT angiography in our study to determine the type of stroke and the distribution of cervicocerebral arterial stenosis in Iraqi patients presented with acute focal neurological deficit.
This study enrolled 54 Iraqi patients with acute stroke, the results of cerebral CT angiography shows 81.5% ischemic and 18.5% is hemorrhagic and these percentages are nearly comparable to results of Andersen et al study(23) but by comparing the ages of ischemic and non ischemic group there is significant difference i.e. non ischemic group younger and generally the Iraqi patients are younger than Denmark's patients who were studied by Andersen et al(23), and Taiwanese patients who were studied by Sung et al(24) and this difference in age may be related to racial origin or dietary habit of Iraqi people who tend to take high salt and high fat diet in addition to sedentary life style. This study shows that diabetes mellitus, hypertension and smoking are proved risk factors to ischemic stroke patients and these results are comparable to Sung et al study(24), and we had proved in another study done in the same center to Iraqi patients that coronary artery disease and hyperlipidemia are also risk factors to ischemic stroke(25). By studying the distribution of stenoses of cervicocerebral arterial system in ischemic group we found 22.7% of patients has extracranial significant stenosis in either carotid ,vertebral or basilar artery and this result is nearly comparable to results of Hon-Man et al study(26)in which the extracranial stenosis was 24% In Iraqi patients total(significant and non significant) extracranial stenosis is 59% which is not comparable to Horowitz et al study in which total extracranial stenosis is 39% (27). The intracranial total abnormalities in our study is 27% which is comparable to Hon-Man et al study which is 25.9% . Concerning the risk factors comparison in extracranial and intracranial group, our study shows that diabetes mellitus, hypertension and smoking all are risk factors to both group as the results of sung et al study(24).So in Iraqi patients the extracranial lesions more common than intracranial lesions and this might lead us to do cerebral angiography as intervention and stenting of extracranial lesions is easier than intracranial
lesions because extracranial lesions are large caliber arteries , easily reachable and usually are not preceded by high tortuous vessels .
Conclusions:
Recommendations:
We recommend and advice the smokers of Iraqi patients to complete abstinence of smoking .Special attention should be given to control the blood pressure and blood sugar in hypertensive and diabetic patients .Also we recommend cerebral angiography and intervention to people with undisabling stroke .
References :
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Extra page :
وتائج المفزاص الحلشوو للعىك والذماغ للمزضى العزال هٍٍ الذ هٌ عٌاوىن مه الطارئة الىعائ ةٍ الذماغ ةٍ)الجلطة الذماغ ةٍ(
دراست بٛاسطت:
د. فاضل عباص الحم زٍي أخصائ أمزاض الجهاس العصب , بىرد أمزاض عصب هٍ
د. وسام سع ذٍ عباص تاج الذ هٌ أخصائ أمزاض الملب , بىرد أمزاض باطى ةٍ , بىرد أمزاض للب ةٍ
د. س ذٌ هادي الخفاج أخصائ الأشعة التشخ صٍ ةٍ والعلاج ةٍ بىرد أشعة
الخلاصة:
خلف ةٍ المىضىع:ا خٌع ١ماث ا ٌّٛخٛدة فٟ شزا ١٠ ا ؼٌ كٕ ٚا ذٌ اِؽ حخٛسع داخ ٚخارج ا مٌحف لذ ٠ىٛ ػ ٍٝ أساص ػزلٟ ٚلذ ٠زحبػ بؼٛا خطٛرة ثِ داء ا سٌىزٞ , ارحفاع ظغػ ا ذٌ , ا خٌذخ ١ اٚ ػّٔ ا حٌ ١اة
الغزض مه الذراسة : ذٌراست ػٛا ا خٌطٛرة ٚ ذِٜ حأث ١ز ا٘ ػ ٍٟ حٛس ٠غ حع ١ماث شزا ١٠ ا ؼٌ كٕ ٚا ذٌ اِؽ داخ ٚخارج ا مٌحف زٌٍّظٝ ا ؼٌزال ١١ ٠ؼا ٛٔ ا طٌارئت ا ٌٛػائ ١ت ا ذٌ اِغ ١ت )ا دٌ طٍت ا ذٌ اِغ ١ت(. ا ذٌ ٠
طزق الذراسة :دراست اسخبال ١ت حع جّٕ 45 زِ ٠ط ػزالٟ ٠ؼا ٛٔ خ طٍت د اِغ ١ت حادة فٌٍخزة وا ٛٔ اٚي 4105 إ ٌٝ وا ٛٔ أٚي 4104 ح حمس ١ ّٙ إ ٌٝ دِ ّٛػخ ١ حسب ٛٔع ا دٌ طٍت إ ٌٝ حصبٍ ١ت ٚ شٔف ١ ٚح جّ ا مٌّار تٔ ب ١ ٕٙ اّ ٚث ح حمس ١ ا دٌّ ّٛػت ا خٌصبٍ ١ت حسب ىِا حصبٍ % ا شٌزا ١٠ فٟ ا ؼٌ كٕ ٚا ذٌ اِؽ إ ٌٝ دِ ّٛػت داخ ا مٌحف ٚخارج ا مٌحف حسب خٔائح ا فٌّزاص ا حٌ شٍٚ ٟٔ ا ٌٍّٛ ٚح ا مٌّار تٔ ب ١ ٕٙ اّ ٚح اػخبار 41 ٚأوثز حع ١ما ِٙ اّ,
الىتائج: حع جّٕ ا ذٌراست 45 زِ ٠عا ٠ؼا ٛٔ خ طٍت د اِغ ١ت ٚوا ؼِذي أػ اّر 16 ±54 س تٕ ٚوا 94,4 % رخاي 1,,0 % سٔاء ٚوا 7, ٠ؼا ٛٔ داء ا سٌىزٞ ٚ %,,,, % ذٌ ٠ٙ ارحفاع ظغػ ا ذٌ 97,4 % ذِخ ٕٛ .ْ إ٘ن 70,4 % ذٌ ٠ٙ خ طٍت حصبٍ ١ت 07,4 % ذٌ ٠ٙ خ طٍت شٔف ١ ٚأثبخج ا ذٌراست إ داء ا سٌىزٞ ٚارحفاع ظغػ ا ذٌ ٚا خٌذخ ١ ٟ٘ ػٛا خٌطٛرة الإصابت با دٌ طٍت ا ذٌ اِغ ١ت ا خٌصبٍ ١ت, ٚ ِٕٙ ) دِ ّٛػت ا دٌ طٍت ا خٌصبٍ ١ت(44 % ذٌ ٠ٙ شزا ١٠ غ ١ز غب ١ؼ ١ت خارج ا مٌحف ٚ 4, % ذٌ ٠ٙ شزا ١٠ غ ١ز غب ١ؼ ١ت داخ ا مٌحف ٚ دِ ّٛػت خارج ا مٌحف إ٘ن 44,,% ذٌ ٠ٙ حع ١ماث ِٙ تّ )41 % أٚ أوثز( ٚ دِ ّٛػت داخ ا مٌحف 4% ذٌ ٠ٙ حع ١ماث ِٙ تّ ٚا فٌزق ب ١ ٕٙ اّ ِٙ إحصائ ١ا ٚف ١ اّ ٠خص ػٛا ا خٌطٛرة لا ٠ٛخذ فزق إحصائٟ ِٙ ب ١ دِ ّٛػت خارج ٚداخ ا مٌحف.
المىالشة والاستىتاجات : مٌذ أثبخج ذ٘ ا ذٌراست أ ا ؼٌزال ١ٛ ؼِزظٛ لٌإصابت با دٌ طٍت ا ذٌ اِغ ١ت سٛاء وا جٔ حصبٍ ١ت أٚ شٔف ١ فٟ أػ اّر اصغز مِار تٔ غِ بم ١ت ا ٌّٛاغ ٕٛ ا ٢س ١ٛ ٠ٛ ٚا ٌّٛاغ ١ٕ الأٚرب ١ٛ ٚ ذ٘ا لذ ٠ؼشٜ إ ٌٝ ػٛا ػزل ١ت أٚ ٠ىٛ بسبب ا ػٌّٕ ا غٌذائٟ ا ؼٌزلٟ ٚا ذٌٞ ٠حخٛٞ ٠ اّرسٛ ا زٌ ٠اظت بشى خِٕظ ل ١ٍ تٍ. ٚوذا هٌ أثبخج ا ذٌراست أ ػ ٍٝ سٔب ػا ١ٌت ا ذٌ ٛ٘ ٚالأ لِاذ بالإظافت إ ٌٝ إ ؼِذلاث ا ؼٌزال ١١ ا ذٌ ٠ إ٘ن دٚر ِٙ لإ زِاض ا سٌىزٞ ٚارحفاع ظغػ ا ذٌ بالإظافت إ ٌٝ ا خٌذخ ١ فٟ حصٛي ا دٌ طٍت ا ذٌ اِغ ١ت ذٌٜ ا ؼٌزال ١ٛ .ْ ٚإ حصبٍاث شزا ١٠ ا ؼٌ كٕ ٚا ذٌ اِؽ خارج ا مٌحف أوثز ِٕٙا داخ ا مٌحف.
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