Perspectives in Medicine (2012) 1, 164—166

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics — an Update.
Perspectives in Medicine (2012) 1, 164—166

journal homepage: www.elsevier.com/locate/permed

The association of carotid intima-media thickness

(cIMT) and stroke: A cross sectional study
Salim Harris

Neurovascular and Neurosonology Division, Neurology Department, Medical Faculty, University of Indonesia, Indonesia

KEYWORDS Summary
cIMT; Objective: To examine the carotid vessels in stroke and non stroke patients using carotid duplex
Stroke; ultrasonography.
Duplex Methods: The author used a cross-sectional approach among 259 patients who were divided into
2 groups: stroke and non-stroke patients. Noninvasive measurements of the intima and media
of the common carotid artery were performed with high-resolution ultrasonography to all the
patients in both groups.
Results: 259 patients, with age ranging from 31 to 75 years old, were divided into the Stroke
group (n = 131) and Non-Stroke group (n = 128). The author found abnormal IMT in both groups,
with an occurrence of 130 patients in the Stroke group, and 46 in the Non-Stroke group
(P < 0.001).
Conclusion: Increased intima and media thickness of the common carotid artery, measured
noninvasively by ultrasonography, are associated with cerebrovascular disease manifested as
stroke.
© 2012 Elsevier GmbH. All rights reserved.

Introduction of hypertension-induced atherosclerosis, blood vessels

Stroke is a cerebrovascular disease that results as an impact
of chronic diseases that induce pathological changes on
the cerebral vessels. Ischemic stroke is the most common
type of stroke with a prevalence rate of 85%. Ischemic
stroke pathophysiology can be acute such as occlusion by
emboli or chronic secondary to atherosclerosis. The early
stage of atherosclerosis is vessel injury induced by multi-
ple conditions that directly or indirectly injure the vessels.
Hypertension is the most common cause of vessel injury.
Hypertension or high blood pressure is a major risk factor
in stroke. It has a stepping gradient in inducing vessel dam-
age that lead to the vessels becoming stiff. In the process
E-mail address: dr salimharris@yahoo.co.id
become smaller in size, rigid and lose compliance. Elevated
blood pressure increases blood flow through the vessels. This
induces shear stress elevation that leads to an increase in
endothelial-derived relaxing factor (EDRF) production from
endothelial cells. This includes nitric oxide, prostaglandin
E and prostacyclin. These vasomotor activators induce the
superoxide production and reduce the vessels permeability.
The endothelial cells in the process of injury will release
increased amounts of pro-inflammatory cytokines that will
activate the leukocyte. This further induces the elevation
of vaso-active substances such as prostacycline and nitric
oxide which eventually induce complete endothelial injury.
The increase in intravascular pressure induces stress on
the vessel wall in hypertension. This alters the vessel wall
thickness through a process called vascular remodeling. Vas-
cular remodeling as a response to high blood pressure leads
to the reduction of the diameter of the blood vessel through

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The association of carotid intima-media thickness (cIMT) and stroke 165

hypertrophy (hypertrophic outer remodeling or hypertrophic

Table 1 Characteristics of the patients.
inner remodeling) or through a eutrophic inner remodeling
process. Characteristics Stroke group Non-stroke
Change in the common-carotid-artery intima—media (n = 131) group
thickness is believed to be an indicator of generalized (n = 128)
atherosclerosis. It has also been adopted as an interme-
diate end point for determining cardiovascular morbidity Mean age, y (SD) 58.17 (9.88) 55.15 (11.31)
and also as a surrogate end point to evaluate the success Male sex (%) 98 (37.84%) 83 (32.04%)
of lipid lowering drug interventions [4,5]. High-resolution Female sex (%) 33 (12.74%) 45 (17.37%)
carotid ultrasonography has been used to obtain measure- Hypertension (%) 88 (33.97%) 72 (27.80%)
ments of the thickness of the tunica intima and media Type-2 Diabetes (%) 43 (16.60%) 42 (16.21%)
of the carotid arteries. Studies in the western countries Dyslipidemia (%) 44 (16.98%) 40 (15.44%)
have shown not only cross-sectional correlations but also Smoking (%) 44 (16.98%) 34 (13.12%)
prospective correlations between common-carotid-artery A total of 259 patients (78 women and 181 men) were included
intima—media thickness and the prevalence of cardiovas- in our study. The study population was divided into two groups:
cular and cerebrovascular disease [1—3]. There are still few stroke patients (n = 131) and non-stroke patients (n = 128). The
studies showing an association between increased carotid- total mean age was 56.65 (10.70) years. Mean age was 58.17
artery intima—media thickness and stroke in Asia, especially (9.88) years old in the stroke group and 55.15 (11.31) years old in
the non-stroke group. There was no statistical difference among
in Indonesia. In this study, we investigated the hypothesis
the characteristics of the population across both groups, accord-
that carotid-artery intima—media thickness is directly cor- ing to sex, hypertension, type 2 diabetes melitus, dyslipidemia
related with the incidence of stroke. and smoking history.

Methodology
Table 2 The association between IMT and other risk factors
Subjects and study design with stroke.

The study subjects were patients in the Cipto Mangunkusumo Risk factor Stroke Non-stroke P
National Hospital, Jakarta, Indonesia with age ranging from Hypertension 88 72 0.07
31 to 75 years old. The patients were categorized into Type-2 Diabetes 43 42 0.99
2 groups, stroke and non stroke groups. There were 131 Dyslipidemia 44 40 0.68
patients in the stroke group and 128 patients in the non- Smoking 44 34 0.22
stroke group. The carotid arteries of all patients were IMT 97 75 0.008
evaluated using high-resolution B-mode ultrasonography
using a cross-sectional methodology. One longitudinal image
of the common carotid artery was acquired. Measurements
correlation between IMT and stroke. Using chi-square test
were made by readers blinded to all clinical information.
for statistical analysis, we found there were no statistical
The maximal rather than the mean intima—media thickness
difference between both group according to hypertension
was used as the key variable in determining the correlation
and smoking. We can therefore conclude that the correlation
between intima—media thickness and stroke. The maximal
of IMT and stroke were statistically significant (P = 0.008)
intima—media thickness of the common carotid artery is
(Table 2).
defined as the mean of the maximal intima—media thick-
ness of the near and far wall on both the left and right
sides. The intima—media thickness was called abnormal if Discussion
the thickness was more than 1 mm.
Many journals have previously reported on the positive cor-
Statistical analysis relation between cardiovascular risk factors and carotid
artery intima—media thickness, and the positive correla-
Statistical analysis was performed using the software pack- tion between carotid-artery intima—media thickness and
age SPSS for Windows 18.0. Association of the variables was the incidence of myocardial infarction and stroke amongst
tested using Chi-square statistics. 2 statistics and inde- Caucasian people [6,7]. This study shows the strong associ-
pendent t-test were used when appropriate to determine ation of the intima—media thickness and stroke (P = 0.008)
significance of difference among background variables com- in the Indonesian population. This direct correlation exists
pared. because intima—media thickness is a marker of generalized
atherosclerosis. This pathologic vascular phenomenon plays
an important role in the pathogenesis of cerebro and cardio-
Results vascular events such as stroke, and explains the association
between IMT and stroke [9,10].
The base-line characteristics of the 259 patients are given Five other studies have previously explored the possible
in Table 1. correlation between carotid-artery intima—media thickness
Other risk factors such as smoking and hypertension and the incidence of cardiovascular events. Three of these
were analyzed to rule out the bias in determining the studies reported results using measurements of the common
166
carotid artery. Salonen and Salonen, in a study of 1257
middle-aged Finnish men, observed an association between
common carotid-artery intima—media thickness and cardiac
events. This observation was based on a one-year follow-
up and a total of 24 events. The Rotterdam Elderly Study
was a single-center, prospective study of disease and dis-
ability in the elderly involving 7983 subjects 55 years of age
or older. They performed a case-control study in a subgroup
of their population that showed an association between
common-carotid-artery intima—media thickness and the risk
of myocardial infarction and stroke [6—8].
The differences between their study and this study may
be explained by the race of population sample, limited
number of subjects and the methodology in our study.
Moreover, our results extend their findings by showing that
common-carotid-artery intima—media thickness has a strong
correlation with the incidence of stroke. This implies that
common carotid artery intima media thickness may be used
as the predictor of cerebrovascular events. This study has
a few other limitations. The small number of participants,
limited data about the characteristics of the patients, and
methodology (retrospective), are some of the weaknesses of
this study. However, our study can be used as a pilot research
in determining the correlation of intima—media thickness
and stroke among Asian people especially in the Indonesian
population.
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