(Stroke. 1995;26:14-20.)
© 1995 American Heart Association, Inc.
Articles |
Race-Ethnicity and Determinants of Intracranial Atherosclerotic Cerebral Infarction
The Northern Manhattan Stroke Study
Presented in part in abstract form at the 19th Joint Conference on Stroke and Cerebrovascular Disease, San Diego, Calif, February 17-19, 1994.
From the Neurological Institute (R.L.S., D.E.K., Q.G., M.C.Z.), Public Health (Epidemiology) (R.L.S.) and the Sergievsky Center (R.L.S., D.E.K.), Columbia–Presbyterian Medical Center, New York, NY.
Correspondence to Ralph L. Sacco, MD, Neurological Institute, 710 W 168th St, New York, NY 10032.
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Abstract |
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Background and Purpose The aim of this investigation was to determine the importance of race as a determinant of intracranial atherosclerotic stroke in a community-based stroke sample.
Methods Residents from northern Manhattan over age 39 years hospitalized for acute ischemic stroke (n=438, black 35%, Hispanic 46%, white 19%) were prospectively evaluated. Index ischemic strokes were classified as atherosclerotic (17%), lacunar (30%), cardioembolic (21%), cryptogenic (31%), and other (1%). Atherosclerotic infarcts were subdivided into extracranial (9%) and intracranial (8%) atherosclerosis.
Results The proportion of extracranial atherosclerotic stroke was similar among the three race-ethnic groups, while intracranial atherosclerosis was more frequent in blacks and Hispanics. The unadjusted odds ratio for nonwhites (blacks and Hispanics combined) was 0.8 (confidence interval [CI], 0.4 to 1.8) for extracranial and 7.8 (CI, 1.04 to 57.7) for intracranial atherosclerosis. Patients with intracranial disease were significantly younger and had an increased frequency of hypercholesterolemia and insulin-dependent diabetes compared with those with nonatherosclerotic disease. The odds ratio for the association of nonwhite race-ethnicity and intracranial atherosclerosis was reduced to 5.2 (CI, 0.7 to 40) after controlling for age and to 4.4 (CI, 0.6 to 35) after controlling for age, education, insulin-dependent diabetes, and hypercholesterolemia.
Conclusions The greater prevalence of diabetes and hypercholesterolemia among blacks and Hispanics from northern Manhattan accounted for much of the increased frequency of intracranial atherosclerotic stroke. Further control of these risk factors could reduce the frequency of this stroke subtype and minimize the disparities among different race-ethnic groups.
Key Words: atherosclerosis • epidemiology • racial differences • risk factors
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Atherosclerotic infarction accounts for a sizable proportion of cerebral infarcts. Infarction occurs from extracranial or intracranial atherosclerotic disease due to flow failure or artery-to-artery embolism. African Americans and Asians have been found to have more intracranial atherosclerosis than whites, while Hispanics have not been separately studied.1 2 3 4 5 6 7 8 9 10 11 12 Whether race is an independent predictor of intracranial atherosclerotic stroke or is confounded by differences in the prevalence of stroke risk factors has not been clearly determined. Former studies have not been community based and have depended on cerebral angiography or autopsy to confirm the diagnosis of large-vessel intracranial atherosclerosis. More recently, duplex Doppler sonography has advanced the diagnosis of extracranial atherosclerosis, and transcranial Doppler (TCD) has made the diagnosis of intracranial atherosclerotic stroke more attainable. The aim of our investigation was to determine whether race-ethnicity was an independent determinant of intracranial atherosclerotic stroke in an urban, ethnically diverse community.
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Subjects and Methods |
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The Northern Manhattan Stroke Study (NOMASS) is an ongoing, prospective registry of stroke patients who reside in the region. Northern Manhattan consists of the area north of 145th Street and south of 218th Street and is bounded on the west by the Hudson River and separated from the Bronx on the east by the Harlem River. In 1990, nearly 260 000 people lived in the region, with 40% over the age of 39 years. There is a rich ethnic distribution in this community, with 15% white, 20% black, and 63% Hispanic residents. There is only one hospital in the area, the Presbyterian Hospital of the City of New York, and statewide planning data have indicated that approximately 80% of all patients with cerebral infarction are hospitalized at Presbyterian Hospital.
Patients eligible for this cohort study were uniformly and prospectively enrolled if they met the following criteria: (1) diagnosis of acute cerebral infarction, (2) over age 39 years at stroke, (3) resident of the northern Manhattan community, and (4) hospitalization at the Milstein Building of Columbia–Presbyterian Medical Center from 1990 to 1993. Patients with transient ischemic attack (ie, neurological deficits lasting less than 24 hours and no ischemic infarct found on brain imaging) were excluded. Over a 3.5-year period, 2091 patients were screened, and 500 were found to be eligible. Ineligible patients included 833 living outside of northern Manhattan, 218 with transient ischemic attack, 165 with intracerebral hemorrhage, 146 with subarachnoid hemorrhage, 146 with other neurological diagnoses, 32 under age 40 years, 6 for unknown reasons, and 45 who were previously enrolled in the cohort. Of the 500 eligible subjects, 447 were enrolled in the study. Only 53 eligible subjects were not enrolled: 19 were discharged before they could be enrolled, 12 were too ill to sign consent, 11 died before enrollment, 7 were not enrolled for other reasons, 2 refused to participate, 1 was previously enrolled, and 1 was not enrolled for unknown reasons.
As in the United States census, race-ethnic group was defined by self-identification. White and black (not Hispanic) were defined by skin color. Hispanics were defined as persons of Hispanic-Spanish origin or descent with light or dark skin. Individuals with mixed race-ethnicity were defined by the patient's choice of a single ethnic group or the maternal ethnic group. Race-ethnic group was categorized into four groups: Hispanic, black non-Hispanic, white non-Hispanic, and other non-Hispanic.
A daily admission report was generated by the Clinical Information System Department (Presbyterian Hospital) and reviewed by the research team to identify eligible patients. Admission diagnoses with stroke, as well as a variety of other neurological syndromes (eg, transient ischemic attack, intracerebral hemorrhage, aphasia, hemiparesis, weakness, coma), were screened. A research assistant and a study neurologist screened the medical record to determine eligibility. After receiving permission from the attending physician, a member of the research team explained the study and obtained written consent from the patient and often the family. The protocol was approved by the Columbia University Institutional Review Board.
Index Ischemic Stroke Evaluation
Each patient was personally examined within 1 week of ischemic
stroke onset by one of the study neurologists. Data were collected
through in-person interview of the patient and family and by review of
hospital records. Details of medical, neurological, and social history,
stroke risk factors, general and neurological examinations, and
laboratory studies were ascertained.
Pertinent historical variables identified on admission were hypertension, diabetes, hypercholesterolemia, prior stroke or transient ischemic attack, myocardial infarction, coronary artery disease, angina, congestive heart failure, atrial fibrillation, other arrhythmias, and valvular heart disease. Any cardiac disease was defined by a history of at least one of the above cardiac conditions. Hypertension was defined on admission when a patient or family stated that they been told of the diagnosis and was categorized as treated or untreated. Systolic and diastolic blood pressures were recorded after admission to the hospital rather than using the emergency department measurements, which are characteristically elevated above baseline levels. Cigarette smoking and ethanol use were recorded and characterized as current or not, and the amounts were recorded as packs per day and the usual number of drinks per day, week, or month, respectively. The initial cholesterol, hematocrit, and blood glucose levels available after ischemic stroke were recorded as continuous measurements.
Infarct Subtype Classification
Neurovascular evaluation on admission included computed
tomographic (CT) scan of the head, electrocardiogram, extracranial
duplex Doppler ultrasonogram, TCD scan, two-dimensional echocardiogram,
Holter monitor results, and when available, findings from magnetic
resonance imaging, conventional cerebral angiogram, and magnetic
resonance angiogram. At the time of hospital discharge, a diagnosis was
determined, taking into account all the available data to characterize
each ischemic stroke by causal mechanism on the basis of a modified
Stroke Data Bank scheme.13 Ischemic strokes were
classified in the following categories: infarction due to
atherosclerosis, embolism from a commonly accepted cardiac source,
lacune, cryptogenic infarction, and stroke from other unusual
causes.
Atherosclerotic stroke was attributed to perfusion failure distal to the site of severe stenosis or occlusion, or it represented cases where the stenosis was insufficient in itself to account for stroke on hemodynamic grounds but possibly served as an embolic source. This subtype characterized patients who usually presented with focal neurological symptoms and signs, brain imaging evidence of a superficial or large, deep infarction, and evidence of stenosis or occlusion detected by Doppler sonography or angiography. Atherosclerotic stroke was subdivided into extracranial or intracranial categories depending on the location of the stenosis or occlusion. Extracranial sites included the common and internal carotid arteries at the bifurcation and the extradural portions of the vertebral arteries. Intracranial sites included the internal carotid siphon, middle cerebral artery stem or branches, anterior cerebral artery, intradural vertebral artery, basilar artery, and posterior cerebral artery stem.
Classification as extracranial atherosclerotic disease required more than 60% stenosis in the symptomatic carotid artery or occlusion or high-resistance flow in the vertebral artery. Doppler criteria (Diasonics Inc) for stenosis or occlusion were 60% to 80% stenosis when the ratio of internal to common carotid artery velocity was >3.0 with no or minimal aliasing; 80% to 99% stenosis when the internal carotid artery peak velocity was >190 cm/s, turbulence was present, and aliasing was detected; occlusion when no flow was detected in a well-imaged artery lumen; and high-resistance flow when there was no detectable anterograde flow in diastole. TCD measurements were made of the middle, anterior, posterior cerebral, and basilar arteries using EME Carolina equipment with a 2-MHz probe. Segmental arterial velocities were recorded and compared on either side, with evidence of intracranial stenosis based on the finding of a significant asymmetry (ratio >2.0) between the peak velocities of the ipsilateral to contralateral arteries or a peak velocity >120 cm/s in the symptomatic artery. If conventional cerebral angiography or magnetic resonance angiography was performed, an occlusion or >60% stenosis of the symptomatic internal carotid origin or vertebral artery was required for the diagnosis of extracranial atherosclerosis; evidence of focal narrowing or occlusion of the symptomatic intracranial artery was required for intracranial atherosclerosis.
Patients with inadequate evaluations, conflicting data, or adequate evaluations that failed to confirm the initial impression of the stroke subtype were diagnosed as cryptogenic infarction. This ensured a more specific classification of the atherosclerotic diagnostic categories. For this analysis, patients were subdivided into three groups: infarction due to extracranial atherosclerosis, infarction due to intracranial atherosclerosis, and nonatherosclerotic infarction. The latter category consisted of the combination of cardioembolism, lacune, and cryptogenic infarction.
Statistical Analyses
The distributions of certain variables identified on admission
for index ischemic infarction were compared among the three diagnostic
categories. Extracranial and intracranial atherosclerosis were compared
separately from nonatherosclerotic infarction. Univariate analyses were
performed, and significance was judged based on the
2 test for categorical variables, Fisher's exact
test for instances in which the individual cells of a 2x2 table had
counts less than 5, or the t test for continuous variables.
Multivariate analyses were performed using a logistic regression model
to identify factors simultaneously predictive of the diagnostic
category. Variables were selected for entry if probability value was
less than .10 after univariate testing or a priori. Modeling was done
using the selected factors as independent variables and extracranial or
intracranial atherosclerosis as the dependent variables. There was no
assumption of multivariate normality for these covariates. The full set
of potential factors was considered by stepwise elimination of those
with probability values greater than .05. Odds ratios were calculated
from the ß coefficients and their standard errors.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Description of the Cohort
The cohort for this analysis consisted of 438 northern Manhattan residents over age 39 years hospitalized at Presbyterian Hospital for acute cerebral infarction and enrolled in the Northern Manhattan Stroke Study. The mean age at ischemic stroke was 70 years (range, 40 to 97 years; 71% aged 65 years or older), and 54% were women. Within the ethnically mixed cohort there were 197 Hispanics, 155 black non-Hispanics, 82 white non-Hispanics, and 4 classified as other non-Hispanic. Atherosclerotic stroke accounted for 17% of the index ischemic strokes, lacunar infarction 30%, cardiac embolism 21%, cryptogenic infarcts 31%, and other causes for 1%. Extracranial atherosclerotic stroke was diagnosed in 40 patients (9%) and intracranial atherosclerotic stroke in 33 (8%). The stroke diagnostic evaluations were extensive: 73% had more than one head CT scan, 92% had extracranial duplex Doppler, 75% had TCD, and 88% had echocardiography. Because the diagnosis of intracranial atherosclerotic stroke could be made on the basis of TCD findings, a greater proportion of patients with intracranial atherosclerotic stroke had TCD (91%) compared with those with extracranial (78%) and nonatherosclerotic stroke (74%). TCD was performed successfully in slightly more Hispanics (83%) than blacks (69%) and whites (68%). Cerebral angiography was performed in 48% of those diagnosed with extracranial atherosclerotic stroke, 45% of those with intracranial atherosclerotic stroke, and only 5% of those with nonatherosclerotic stroke.
Cerebral Infarct Subtypes and Race-Ethnicity
There were no differences in cerebral infarct subtypes by sex;
however, infarct subtypes differed among the three race-ethnic groups
(Figure
). Cardioembolism was more frequent in whites,
and lacunes were more frequent in blacks and Hispanics. The proportion
of extracranial atherosclerotic stroke was similar among the three
race-ethnic groups: 11% of whites, 8% of blacks, and 9% of
Hispanics. Intracranial atherosclerotic stroke was significantly more
frequent in blacks and Hispanics than whites: 1% of whites, 6% of
blacks, and 11% of Hispanics (P=.014). The ratio of
extracranial to intracranial disease was 1.2 in blacks, 0.9 in
Hispanics, and 9.0 in whites. Only 1 white patient had an intracranial
atherosclerotic stroke. The unadjusted odds ratio for nonwhites (blacks
and Hispanics combined) was 0.8 (confidence interval [CI], 0.4 to
1.8) for extracranial and 7.8 (CI, 1.04 to 57.7) for intracranial
atherosclerotic stroke.
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Among those with extracranial atherosclerotic disease, the internal
carotid artery was more frequently affected than the vertebral artery
in all three race-ethnic groups (Table 1). There was an
increasing proportion of vertebral artery stenosis or occlusion in
Hispanics and blacks compared with whites. The one white patient with
intracranial atherosclerotic stroke had basilar stenosis. Nearly half
of the blacks with intracranial atherosclerotic disease had basilar
stenosis, whereas the middle cerebral artery stem was the most frequent
site for Hispanics.
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Cerebral Infarct Subtypes and Vascular Risk Factors
Patients with intracranial atherosclerotic stroke were
significantly younger than those with extracranial and
nonatherosclerotic stroke (Table 2). Patients with
extracranial atherosclerotic stroke were slightly better educated than
the other two groups. Untreated hypertension was slightly more
prevalent in the atherosclerotic groups (Table 3).
Cardiac disease was slightly less frequent among those with
intracranial disease compared with nonatherosclerotic stroke, but this
was unadjusted for age.
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A history of hypercholesterolemia was significantly more frequent among
those with extracranial and intracranial atherosclerotic disease, and
mean serum cholesterol level was significantly elevated among those
with extracranial disease (Table 4). The unadjusted odds
ratio for hypercholesterolemia was 3.4 (CI, 1.7 to 6.5) for
extracranial and 2.9 (CI, 1.4 to 6.0) for intracranial atherosclerotic
stroke. Diabetes was most frequent among those with intracranial
atherosclerotic stroke, intermediate with extracranial disease, and
least among those with nonatherosclerotic stroke. Insulin-dependent
diabetes was more prevalent in both extracranial and intracranial
atherosclerotic stroke compared with nonatherosclerotic stroke, with
unadjusted odds ratios of 3.1 (CI, 1.4 to 6.8) and 3.4 (CI, 1.5 to
8.0), respectively.
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History of cigarette smoking and alcohol use was not significantly different among the three diagnostic groups; however, the mean number of drinks per week was significantly less in the extracranial atherosclerotic group. Claudication and transient ischemic attacks were more prevalent among those with extracranial compared with intracranial disease.
Independent Discriminators of Infarct Subtype
Prior analyses of this northern Manhattan cohort have
demonstrated that the prevalence of risk factors differs among the
race-ethnic groups. In particular, Hispanics had more diabetes, and
blacks had a slightly higher mean cholesterol level (Table 5). Logistic regression confirmed that younger age,
history of hypercholesterolemia, and insulin-dependent diabetes were
predictors of intracranial atherosclerosis. The odds ratio for the
association of nonwhite (black or Hispanic) race-ethnicity and
intracranial atherosclerosis was reduced from 7.9 to 5.2 (CI, 0.7 to
40) after controlling for age and to 4.4 (CI, 0.6 to 35) after
controlling for age, education, insulin-dependent diabetes, and
hypercholesterolemia (Table 6).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Despite a decline in stroke mortality in all race-gender groups, the relative difference between races in stroke mortality has remained fairly uniform at nearly a twofold increase in stroke mortality in blacks compared with whites.14 Moreover, stroke is still among the major causes of the excess mortality among African Americans compared with mortality in whites.15 Differences in stroke subtype distributions by race-ethnicity may help account for some of the differences in overall mortality. Some have observed that the death rate from cerebral hemorrhage in blacks is about twice that of whites and that subarachnoid hemorrhage is at least twice as frequent in blacks.16 17 Because hemorrhagic stroke subtypes have greater case-fatality rates, any increase in the proportion of these stroke subtypes in a specific race-ethnic group would result in a greater overall mortality from stroke. The same would be true if certain cerebral infarction subtypes, associated with a worse prognosis, were more frequent in specific race-ethnic groups. However, few studies have had enough of a race-ethnic mixture to compare stroke subtypes in multiethnic groups in the same region.
The first observation regarding stroke subtype distribution in our cohort was that atherosclerotic infarction, whether extracranial or intracranial, accounted for only 17% of the cerebral infarcts. Extracranial atherosclerotic stroke was diagnosed in 9% and intracranial in 8%. This is less than the proportions reported in older studies, in which atherosclerotic infarction diagnoses were sometimes based on presumed mechanism without confirmatory laboratory data, and there was not a category of cryptogenic infarction. In the Northern Manhattan Stroke Study, if there were insufficient data to reliably categorize patients as atherosclerotic, patients were classified as having cryptogenic infarction. The frequency of cryptogenic infarction did not differ by race-ethnicity; however, lacunes were more frequent among blacks and Hispanics, and cardioembolism was more frequent among whites. These differences are a reflection of the increased frequency of hypertension and diabetes in blacks and Hispanics and of the increased frequency of ischemic cardiac disease among whites.
In our cohort, the proportion of extracranial atherosclerotic stroke was similar among the three race-ethnic groups, while intracranial atherosclerotic stroke was more prevalent in blacks and Hispanics compared with whites. Patients with intracranial atherosclerotic stroke were younger and had an increased frequency of hypercholesterolemia and insulin-dependent diabetes. The odds ratio for the association of nonwhite (black or Hispanic) race-ethnicity and intracranial atherosclerotic stroke was reduced from 7.8 to 5.2 after controlling for age and to 4.4 after controlling for age, education, insulin-dependent diabetes, and hypercholesterolemia. This implies that race-ethnicity is a determinant of intracranial atherosclerotic stroke, but that differences in stroke risk factors (particularly insulin-dependent diabetes and hypercholesterolemia) account for some of the effect.
Hispanics can now be added to the list of ethnic groups with an increased risk of intracranial atherosclerotic stroke. In northern Manhattan, the Hispanic cohort was similar to blacks with regard to stroke subtype distribution. In other studies, blacks have been found to be underrepresented among patients with carotid endarterectomies18 and have an increased frequency of intracranial occlusive disease.1 2 3 4 5 6 7 8 9 Japanese and Chinese patients also have been found to have an increased frequency of intracranial atherosclerotic disease.9 10 11 12 Autopsy studies of the circle of Willis have demonstrated that US blacks had significantly greater atherosclerotic disease of the intracranial vessels than US whites, while African blacks had the least amount of atherosclerosis.19 Other autopsy studies have confirmed these observations in blacks, as well as reported less atherosclerotic disease of the aorta and coronary arteries compared with whites.20 21 Angiographic studies have reported more atherosclerotic lesions of the supraclinoid carotid, middle, and anterior cerebral artery stems and basilar artery in blacks, while whites had greater atherosclerotic involvement of the internal carotid artery at the bifurcation, the origin of the vertebral artery, or the extracranial vertebral artery.1 2 3 4 5 6 7 The authors often acknowledge the problem of selection bias, which could influence the findings in any hospital-based study or clinical trial that requires an invasive procedure to arrive at the diagnosis. More recently, studies have used noninvasive techniques; one study has found race to be a significant independent risk factor for predicting carotid stenosis,8 whereas two studies have not found race-ethnic differences.22 23 Cross-sectional studies still have the problem of selection bias, since none have been community based and socioeconomic differences may confound the results. Even with noninvasive tests there can be some detection bias if the likelihood of undergoing a successful test such as TCD sonography differs by race-ethnic group. This could lead to differential bias in the diagnosis of intracranial atherosclerotic stroke. In our cohort, Hispanics were more likely to have successful TCD than blacks and whites, perhaps because of their younger age, which improved the ability to obtain a temporal window of insonation. This degree of diagnostic bias, however, would not account for the black-white difference in stroke subtype and is too small to account for the Hispanic-white difference.
Our cohort offers several advantages for the study of stroke subtypes. It is both hospital and community based, since all of our cases were from the immediate region surrounding the only hospital in the area. Our estimates indicate that 80% of all patients with ischemic strokes that occur in northern Manhattan were hospitalized at Presbyterian Hospital and that the proportion of nonhospitalized stroke is less than 10%. This helps to minimize selection and referral biases and maximize accuracy of stroke diagnoses and uniformity of acute-stage evaluations by race-ethnic group. In other ongoing studies, we are gathering information regarding patients with stroke who are not hospitalized at Presbyterian Hospital to evaluate stroke subtypes and ensure that our stroke sample is representative of the underlying population. The urban region also allows for the evaluation of black and Hispanic patients, often underrepresented in stroke studies.
Part of the difficulty in classification of ischemic stroke stems from the inability to discriminate between infarct subtypes on clinical grounds alone. In the Stroke Data Bank, some clinical characteristics were helpful in distinguishing infarct subtypes; however, clinical features that were observed at stroke onset were not reliable enough to lead to a definite determination of infarct subtype without confirmatory laboratory data.24 25 The choice of diagnostic laboratory tests may be influenced by physician bias, safety considerations, availability of certain technologies, and socioeconomic considerations. Studies that rely on cerebral angiography to diagnose cerebral atherosclerosis could be more susceptible to such selection biases, particularly if the decision to pursue an angiogram in a patient with cerebral infarction was differential across race-ethnic groups. The use of noninvasive tests for the determination of cerebral infarction subtypes has helped minimize concerns about patient safety and eliminate race-ethnic selection biases. Moreover, TCD and magnetic resonance angiography have made the diagnosis of intracranial atherosclerotic infarction possible without the use of conventional cerebral angiography. In the Northern Manhattan Stroke Study, atherosclerotic stroke subtypes were diagnosed based on the frequent use of such noninvasive tests.
The explanation for the increased frequency of intracranial atherosclerotic stroke in black, Chinese, Japanese, and Hispanic individuals is not known. Genetic differences may play some role, but given the diversity of these population groups it seems unlikely that they would share a common genetic explanation that could promote intracranial atherosclerosis. In northern Manhattan, blacks and Hispanics were younger, had a greater frequency of hypertension and diabetes, were more obese, and had a decreased prevalence of cardiac disease compared with whites. Because some of these factors are clearly independent predictors of intracranial atherosclerotic stroke, they account for part of the increased risk of this stroke subtype in certain populations who have a greater prevalence of these conditions. Interactions among these risk factors could be particularly important but are difficult to detect without larger sample sizes. Alternatively, the absence of a particular set of risk factors or the protective effect of some factor, as yet undetermined, may account for the lack of intracranial atherosclerotic disease among whites.
Prior cross-sectional studies that have reported on racial differences in intracranial atherosclerotic stroke have also documented an increased prevalence of certain stroke risk factors in these race-ethnic groups. Some of the angiographic studies have found that hypercholesterolemia and ischemic heart disease were more frequent in whites, while hypertension and diabetes were more frequent in blacks.3 9 However, race-ethnicity still had retained an effect even after these conditions were controlled for in the analyses. Other potential stroke risk factors that have not been investigated but could also help account for race-ethnic stroke subtype differences include diet, lipoprotein(a) levels, cholesterol fractions, coagulation factors, homocysteine, and level of stress. Further study in population-based cohorts should help provide other answers to these race-ethnic disparities in stroke subtype.
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Acknowledgments |
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This work was supported by grants from the National Institute of Neurological Disorders and Stroke (R01-NS-27517, R01-NS-29993, and T32-NS-07153).
Received August 19, 1994; revision received October 17, 1994; accepted October 17, 1994.
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S. P. Waddy, G. Cotsonis, M. J. Lynn, M. R. Frankel, S. Chaturvedi, J. E. Williams, and M. Chimowitz Racial Differences in Vascular Risk Factors and Outcomes of Patients With Intracranial Atherosclerotic Arterial Stenosis Stroke, March 1, 2009; 40(3): 719 - 725. [Abstract] [Full Text] [PDF]
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T. N. Turan, L. Maidan, G. Cotsonis, M. J. Lynn, J. G. Romano, S. R. Levine, M. I. Chimowitz, and for the WASID Investigators Failure of Antithrombotic Therapy and Risk of Stroke in Patients With Symptomatic Intracranial Stenosis Stroke, February 1, 2009; 40(2): 505 - 509. [Abstract] [Full Text] [PDF]
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U. Khan, C. Crossley, L. Kalra, A. Rudd, C. D.A. Wolfe, P. Collinson, and H. S. Markus Homocysteine and Its Relationship to Stroke Subtypes in a UK Black Population: The South London Ethnicity and Stroke Study Stroke, November 1, 2008; 39(11): 2943 - 2949. [Abstract] [Full Text] [PDF]
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F. Siddiq, G. Vazquez, M. Z. Memon, M. F. K. Suri, R. A. Taylor, J. C. Wojak, J. C. Chaloupka, and A. I. Qureshi Comparison of Primary Angioplasty With Stent Placement for Treating Symptomatic Intracranial Atherosclerotic Diseases: A Multicenter Study Stroke, September 1, 2008; 39(9): 2505 - 2510. [Abstract] [Full Text] [PDF]
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P. B. Gorelick, K. S. Wong, H.-J. Bae, and D. K. Pandey Large Artery Intracranial Occlusive Disease: A Large Worldwide Burden but a Relatively Neglected Frontier Stroke, August 1, 2008; 39(8): 2396 - 2399. [Abstract] [Full Text] [PDF]
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J. F. Arenillas, J. Alvarez-Sabin, C. A. Molina, P. Chacon, I. Fernandez-Cadenas, M. Ribo, P. Delgado, M. Rubiera, A. Penalba, A. Rovira, et al. Progression of Symptomatic Intracranial Large Artery Atherosclerosis Is Associated With a Proinflammatory State and Impaired Fibrinolysis Stroke, May 1, 2008; 39(5): 1456 - 1463. [Abstract] [Full Text] [PDF]
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O. O. Zaidat, R. Klucznik, M. J. Alexander, J. Chaloupka, H. Lutsep, S. Barnwell, M. Mawad, B. Lane, M. J. Lynn, M. Chimowitz, et al. The NIH registry on use of the Wingspan stent for symptomatic70-99% intracranial arterial stenosis Neurology, April 22, 2008; 70(17): 1518 - 1524. [Abstract] [Full Text] [PDF]
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E. C. Haley Jr Registries: They're not just for weddings anymore Neurology, April 22, 2008; 70(17): 1508 - 1509. [Full Text] [PDF]
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 D.C. Suh, J.K. Kim, J.W. Choi, B.S. Choi, H.W. Pyun, Y.J. Choi, M.-H. Kim, H.R. Yang, H.I. Ha, S.J. Kim, et al. Intracranial Stenting of Severe Symptomatic Intracranial Stenosis: Results of 100 Consecutive Patients AJNR Am. J. Neuroradiol., April 1, 2008; 29(4): 781 - 785. [Abstract] [Full Text] [PDF]
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M. N. Nguyen-Huynh, M. Wintermark, J. English, J. Lam, E. Vittinghoff, W. S. Smith, and S. C. Johnston How Accurate Is CT Angiography in Evaluating Intracranial Atherosclerotic Disease? Stroke, April 1, 2008; 39(4): 1184 - 1188. [Abstract] [Full Text] [PDF]
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M. Mazighi, J. Labreuche, F. Gongora-Rivera, C. Duyckaerts, J.-J. Hauw, and P. Amarenco Autopsy Prevalence of Intracranial Atherosclerosis in Patients With Fatal Stroke Stroke, April 1, 2008; 39(4): 1142 - 1147. [Abstract] [Full Text] [PDF]
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S. Prabhakaran, C. B. Wright, M. Yoshita, R. Delapaz, T. Brown, C. DeCarli, and R. L. Sacco Prevalence and determinants of subclinical brain infarction: The Northern Manhattan Study Neurology, February 5, 2008; 70(6): 425 - 430. [Abstract] [Full Text] [PDF]
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V. Puetz, G. Gahn, U. Becker, D. Mucha, A. Mueller, N.U. Weir, B. Wiedemann, and R. von Kummer Endovascular Therapy of Symptomatic Intracranial Stenosis in Patients With Impaired Regional Cerebral Blood Flow or Failure of Medical Therapy AJNR Am. J. Neuroradiol., February 1, 2008; 29(2): 273 - 280. [Abstract] [Full Text] [PDF]
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J. Valaikiene, G. Schuierer, B. Ziemus, J. Dietrich, U. Bogdahn, and F. Schlachetzki Transcranial Color-Coded Duplex Sonography for Detection of Distal Internal Carotid Artery Stenosis AJNR Am. J. Neuroradiol., February 1, 2008; 29(2): 347 - 353. [Abstract] [Full Text] [PDF]
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M. J. Bos, P. J. Koudstaal, A. Hofman, J. C.M. Witteman, and M. M.B. Breteler Transcranial Doppler Hemodynamic Parameters and Risk of Stroke: The Rotterdam Study Stroke, September 1, 2007; 38(9): 2453 - 2458. [Abstract] [Full Text] [PDF]
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J. E. Williams, M. I. Chimowitz, G. A. Cotsonis, M. J. Lynn, S. P. Waddy, and for the WASID Investigators Gender Differences in Outcomes Among Patients With Symptomatic Intracranial Arterial Stenosis Stroke, July 1, 2007; 38(7): 2055 - 2062. [Abstract] [Full Text] [PDF]
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E. Feldmann, J. L. Wilterdink, A. Kosinski, M. Lynn, M. I. Chimowitz, J. Sarafin, H. H. Smith, F. Nichols, J. Rogg, H. J. Cloft, et al. The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) Trial Neurology, June 12, 2007; 68(24): 2099 - 2106. [Abstract] [Full Text] [PDF]
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M. S. Dhamoon, W. Tai, B. Boden-Albala, T. Rundek, M. C. Paik, R. L. Sacco, and M. S.V. Elkind Risk of Myocardial Infarction or Vascular Death After First Ischemic Stroke: The Northern Manhattan Study Stroke, June 1, 2007; 38(6): 1752 - 1758. [Abstract] [Full Text] [PDF]
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A. Bose, M. Hartmann, H. Henkes, H. M. Liu, M. M.H. Teng, I. Szikora, A. Berlis, J. Reul, S. C.H. Yu, M. Forsting, et al. A Novel, Self-Expanding, Nitinol Stent in Medically Refractory Intracranial Atherosclerotic Stenoses: The Wingspan Study Stroke, May 1, 2007; 38(5): 1531 - 1537. [Abstract] [Full Text] [PDF]
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C.G. Choi, D.H. Lee, J.H. Lee, H.W. Pyun, D.W. Kang, S.U. Kwon, J.K. Kim, S.J. Kim, and D.C. Suh Detection of Intracranial Atherosclerotic Steno-Occlusive Disease with 3D Time-of-Flight Magnetic Resonance Angiography with Sensitivity Encoding at 3T AJNR Am. J. Neuroradiol., March 1, 2007; 28(3): 439 - 446. [Abstract] [Full Text] [PDF]
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J.C. Wojak, D.C. Dunlap, K.R. Hargrave, L.A. DeAlvare, H.S. Culbertson, and J.J. Connors III Intracranial angioplasty and stenting: long-term results from a single center. AJNR Am. J. Neuroradiol., October 1, 2006; 27(9): 1882 - 1892. [Abstract] [Full Text] [PDF]
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R. Gupta, F. Al-Ali, A. J. Thomas, M. B. Horowitz, T. Barrow, N. A. Vora, K. Uchino, M. D. Hammer, L. R. Wechsler, and T. G. Jovin Safety, Feasibility, and Short-Term Follow-Up of Drug-Eluting Stent Placement in the Intracranial and Extracranial Circulation Stroke, October 1, 2006; 37(10): 2562 - 2566. [Abstract] [Full Text] [PDF]
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M. Moussouttas, L. Aguilar, K. Fuentes, B. Anyanwu, H. Manassarians, N. Papamitsakis, Q. Shi, and P. Visintainer Cerebrovascular disease among patients from the Indian subcontinent. Neurology, September 12, 2006; 67(5): 894 - 896. [Abstract] [Full Text] [PDF]
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C. D. Bushnell, P. Hurn, C. Colton, V. M. Miller, G. del Zoppo, M. S.V. Elkind, B. Stern, D. Herrington, G. Ford-Lynch, P. Gorelick, et al. Advancing the Study of Stroke in Women: Summary and Recommendations for Future Research From an NINDS-Sponsored Multidisciplinary Working Group Stroke, September 1, 2006; 37(9): 2387 - 2399. [Abstract] [Full Text] [PDF]
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 B. I. Freedman, D. W. Bowden, M. M. Sale, C. D. Langefeld, and S. S. Rich Genetic Susceptibility Contributes to Renal and Cardiovascular Complications of Type 2 Diabetes Mellitus Hypertension, July 1, 2006; 48(1): 8 - 13. [Full Text] [PDF]
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C. J. Rodriguez, F. Lin, R. L. Sacco, Z. Jin, B. Boden-Albala, S. Homma, and M. R. Di Tullio Prognostic Implications of Left Ventricular Mass Among Hispanics: The Northern Manhattan Study Hypertension, July 1, 2006; 48(1): 87 - 92. [Abstract] [Full Text] [PDF]
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C. B. Wright, M. S.V. Elkind, T. Rundek, B. Boden-Albala, M. C. Paik, and R. L. Sacco Alcohol Intake, Carotid Plaque, and Cognition: The Northern Manhattan Study Stroke, May 1, 2006; 37(5): 1160 - 1164. [Abstract] [Full Text] [PDF]
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M. Mazighi, R. Tanasescu, X. Ducrocq, E. Vicaut, S. Bracard, E. Houdart, and F. Woimant Prospective study of symptomatic atherothrombotic intracranial stenoses: The GESICA Study Neurology, April 25, 2006; 66(8): 1187 - 1191. [Abstract] [Full Text] [PDF]
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M. P. Marks, J. C. Wojak, F. Al-Ali, M. Jayaraman, M. L. Marcellus, J. J. Connors, and H. M. Do Angioplasty for Symptomatic Intracranial Stenosis: Clinical Outcome Stroke, April 1, 2006; 37(4): 1016 - 1020. [Abstract] [Full Text] [PDF]
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S. E. Kasner, M. I. Chimowitz, M. J. Lynn, H. Howlett-Smith, B. J. Stern, V. S. Hertzberg, M. R. Frankel, S. R. Levine, S. Chaturvedi, C. G. Benesch, et al. Predictors of Ischemic Stroke in the Territory of a Symptomatic Intracranial Arterial Stenosis Circulation, January 31, 2006; 113(4): 555 - 563. [Abstract] [Full Text] [PDF]
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R. Kern, W. Steinke, M. Daffertshofer, R. Prager, and M. Hennerici Stroke recurrences in patients with symptomatic vs asymptomatic middle cerebral artery disease Neurology, September 27, 2005; 65(6): 859 - 864. [Abstract] [Full Text] [PDF]
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D. H. Shin, P. H. Lee, and O. Y. Bang Mechanisms of Recurrence in Subtypes of Ischemic Stroke: A Hospital-Based Follow-up Study Arch Neurol, August 1, 2005; 62(8): 1232 - 1237. [Abstract] [Full Text] [PDF]
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M. S.V. Elkind, A. C. Flint, R. R. Sciacca, and R. L. Sacco Lipid-lowering agent use at ischemic stroke onset is associated with decreased mortality Neurology, July 26, 2005; 65(2): 253 - 258. [Abstract] [Full Text] [PDF]
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J. F. Arenillas, J. Candell-Riera, G. Romero-Farina, C. A. Molina, P. Chacon, S. Aguade-Bruix, J. Montaner, G. de Leon, J. Castell-Conesa, and J. Alvarez-Sabin Silent Myocardial Ischemia in Patients With Symptomatic Intracranial Atherosclerosis: Associated Factors Stroke, June 1, 2005; 36(6): 1201 - 1206. [Abstract] [Full Text] [PDF]
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S. Bash, J. P. Villablanca, R. Jahan, G. Duckwiler, M. Tillis, C. Kidwell, J. Saver, and J. Sayre Intracranial Vascular Stenosis and Occlusive Disease: Evaluation with CT Angiography, MR Angiography, and Digital Subtraction Angiography AJNR Am. J. Neuroradiol., May 1, 2005; 26(5): 1012 - 1021. [Abstract] [Full Text] [PDF]
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S. U. Kwon, Y.-J. Cho, J.-S. Koo, H.-J. Bae, Y.-S. Lee, K.-S. Hong, J. H. Lee, and J. S. Kim Cilostazol Prevents the Progression of the Symptomatic Intracranial Arterial Stenosis: The Multicenter Double-Blind Placebo-Controlled Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis Stroke, April 1, 2005; 36(4): 782 - 786. [Abstract] [Full Text] [PDF]
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M. I. Chimowitz, M. J. Lynn, H. Howlett-Smith, B. J. Stern, V. S. Hertzberg, M. R. Frankel, S. R. Levine, S. Chaturvedi, S. E. Kasner, C. G. Benesch, et al. Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis N. Engl. J. Med., March 31, 2005; 352(13): 1305 - 1316. [Abstract] [Full Text] [PDF]
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H. White, B. Boden-Albala, C. Wang, M. S.V. Elkind, T. Rundek, C. B. Wright, and R. L. Sacco Ischemic Stroke Subtype Incidence Among Whites, Blacks, and Hispanics: The Northern Manhattan Study Circulation, March 15, 2005; 111(10): 1327 - 1331. [Abstract] [Full Text] [PDF]
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D. L. Tirschwell, N. L. Smith, S. R. Heckbert, R. N. Lemaitre, W. T. Longstreth Jr., and B. M. Psaty Association of cholesterol with stroke risk varies in stroke subtypes and patient subgroups Neurology, November 23, 2004; 63(10): 1868 - 1875. [Abstract] [Full Text] [PDF]
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 M. E. Bleil, J. M. McCaffery, M. F. Muldoon, K. Sutton-Tyrrell, and S. B. Manuck Anger-Related Personality Traits and Carotid Artery Atherosclerosis in Untreated Hypertensive Men Psychosom Med, September 1, 2004; 66(5): 633 - 639. [Abstract] [Full Text] [PDF]
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K. Uchino, J. M.H. Risser, M. A. Smith, L. A. Moye, and L. B. Morgenstern Ischemic stroke subtypes among Mexican Americans and non-Hispanic whites: The BASIC Project Neurology, August 10, 2004; 63(3): 574 - 576. [Abstract] [Full Text] [PDF]
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 K. D. Flemming, R. D. Brown Jr, G. W. Petty, J. Huston III, D. F. Kallmes, and D. G. Piepgras Evaluation and Management of Transient Ischemic Attack and Minor Cerebral Infarction Mayo Clin. Proc., August 1, 2004; 79(8): 1071 - 1086. [Abstract] [PDF]
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C. B. Wright, H. -S. Lee, M. C. Paik, S. P. Stabler, R. H. Allen, and R. L. Sacco Total homocysteine and cognition in a tri-ethnic cohort: The Northern Manhattan Study Neurology, July 27, 2004; 63(2): 254 - 260. [Abstract] [Full Text] [PDF]
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J. F. Arenillas, C. A. Molina, P. Chacon, A. Rovira, J. Montaner, P. Coscojuela, E. Sanchez, M. Quintana, and J. Alvarez-Sabin High lipoprotein (a), diabetes, and the extent of symptomatic intracranial atherosclerosis Neurology, July 13, 2004; 63(1): 27 - 32. [Abstract] [Full Text] [PDF]
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A. T. Schneider, B. Kissela, D. Woo, D. Kleindorfer, K. Alwell, R. Miller, J. Szaflarski, J. Gebel, J. Khoury, R. Shukla, et al. Ischemic Stroke Subtypes: A Population-Based Study of Incidence Rates Among Blacks and Whites Stroke, July 1, 2004; 35(7): 1552 - 1556. [Abstract] [Full Text] [PDF]
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V. L. Feigin and A. Rodgers Editorial Comment--Ethnic Disparities in Risk Factors for Stroke: What Are the Implications? Stroke, July 1, 2004; 35(7): 1568 - 1569. [Full Text] [PDF]
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The SSYLVIA Study Investigators Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): Study Results Stroke, June 1, 2004; 35(6): 1388 - 1392. [Abstract] [Full Text] [PDF]
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M. A. Sloan, A. V. Alexandrov, C. H. Tegeler, M. P. Spencer, L. R. Caplan, E. Feldmann, L. R. Wechsler, D. W. Newell, C. R. Gomez, V. L. Babikian, et al. Assessment: Transcranial Doppler ultrasonography: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Neurology, May 11, 2004; 62(9): 1468 - 1481. [Abstract] [Full Text] [PDF]
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 R. du Mesnil de Rochemont, B. Turowski, M. Buchkremer, M. Sitzer, F. E. Zanella, and J. Berkefeld Recurrent Symptomatic High-Grade Intracranial Stenoses: Safety and Efficacy of Undersized Stents-- Initial Experience Radiology, April 1, 2004; 231(1): 45 - 49. [Abstract] [Full Text] [PDF]
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 A. E. Li, I. Kamel, F. Rando, M. Anderson, B. Kumbasar, J. A. C. Lima, and D. A. Bluemke Using MRI to Assess Aortic Wall Thickness in the Multiethnic Study of Atherosclerosis: Distribution by Race, Sex, and Age Am. J. Roentgenol., March 1, 2004; 182(3): 593 - 597. [Abstract] [Full Text] [PDF]
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R. Gupta, H.C. Schumacher, S. Mangla, P.M. Meyers, H. Duong, A.G. Khandji, R.S. Marshall, J.P. Mohr, and J. Pile-Spellman Urgent endovascular revascularization for symptomatic intracranial atherosclerotic stenosis Neurology, December 23, 2003; 61(12): 1729 - 1735. [Abstract] [Full Text] [PDF]
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S. J. Lee, S.-J. Cho, H.-S. Moon, Y.-M. Shon, K. H. Lee, D.-I. Kim, B.-B. Lee, H. S. Byun, S.-H. Han, and C.-S. Chung Combined Extracranial and Intracranial Atherosclerosis in Korean Patients Arch Neurol, November 1, 2003; 60(11): 1561 - 1564. [Abstract] [Full Text] [PDF]
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J. F. Arenillas, J. Alvarez-Sabin, C. A. Molina, P. Chacon, J. Montaner, A. Rovira, B. Ibarra, and M. Quintana C-Reactive Protein Predicts Further Ischemic Events in First-Ever Transient Ischemic Attack or Stroke Patients With Intracranial Large-Artery Occlusive Disease Stroke, October 1, 2003; 34(10): 2463 - 2468. [Abstract] [Full Text] [PDF]
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H. C. Schumacher, K. Tanji, S. Mangla, P. Meyers, J. Pile-Spellman, A. P. Hays, and J.P. Mohr Histopathological Evaluation of Middle Cerebral Artery After Percutaneous Intracranial Transluminal Angioplasty Stroke, September 1, 2003; 34 (9): e170 - e173. [Abstract] [Full Text] [PDF]
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L. S. Babiarz, D. M. Yousem, B. A. Wasserman, C. Wu, W. Bilker, and N. J. Beauchamp Jr. Cavernous Carotid Artery Calcification and White Matter Ischemia AJNR Am. J. Neuroradiol., May 1, 2003; 24(5): 872 - 877. [Abstract] [Full Text] [PDF]
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D. C. Suh, S.-H. Lee, K. R. Kim, S. T. Park, S. M. Lim, S. J. Kim, C. G. Choi, and H. K. Lee Pattern of Atherosclerotic Carotid Stenosis in Korean Patients with Stroke: Different Involvement of Intracranial versus Extracranial Vessels AJNR Am. J. Neuroradiol., February 1, 2003; 24(2): 239 - 244. [Abstract] [Full Text] [PDF]
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A. T. Schneider, A. M. Pancioli, J. C. Khoury, E. Rademacher, A. Tuchfarber, R. Miller, D. Woo, B. Kissela, and J. P. Broderick Trends in Community Knowledge of the Warning Signs and Risk Factors for Stroke JAMA, January 15, 2003; 289(3): 343 - 346. [Abstract] [Full Text] [PDF]
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J. L. Hunt, R. Fairman, M. E. Mitchell, J. P. Carpenter, M. Golden, T. Khalapyan, M. Wolfe, D. Neschis, R. Milner, B. Scoll, et al. Bone Formation in Carotid Plaques: A Clinicopathological Study Stroke, May 1, 2002; 33(5): 1214 - 1219. [Abstract] [Full Text] [PDF]
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K. S. Wong, H. Li, W. W.M. Lam, Y. L. Chan, and R. Kay Progression of Middle Cerebral Artery Occlusive Disease and Its Relationship With Further Vascular Events After Stroke Stroke, February 1, 2002; 33(2): 532 - 536. [Abstract] [Full Text] [PDF]
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T. Hirai, Y. Korogi, K. Ono, M. Nagano, K. Maruoka, S. Uemura, and M. Takahashi Prospective Evaluation of Suspected Stenoocclusive Disease of the Intracranial Artery: Combined MR Angiography and CT Angiography Compared with Digital Subtraction Angiography AJNR Am. J. Neuroradiol., January 1, 2002; 23(1): 93 - 101. [Abstract] [Full Text] [PDF]
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M. S. Elkind, J. Cheng, B. Boden-Albala, T. Rundek, J. Thomas, H. Chen, L. E. Rabbani, R. L. Sacco, and A. G. Thrift Tumor Necrosis Factor Receptor Levels Are Associated With Carotid Atherosclerosis * Editorial Comment Stroke, January 1, 2002; 33(1): 31 - 38. [Abstract] [Full Text] [PDF]
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J. F. Arenillas, C. A. Molina, J. Montaner, S. Abilleira, M. A. Gonzalez-Sanchez;, and J. Alvarez-Sabin Progression and Clinical Recurrence of Symptomatic Middle Cerebral Artery Stenosis: A Long-Term Follow-Up Transcranial Doppler Ultrasound Study Stroke, December 1, 2001; 32(12): 2898 - 2904. [Abstract] [Full Text] [PDF]
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M. I. Chimowitz Angioplasty or Stenting Is Not Appropriate as First-Line Treatment of Intracranial Stenosis Arch Neurol, October 1, 2001; 58(10): 1690 - 1692. [Full Text] [PDF]
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R. L. Sacco, R. T. Benson, D. E. Kargman, B. Boden-Albala, C. Tuck, I-F. Lin, J. F. Cheng, M. C. Paik, S. Shea, and L. Berglund High-Density Lipoprotein Cholesterol and Ischemic Stroke in the Elderly: The Northern Manhattan Stroke Study JAMA, June 6, 2001; 285(21): 2729 - 2735. [Abstract] [Full Text] [PDF]
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M. S. Elkind, J. Cheng, B. Boden-Albala, M. C. Paik, and R. L. Sacco Elevated White Blood Cell Count and Carotid Plaque Thickness : The Northern Manhattan Stroke Study Stroke, April 1, 2001; 32(4): 842 - 849. [Abstract] [Full Text] [PDF]
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K. S. Wong, H. Li, Y. L. Chan, A. Ahuja, W. W.M. Lam, A. Wong, and R. Kay Use of Transcranial Doppler Ultrasound to Predict Outcome in Patients With Intracranial Large-Artery Occlusive Disease Stroke, November 1, 2000; 31(11): 2641 - 2647. [Abstract] [Full Text] [PDF]
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H. L. Lutsep and W. M. Clark Association of intracranial stenosis with cortical symptoms or signs Neurology, September 12, 2000; 55(5): 716 - 718. [Abstract] [Full Text] [PDF]
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V. N. Thijs and G. W. Albers Symptomatic intracranial atherosclerosis: Outcome of patients who fail antithrombotic therapy Neurology, August 22, 2000; 55(4): 490 - 498. [Abstract] [Full Text] [PDF]
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M. S. V. Elkind, I-F. Lin, J. T. Grayston, and R. L. Sacco Chlamydia pneumoniae and the Risk of First Ischemic Stroke : The Northern Manhattan Stroke Study Stroke, July 1, 2000; 31(7): 1521 - 1525. [Abstract] [Full Text] [PDF]
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M. R. Jones, R. D. Horner, L. J. Edwards, J. Hoff, S. B. Armstrong, C. A. Smith-Hammond, D. B. Matchar, and E. Z. Oddone Racial Variation in Initial Stroke Severity Stroke, March 1, 2000; 31(3): 563 - 567. [Abstract] [Full Text] [PDF]
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W. N. Kernan, C. M. Viscoli, L. M. Brass, R. W. Makuch, P. M. Sarrel, R. S. Roberts, M. Gent, P. Rothwell, R. L. Sacco, R.-C. Liu, et al. The Stroke Prognosis Instrument II (SPI-II) : A Clinical Prediction Instrument for Patients With Transient Ischemia and Nondisabling Ischemic Stroke Stroke, February 1, 2000; 31(2): 456 - 462. [Abstract] [Full Text] [PDF]
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D. Woo, J. Gebel, R. Miller, R. Kothari, T. Brott, J. Khoury, S. Salisbury, R. Shukla, A. Pancioli, E. Jauch, et al. Incidence Rates of First-Ever Ischemic Stroke Subtypes Among Blacks : A Population-Based Study Stroke, December 1, 1999; 30(12): 2517 - 2522. [Abstract] [Full Text] [PDF]
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E. R Mohler III, N. Delanty, D. J Rader, and E. C Raps Statins and cerebrovascular disease: plaque attack to prevent brain attack Vascular Medicine, November 1, 1999; 4(4): 269 - 272. [Abstract] [PDF]
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T. H. Wein, M. A. Smith, and L. B. Morgenstern Race/Ethnicity and Location of Stroke Mortality : Implications for Population-Based Studies Stroke, August 1, 1999; 30(8): 1501 - 1505. [Abstract] [Full Text] [PDF]
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C. P. Derdeyn, R. L. Grubb Jr., and W. J. Powers Cerebral hemodynamic impairment: Methods of measurement and association with stroke risk Neurology, July 1, 1999; 53(2): 251 - 251. [Abstract] [Full Text] [PDF]
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L. J. Kappelle, M. Eliasziw, A. J. Fox, B. L. Sharpe, and H. J. M. Barnett Importance of Intracranial Atherosclerotic Disease in Patients With Symptomatic Stenosis of the Internal Carotid Artery Stroke, February 1, 1999; 30(2): 282 - 286. [Abstract] [Full Text] [PDF]
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R. W. Baumgartner, H. P. Mattle, and G. Schroth Assessment of >=50% and <50% Intracranial Stenoses by Transcranial Color-Coded Duplex Sonography Stroke, January 1, 1999; 30(1): 87 - 92. [Abstract] [Full Text] [PDF]
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P. B. Gorelick Cerebrovascular Disease in African Americans Stroke, December 1, 1998; 29(12): 2656 - 2664. [Full Text] [PDF]
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D. T. Lackland, D. L. Bachman, T. D. Carter, D. L. Barker, S. Timms, and H. Kohli The Geographic Variation in Stroke Incidence in Two Areas of the Southeastern Stroke Belt : The Anderson and Pee Dee Stroke Study Stroke, October 1, 1998; 29(10): 2061 - 2068. [Abstract] [Full Text] [PDF]
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H. Yonas, M. R. R. Pindzola, C. Yokota, M. Y. Hasegawa, M. K. Minematsu, and M. T. Yamaguchi Effect of Acetazolamide Reactivity and Long-term Outcome in Patients With Major Cerebral Artery Occlusive Diseases • Response Stroke, August 1, 1998; 29 (8): 1742 - 1744. [Full Text]
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Prognosis of Patients With Symptomatic Vertebral or Basilar Artery Stenosis Stroke, July 1, 1998; 29(7): 1389 - 1392. [Abstract] [Full Text] [PDF]
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H. Mast, J. L.P. Thompson, I-F. Lin, C. Hofmeister, A. Hartmann, P. Marx, J. P. Mohr, and R. L. Sacco Cigarette Smoking as a Determinant of High-Grade Carotid Artery Stenosis in Hispanic, Black, and White Patients With Stroke or Transient Ischemic Attack Stroke, May 1, 1998; 29(5): 908 - 912. [Abstract] [Full Text] [PDF]
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C. P. Derdeyn, K. D. Yundt, T. O. Videen, D. A. Carpenter, R. L. Grubb Jr, and W. J. Powers Increased Oxygen Extraction Fraction Is Associated With Prior Ischemic Events in Patients With Carotid Occlusion Stroke, April 1, 1998; 29(4): 754 - 758. [Abstract] [Full Text] [PDF]
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T. Segura, J. Serena, A. Molins, and A. Davalos Clusters of Microembolic Signals: A New Form of Cerebral Microembolism Presentation in a Patient With Middle Cerebral Artery Stenosis Stroke, March 1, 1998; 29(3): 722 - 724. [Abstract] [Full Text] [PDF]
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R. L. Sacco, R. Gan, B. Boden-Albala, I-F. Lin, D. E. Kargman, W. A. Hauser, S. Shea, and M. C. Paik Leisure-Time Physical Activity and Ischemic Stroke Risk : The Northern Manhattan Stroke Study Stroke, February 1, 1998; 29(2): 380 - 387. [Abstract] [Full Text] [PDF]
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P. T. Akins, T. K. Pilgram, D. T. Cross III, and C. J. Moran Natural History of Stenosis From Intracranial Atherosclerosis by Serial Angiography Stroke, February 1, 1998; 29(2): 433 - 438. [Abstract] [Full Text] [PDF]
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J. L. Frey, H. K. Jahnke, and E. W. Bulfinch Differences in Stroke Between White, Hispanic, and Native American Patients : The Barrow Neurological Institute Stroke Database Stroke, January 1, 1998; 29(1): 29 - 33. [Abstract] [Full Text] [PDF]
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P.-K. Yip, J.-S. Jeng, T.-K. Lee, Y.-C. Chang, Z.-S. Huang, S.-K. Ng, and R.-C. Chen Subtypes of Ischemic Stroke : A Hospital-Based Stroke Registry in Taiwan (SCAN-IV) Stroke, December 1, 1997; 28(12): 2507 - 2512. [Abstract] [Full Text]
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