The Relationship of Carotid Plaque, Intima Media Thickness (IMT), Resistivity Index (RI) and Pulsatility Index(PI) in Asian-Indian Patients with Acute Ischemic Stroke with and without Type2 DM


Aim: To determine the relationship of carotid plaque, intima media thickness (IMT), resistivity index (RI) and pulsatility index (PI) and prevalence of different risk factors with acute ischemic stroke and stroke subtypes in both diabetic and non-diabetic subjects. Materials and methods: 80 cases of acute ischemic strokes and 40 healthy controls were included in the study. The plaque, IMT, RI and PI were measured by carotid duplex ultrasound. Results: 31 subjects were Type 2 diabetic, 54 hypertensive while 25 were both diabetic and hypertensive. 23 cases (28.75%) had lacunar stroke (LACI), 32 (40%) stroke involving partial anterior circulation(PACI), 10(12.5%) stroke in posterior circulation (PACI) and 15(18.75%) stroke involving total anterior circulation(TACI) respectively. The mean IMT (0.88 ± 0.19mm), RI(0.76 ± 0.05) and PI(1.71 ± 0.19) of patients and mean IMT (0.6±0.09mm), RI (0.61 ± 0.06) and PI (1.53 ± 0.11) of controls were statistically significant (p-0.000). The mean values of IMT, PI and RI were significantly higher in diabetics (IMT-0.90 ± 0.16 VS 0.64 ± 0.11, p-0.013; PI-1.76 ± 0.20 VS 1.49 ± 0.09, P-0.000 and RI-0.76 ± 0.04 VS 0.59 ± 0.06, P-0.000) and similarly the mean values for IMT, PI and RI in hypertensives as compared to controls (IMT-0.88 ± 0.16 vs 0.65 ± 0.10, P-0.006; PI1.69 ± 0.18 vs 1.49 ± 0.09, P-0.000 and RI 0.76 ± 0.04 vs 0.59 ± 0.06, P-0.000). The mean IMT, PI and RI were increased significantly in smokers compared to controls (IMT-0.93 ± 0.20 vs 0.63 ± 0.06, P-0.000; PI-1.82 ± 0.22 vs 1.49 ± 0.09, P-0.000 and RI-0.77 ± 0.04 vs 0.59 ± 0.06, P-0.000). Type 3 plaque accounted for 27 (56.2%) cases and Type 2 plaque 12 (25%) cases. The total number of plaques in patients as compared to controls were significantly more (P-0.0034) and the mean plaque area was 46 mm2 for cases and 20 mm2 for control (P-0.0001). TACI was the most common type of ischemic stroke seen in DM (60%), HTN (66.6%) and smokers (66.7%). Plaques (73.3%), IMT (0.90 ± 0.12), PI(1.72 ± 0.14) and RI (0.76 ± 0.13) were more commonly associated with TACI subtype. On multivariate analysis using ANOVA, the mean PI was highly significant (0.000) in relation to types of plaque. Summary and Conclusions: IMT, RI, PI and plaque type are useful diagnostic parameters for acute ischemic stroke and its subtypes. They can be used as noninvasive tools for predicting and preventing ischemic stroke in smokers as well as subjects with DM and hypertension.

Share and Cite:

S. Das, K. Chakrabarty, M. Patnaik, L. Roul, J. Mohanty and S. Singh, "The Relationship of Carotid Plaque, Intima Media Thickness (IMT), Resistivity Index (RI) and Pulsatility Index(PI) in Asian-Indian Patients with Acute Ischemic Stroke with and without Type2 DM," International Journal of Clinical Medicine, Vol. 2 No. 5, 2011, pp. 561-567. doi: 10.4236/ijcm.2011.25092.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] S. E. Sridharan, J. P. Unnikrisnan, S. Sukumaran, P. N. Sylyja, S. D. Nayak, P. S. Sarma, et al., “Incidence, Types, Risk Factors, and Outcome of Stroke in a Developing Country: The Trivandrum Stroke Registry,” Stroke, Vol. 40, No. 4, 2009, pp. 1212-1218. doi:10.1161/STROKEAHA.108.531293
[2] G. A. Donnan, M. Fisher, M. Macleod and S. M. Davis, “Stroke,” Lancet, Vol. 371, 2008, pp. 1612-1623. doi:10.1016/S0140-6736(08)60694-7
[3] K. Strong, C. Mathers and R. Bonita, “Preventing Stroke: Saving Lives around the World,” Lancet Neurology, Vol. 6, No. 2, 2007, pp. 182-187. doi:10.1016/S1474-4422(07)70031-5
[4] C. J. Murray and A. D. Lopez, “Alternative Projections of Mortality and Disability by Cause. 1990-2020: Global Burden of Disease Study,” Lancet, Vol. 349, No. 9064, 1997, pp. 1498-1504. doi:10.1016/S0140-6736(96)07492-2
[5] J. D. Pandian, V. Srikanth, S. J. Read and A. G. Thrift, “Poverty and Stroke in India: A Time to Act,” Stroke, Vol. 38, No. 11, 2007, pp. 3063-3069. doi:10.1161/STROKEAHA.107.496869
[6] Indian Economy Overview, 2011.
[7] World Health Organization. The World Health report 2004: Changing history. Geneva: WHO, 2004.
[8] V. L. Feigin, “Stroke in Developing Countries: Can the Epidemic Be Stopped and Outcomes Improved?” Lancet Neurology, Vol. 6, No. 2, 2007, pp. 94-97. doi:10.1016/S1474-4422(07)70007-8
[9] W. S. Smith, J. D. English and S. C. Johnston, “Cerebrovascular Disease,” 17th Edition, Harrison’s Principle of Internal Medicine, McGraw Hill & Co., New York, 2008, pp. 2513-2535.
[10] D. A. De Silva, F. P. Woon, M. P. Lee, C. P. Chen, H. M. Chang and M. C. Wong, “South Asian Patients with Ischemic Stroke Intracranial Large Arteries Are the Predominant Site of Disease,” Stroke, Vol. 38, No. 9, 2007, pp. 2592-2594. doi:10.1161/STROKEAHA.107.484584
[11] M. L. Eigenbrodt, Z. Brusac, R. E. Tracy, J. L. Meheta, K. M. Rose and D. J. Couper, “B-Mode Ultrasound Common Carotid Artery Intima-Media Thickness and External Diameter: Cross-Sectional and Longitudinal Associations with Carotid Atherosclerosis in a Large Population Sample,” Cardiovascular Ultrasound, Vol. 6, No. 10, 2008, pp. 10- 16. doi:10.1186/1476-7120-6-10
[12] S. H. Johnsen and E. B. Mathiesen, “Carotid Plaque Compared with Intima-Media Thickness as a Predictor of Coronary and Cerebrovascular Disease,” Current Cardiology Reports, Vol. 11, No. 1, 2009, pp. 21-27. doi:10.1007/s11886-009-0004-1
[13] G. Belcaro, A. N. Nicolaides, G. Laurora, M. R. Cesarone, M. De Sanctis, L. Incandela, et al., “Ultrasound Morphology Classification of the Arterial Wall and Cardiovascular Events in a 6-Year Follow-up Study,” Arteriosclerosis, Thrombosis, and Vascular Biology, Vol. 16, No. 7, 1996, pp. 851-856. doi:10.1161/01.ATV.16.7.851
[14] M. G. Veller, C. M. Fisher and A. N. Nicolaides, “Measurement of the Ultrasonic Intima-Media Complex Thickness in Normal Subjects,” Journal of Vascular Surgery, Vol. 17, No. 4, 1993, pp. 719-725. doi:10.1016/0741-5214(93)90116-4
[15] S. Ebrahim, O. Papacosta, P. Whincup, G. Wannamethee, M. Walker, A. N. Nicolaides, et al., “Carotid Plaque, Intima Media Thickness, Cardiovascular Risk Factors, and Prevalent Cardiovascular Disease in Men and Women. The British Regional Heart Study,” Stroke, Vol. 30, 1999, pp. 841-850. doi:10.1161/01.STR.30.4.841
[16] K. Potter, C. J. Reed, D. J. Green, G. J. Hankey and L. F. Arnolda, “Ultrasound Settings Significantly Alter Arterial Lumen and Wall Thickness Measurements,” Cardiovascular Ultrasound, Vol. 6, No. 6, 2008, pp. 1-6.
[17] J. T. Salonen and R. Salonen, “Ultrasound B-Mode Imaging in Observational Studies of Atherosclerotic Progression,” Circulation, Vol. 87, Supplement 2, 1993, pp. 56-65.
[18] C. Bonithon-Kopp, P. J. Touboul and C. Berr, “Relation of Intima-Media Thickness to Atherosclerotic Plaques in Carotid Arteries. The Vascular Aging (EVA) Study,” Arteriosclerosis, Thrombosis, and Vascular Biology, Vol. 16, 1996, pp. 310-316. doi:10.1161/01.ATV.16.2.310
[19] M. L. Bots, A. Hofman, P. T. De Jong and D. E. Grobbee, “Common Carotid Intima-Media Thickness as an Indicator of Atherosclerosis at Other Sites of the Carotid Artery. The Rotterdam Study,” Annals of Epidemiology, Vol. 6, No. 2, 1996, pp. 147-153. doi:10.1016/1047-2797(96)00001-4
[20] S. Glagov, C. Zarins, D. P. Giddens and D. N. Ku, “Hemodynamics and Atherosclerosis. Insights and Perspectives Gained from Studies of Human Arteries,” Archives of Pathology & Laboratory Medicine, Vol. 112, 1988, pp. 1018-1031.
[21] P. M. Dalal, “Studies in Young and Elderly: Risk Factors and Strategies for Stroke Prevention,” Journal of the Association of Physicians of India, Vol. 45, 1997, pp. 125- 131.
[22] P. M. Dalal and M. Bhattacharjee, “Stroke Epidemic in India: Hypertension-Stroke Control Programme Is Urgently Needed,” Journal of the Association of Physicians of India, Vol. 55, 2007, pp. 689-691.
[23] P. A. Barnett, J. D. Spence, S. B. Manuck and J. R. Jennings, “Psychological Stress and the Progression of Carotid Artery Disease,” Journal of Hypertension, Vol. 15, 1997, pp. 49-55. doi:10.1097/00004872-199715010-00004
[24] J. D. Spence, M. Eliasziw, M. DiCicco, G. D. Hackam, R. Galil and T. Lohmann, “Carotid Plaque Area: A Tool for Targeting and Evaluating Vascular Preventive Therapy,” Stroke, Vol. 33, 2002, pp. 2916-2922. doi:10.1161/01.STR.0000042207.16156.B9
[25] L. M. Cupini, P. Pasqualetti, M. Diomedi, F. Vernieri, M. Silvestrini, B. Rizzato, et al., “Carotid Artery Intimamedia Thickness and Lacunar versus Nonlacunar Infarcts,” Stroke, Vol. 33, No. 3, 2002, pp. 689-694. doi:10.1161/hs0302.103661
[26] D. H. O’Leary, J. F. Polak, R. A. Kronmal, T. A. Manolio, G. L. Burke and S. K. Wolfson, “Carotid-Artery Intima and Media Thickness as a Risk Factor for Myocardial Infarction and Stroke in Older Adults,” New England Journal of Medicine, Vol. 340, No. 1, 1999, pp. 14-22. doi:10.1056/NEJM199901073400103
[27] T. Fukuhara and K. Hida, “Pulsatility Index at the Cervical Internal Carotid Artery as Parameter of Microangiopathy in Patients with Type 2 Diabetes,” Journal of Ultrasound in Medicine, Vol. 25, No. 5, 2006, pp. 599- 605.
[28] K. Y. Lee, Y. H. Sohn, J. S. Baik, G. W. Kim and J. S. Kim, “Arterial Pulsatility as an Index of Cerebral Microangiopathy in Diabetes,” Stroke, Vol. 31, No. 5, 2000, pp. 1111-1115. doi:10.1161/01.STR.31.5.1111
[29] K. O. Lee, K. Y. Lee, Y. S. Lee, C. W. Ahn and J. S. Park, “Lacunar Infarction in Type 2 Diabetes Is Associated with an Elevated Intracranial Arterial Pulsatility Index,” Yonsei Medical Journal, Vol. 48, No. 5, 2007, pp. 802- 806. doi:10.3349/ymj.2007.48.5.802
[30] D. Staub, A. Meyerhans, B. Bundi, H. P. Schmid and B. Frauchiger, “Prediction of Cardiovascular Morbidity and Mortality: Comparison of the Internal Carotid Artery Resistive Index with the Common Carotid Artery Intima-Media Thickness,” Stroke, Vol. 37, 2006, pp. 800- 805. doi:10.1161/01.STR.0000202589.47401.c6
[31] D. Nagaraja, G. Gururaj, N. Girish, S. Panda, A. K. Roy, G. R. K. Sarma, et al., “Feasibility Study of Stroke Surveillance: Data from Bangalore, India,” Indian Journal of Medical Research, Vol. 130, No. 4, 2009, pp. 396-403.
[32] T. Nakatou, K. Nakata, A. Nakamura and T. Itoshima, “Carotid Haemodynamic Parameters as a Risk Factors in Type2 Diabetic Patients,” Diabetic Medicine, Vol. 21, 2004, pp. 223-229. doi:10.1111/j.1464-5491.2004.01108.x
[33] R. Sahoo, M. V. Krishna, D. K. S. Subrahmaniyan, T. K. Dutta and S. Elangovan, “Common Carotid Intima-Media Thickness in Acute Ischemic Stroke: A Case Control Study,” Neurology India, Vol. 57, No. 5, 2009, pp. 627- 630. doi:10.4103/0028-3886.57822
[34] J. Bamford, P. Sandercock, M. Dennis, J. Burn and C. Warlow, “Classification and Natural History of Clinically Identifiable Subtypes of Cerebral Infarction,” Lancet, Vol. 337, 1991, pp. 1521-1526. doi:10.1016/0140-6736(91)93206-O
[35] B. Frauchiger, H. P. Schmid, C. Roedel, P. Moosmann and D. Staub, “Comparison of Carotid Arterial Resistive Indices with Intima-Media Thickness as Sonographic Markers of Atherosclerosis,” Stroke, Vol. 32, 2001, pp. 836-841. doi:10.1161/01.STR.32.4.836
[36] P. Nikic, M. Savic, V. Jakovljevic and D. Djuric, “Carotid Atherosclerosis, Coronary Atherosclerosis and Carotid Intima-Media Thickness in Patients with Ischemic Cerebral Disease: Is There Any Link?” Experimental & Clinical Cardiology, Vol. 11, No. 2, 2006, pp. 102-106.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.