Perspectives in Medicine (2012) 1, 156159

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

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 156159

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

Breath holding index and arterial stiffness in

evaluation of stroke risk in diabetic patients
Iris Zavoreo, Vanja Basic Kes, Lejla Coric, Vida Demarin

University Department of Neurology, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia

KEYWORDS Summary
Background: The aim of the study was to evaluate correlation of breath holding index (BHI) as
Arterial stiffness;
functional parameter for intracranial subclinical atherosclerotic changes we have shown in
Breath holding index;
our previous works and arterial stiffness (AS functional parameter for extracranial subclinical
Diabetes mellitus
atherosclerotic changes) in diabetic patients with well and poor controlled glucose blood values
in correlation with healthy population.
Patients and methods: We included 60 volunteers divided into 3 aged standardized groups
healthy volunteers, patients with well controlled diabetes and patients with poor controlled
diabetes. We excluded individuals with moderate and severe carotid stenosis.
Results: There was decreasing trend in BHI values and increasing trend in AS values in diabetic
patients, especially with poor regulated blood glucose values (r = 0.14 and 1.42; p < 0.05).
Conclusion: These results show that decline in BHI as parameter for intracranial microvessel
dysfunction is in good correlation with increase of AS as functional parameter of extracranial
vascular aging in diabetic patients.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Introduction morbidity is greater than in those without this underlying

Stroke is the third most frequent cause of death worldwide
and the most frequent cause of permanent disability. There
are numerous risk factors for atherosclerosis and stroke,
some of them can be modied and some of them not. A
large proportion of patients who suffered stroke, either
has or is later diagnosed with diabetes (1624%). Patients
with diabetes are at 1.53 times the risk of stroke com-
pared with general population and associated mortality and
Corresponding author at: Fellow of Croatian Academy of Sci-
ence and Arts, Head of University Department of Neurology, Sestre
Milosrdnice University Hospital, HR-10000, Zagreb, Vinogradska 29,
Croatia. Tel.: +385 1 376 82 82; fax: +385 1 376 82 82.
E-mail address: vida.demarin@zg.t-com.hr (V. Demarin).
condition. Even patients with metabolic syndrome compo-
nent have a 1.5-fold increased risk of stroke [1,2]. This is
primarily due to increased proatherogenic risk factors
abnormal plasma lipid proles, hypertension, and hyper-
glycemia. However, other pathological features associated
with diabetes, such as insulin resistance and hyperinsuline-
mia, also lead to atherosclerotic changes in extracranial
and intracranial vessels independently of glycemia or other
attendant risk factors. This is particularly expressed in
smaller cerebral vessels increasing the incidence of both
overt and silent lacunar infarctions. One of the modiable
risk factors is diabetes mellitus.
Generally, vascular complications of diabetes can be
separated into microvascular (diabetic nephropathy, neu-
ropathy and retinopathy) and macrovascular (coronary
disease, cerebrovascular disease, peripheral artery disease)
complications.

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

doi:10.1016/j.permed.2012.02.042
BHI and AS in diabetic patients
Atherosclerotic manifestations can be divided in early
stages endothelial dysfunction, increase in arterial
stiffness, and increase of intimamedia thickness. Later
atherosclerotic of blood vessels stages can be recognized
as atherosclerotic plaques which provide different grade of
vessel lumen stenoses [3].
In addition to atheroma formation, there is a strong evi-
dence of increased platelet adhesion, hypercoagulability,
impaired nitric oxide generation and increased free radical
formation as well as altered calcium regulation in diabetic
patients.
Cerebral autoregulation is the ability to maintain con-
stant cerebral blood ow despite changes in the cerebral
perfusion pressure. Breath holding method was introduced
in early 90s as reproducible, non-invasive screening method
to study cerebral hemodynamic by means of Transcranial
Doppler (TCD). It is accurate, specic and sensitive method
for evaluation of cerebral vasoreactivity in comparison with
other methods (functional magnetic resonance imaging
MR, positron emission tomography PET, single photon
emission computed tomography SPECT). In our previous
works we standardized breath holding index (BHI) values for
different age and sex groups [3,4].
Recently pulse pressure amplication and arterial
mechanics, most often explored as arterial stiffness
(inversely related to arterial strain-measurement of arte-
rial volume load and physiological answer of the body to
increased pressure load expressed as pulse pressure) are
named as those with greatest sensitivity for vascular event
prediction [57].
E-tracking is new automatized software for evaluation
of the vessel wall functions, it enables monitoring vessel
wall biomechanical parameters and early detection of the
subclinical extracranial vessel atherosclerotic changes [8,9].
The most efcient stroke management is primary and
secondary prevention, optimal prevention would be to rec-
ognize atherosclerotic changes in their early subclinical
stages. BHI would provide information about intracra-
nial vessel function and arterial stiffness would provide
information about extracranial arteries biomechanical char-
acteristics. According to those ndings we can recognize
atherosclerosis in its subclinical stages and apply principles
of primary and secondary prevention [10,11].
Patients and methods
We included 60 volunteers in our study, 20 healthy vol-
unteers and 40 diabetic type 2 patients 20 with well
controlled serum glucose levels and 20 with poor controlled
serum glucose levels. All subjects were fully informed about
the study and they signed informed consent approved by the
Hospital Ethic Committee.
We performed standard laboratory workup, blood pres-
sure measurement, CT scan, Color Doppler and Power
Doppler of the main head and neck vessels and Transcra-
nial Doppler, as well as BHI and arterial stiffness (measured
by means of e-Tracking software).
All ultrasound measurements were performed in supine
position with head elevation of up 45 and side tilt of 30 to
the right and to the left.
157
The TCD examination was performed by TCD DWL Mul-
tidop X4 instrument with 2 MHz hand-held pulsed wave
Doppler probe. TCD was performed in supine position
after 5 min bed rest. Probe was positioned over each
transtemporal window, arteries of the Willis circle were
insonated by standard protocol and mean blood ow values
(MBFV) were recorded. Blood vessels of the vertebrobasi-
lar system were insonated by standard protocol trough the
suboccipital window with the same probe, in the sitting
position.
Mean velocity of middle cerebral artery (MCA) was
continuously monitored during the breath holding test.
Baseline was dened as a continuous mean velocity value
through 30 s after an initial 5 min resting period Vmean .
Subjects were asked to hold their breath for 30 s after
normal inspiratory breath to exclude Vasalva maneuver.
Subjects who could not hold their breath for 30 s, held
their breath as long as they could and that time was
taken for the calculations afterwards. MBFV of last 3 s
of breath hold period were recorded and taken as Vmax .
This procedure was repeated after 2 min resting period
and the mean value of both measurements was taken.
For further analysis BHI was calculated as percentage
increase in MBFV occurring during breath holding divided
by the time (s) for which the subject hold his/her breath
[12,13].
Technology of new software application enables calculat-
ing of functional indexes of the blood vessel walls during the
examination. Aloka is one of the leading companies which
developed such software for evaluating patients vascular
status and vascular age at bedside. Evaluation of extracra-
nial blood vessels was performed by Color Doppler Flow
Imaging (CDFI) and Power Doppler Imaging (PDI) method
by Aloka 5500 Prosound, 7.5 MHz linear probe in a stan-
dardized manner (B, D and M mode, and/or combination).
In this application we use two waves in order to collect
data pulse wave for Doppler (D mode) information and
continuous ultrasonic wave (M mode). These two waves
are independent because they are using different angle of
insonation (M mode = 90 , D mode <60 ). These two waves
cross in the middle of the sample volume (angle modi-
cation 30 up to +30 ), the sample volume is placed in
the middle of the arterial lumen (at 1.5 cm in the common
carotid artery proximally to the ow divider) and cursors
for vessel wall motility monitoring are placed at the bor-
der of the tunica media and tunica adventitia at the far
and near arterial wall (the rst hyperechoic line is repre-
senting the border between the vessel lumen and IMT, the
second one is representing the border between IMT and
adventitia). This software also includes ECG monitoring in
order to monitor vessel wall motility during cardiac cycle
(systolic and diastolic changes). At the end of the mea-
surement, vessel motility parameters appear in the form
of report arterial stiffness was taken as measure of ves-
sel wall function (blood pressure logarithm/change of vessel
wall diameter).
Statistical analysis of different groups of subjects was
performed by Students t test (statistical signicance was
obtained at p < 0.05 value). Variation coefcient was calcu-
lated for BHI values as a measure of data dispersion for each
group. MBFV and BHI values were compared using Pearsons
linear correlation coefcient.
158 I. Zavoreo et al.

Table 1 Patients data (values are presented as mean values and standard deviations).

Mean age Serum glucose levels (mmol/L) AS BHI

Controls 55 12 4.63 0.71 6.57 1.14 1.56 0.18

Well controlled diabetic patients 56 11 5.25 0.65 9.21 0.8 1.34 0.09
Poor controlled diabetic patients 58 10 7.84 1.61 12.15 1.16 1.09 0.08

Results measured BHI in MCA. Also, in our previous studies we have

The aim of this study was to evaluate BHI and AS in healthy
population in correlation with diabetic patients with good
and poor regulated serum glucose levels, groups were aged
standardized in order to minimize impact of age as risk fac-
tor for vascular aging.
Data did not show any statistically signicant differences
in BHI and AS values between the left and right side of Willis
circle as well as for common carotid artery, and this distinc-
tion was excluded from the model. There was no difference
in mean BHI and AS values between males and females there-
fore we presented pooled data mean BHI and AS values and
SD for each group (Table 1). In healthy volunteers all values
remain in range between 1.03 and 1.65 there is decreas-
ing trend in BHI values and increasing trend of AS values
depending on glucose control (p < 0.05) (Fig. 1).
There was increase in AS in correlation with glucose lev-
els (r = 1.42, p < 0.05), there was no statistically signicant
differences between left and right side as well as the sex dif-
ferences in evaluated model, therefore we presented pooled
data. There was statistically signicant negative correlation
between BHI and serum glucose levels (r = 0.14, p < 0.05)
in all groups, especially in group of diabetic patients with
poorly controlled glucose levels.
Discussion
Results of the previous studies have shown that there is no
statistically signicant differences between BHI in anterior
(anterior ACA and middle cerebral artery MCA) and
posterior circulation (posterior PCA, vertebral VA and
basilar BA arteries) in individuals without atherosclerotic
plaques on the main head and neck vessels, therefore we
16
AS
14
12
10
8
6
4 In our case we have shown that glucose control is of great
2 importance in diabetic patients in order to prevent vascular
0
BHI
0 2 4 6 8 10
Glucose levels mmol/L
Fig. 1 Correlation between breath holding index and arterial
stiffness according to different serum glucose values.
standardized BHI measurement method and we have shown
that BHI is linear index, therefore there is no difference
between short (<27 s) and long (>27 s) measurement times
[1214].
Due to changes that are present as a part of a cardio-
vascular aging including small vessel pathomorphological
changes amyloid angiopathy, arteriolosclerosis, capillary
endothelial and basement membrane changes (increasing of
the vessel wall stiffness) we found normal decrease of BHI
and increase of AS in healthy population (risk free) according
to age and pathological changes of this parameters accord-
ing to changed glucose metabolism [15]. This data are in
correlation with previous studies IRAS (The Insulin Resis-
tance Atherosclerosis Study) has shown that diabetes and
glucose intolerance are independent risk factors connected
with increase in intimamedia thickness (IMT). SANDS trial
(The Stop Atherosclerosis in Native Diabetics Study) have
shown that reduction in other cerebrovascular risk factors
(hypertension, hyperlipoproteinemia) can slower progres-
sion of IMT thickening in diabetic patients [16,17].
Previous studies as well as our results suggest that
mechanical arterial properties (changes in BHI, AS as func-
tional parameters) are affected rst while hemodynamic
remains preserved (mean velocities were unchanged due
to cerebral autoregulation mechanisms which are preserved
in healthy individuals). Our results suggesting that there is
a good correlation of BHI as functional parameter which
reect functional state of the intracerebral blood vessels
with arterial stiffness as functional parameter for extracra-
nial blood vessels (CCA in our case) in population with
diabetes mellitus [10,1517].
Different pathophysiological mechanisms during the life-
time cause vessel wall aging and subclinical endothelial
dysfunction which is the rst stage of the atherosclerosis,
subtle change of vessel wall before appearance of either
vascular remodeling (diameter increase), intimamedia
thickening or plaque formation. This state is irreversible and
it is early marker of atherosclerosis as well as systolic pres-
sure increase and pulse pressure increase. Increased arterial
stiffness and decrease in BHI values are normal in advanced
age, but in younger individuals this changes are rst signs
of subclinical atherosclerosis, such individuals should be
screened for cerebrovascular risk factors and followed up.
aging [3,7,11,15].
We have shown that diabetic patients are at increased
risk for cerebrovascular disease, but further studies should
be performed in order to evaluate impact of changes in AS
and BHI on other clinical manifestations (cognitive decline,
every day activities, etc.) in diabetic patients [18,19].
BHI and AS in diabetic patients 159

References evaluation of carotid arterial wave intensity and reproducibil-

ity. Heart Vessels 2000;17:1221.
[10] Jurasic M-J, Lovrencic-Huzajn A, Roje Bedekovic M, Demarin
[1] Warlow C, Sudlow C, Dennis M, Wardlaw J, Sanderack P. Stroke.
V. How to monitor vascular aging with ultrasound. J Neurol Sci
Lancet 2003;362:121124.
2007;257:13942.
[2] Demarin V, Lovrencic-Huzjan A, Trkanjec Z, Vukovic V,
[11] Zavoreo I, Demarin V. Breath Holding Index and arte-
Vargek-Solter V, Seric V, et al. Recommendations for
rial stiffness as markers of vascular aging. Curr Aging Sci
stroke management 2006 update. Acta Clin Croat 2006;45:
2010;3(1):6770.
21985.
[12] Markus HS, Harrison MJG. Estimation of cerebrovascular reac-
[3] Spence JD. New approaches to atherosclerosis based on
tivity using transcranial Doppler, including the use of breath-
endothelial function. In: U: Fisher M, Bogousslavsky J, edi-
holding as the vasodilatory stimulus. Stroke 1992;23:66873.
tors. Current review of cerebrovascular disease. Philadelphia:
[13] Zavoreo I, Demarin V. Breath holding indexes in evaluation of
Current Medicine Inc.; 2001. p. 114.
cerebral vasoreactivity. Acta Clin Croat 2004;43:159.
[4] Aleksandrov AV. Imaging cerebrovascular disease with ultra-
[14] Gur AY, Bornstein NM. Cerebral vasomotor reactivity of the pos-
sound. Cerebrovasc Dis 2003;16:13.
terior circulation in patients with carotid occlusive disease. Eur
[5] Howard G, Sharrett AR, Heiss G, Evans GW, Chambless LE,
J Neurol 2003;10(1):758.
Riley WA, et al. Carotid intimal-medial thickness distribution in
[15] Rajala U, Laakso M, Paivansalo M, PelkonenO, Suramo I,
general populations as evaluated by B-mode ultrasound. ARIC
Keinanen-Kiukaanniemi S. Associations of blood pressure with
Investigators. Stroke 1993;24:1297304.
carotid intimamedia thickness in elderly Finns with dia-
[6] Iglesias del Sol A, Moons KGM, Hollander M, Hofman A, Kous-
betes mellitus or impaired glucose tolerance. J Hum Hypertens
taal PJ, Diederick. Is carotid intimamedia thickness useful in
2003;17(10):70511.
cardiovascular disease risk assessment? The Rotterdam study.
[16] Festa A, DAgostino Jr R, Tracy RP, Haffner SM. The insulin
Stroke 2001;32:15328.
resistance atherosclerosis study. Circulation 2000;102:427.
[7] Sugioka K, Hozumi T, Sciacca RR, Miyake Y, Titova I, Gaspard G,
[17] Evans EL, Ojhita RP, Fischbach LA. Oral hypoglycemic use and
et al. Impact of aortic stiffness on ischemic stroke in elderly
the SANDS Trial. JAMA 2008;300(4):38992.
patients. Stroke 2002;33(8):207781.
[18] Demarin V, Basic Kes V, Morovic S, Zavoreo I. Neurosonology:
[8] Van Bortel LM, Duprez D, Starmans-Kool MJ, Safar ME, Gian-
a means of evaluating normal aging versus dementia. Aging
nattasio C, Cockcroft J, et al. Clinical applications of arterial
Health 2008;4(5):52934.
stiffness, task force. III. Recommendations for user procedures.
[19] Zavoreo I, Kes VB, Morovic S, Seric V, Demarin V. Breath hold-
AJH 2002;15:44552.
ing index in detection of early cognitive decline. J Neurol Sci
[9] Niki K, Sugawara M, Chang D, Harada A, Okada T, Sakai R, et al.
2010;299(December (12)):1169.
A new noninasive measurement system for wave intensity: