Intracranial atherosclerotic stenosis: risk factors, diagnosis, and treatment

High-risk characteristics of recurrent ischemic stroke after intensive medical management for 6-month follow-up: a histogram study on vessel wall MRI

OBJECTIVE

Intensive medical management has been recommended for ischemic stroke of intracranial atherosclerosis (ICAS), but 9.4-15% probability of recurrent stroke remains an inevitable reality. The characteristics of high-risk intracranial plaque that contribute to stroke recurrence after intensive therapy are unclear.

METHODS

The patients of acute ischemic stroke due to ICAS from two centers were prospectively analyzed, who underwent the 3D high-resolution head and neck vessel wall magnetic resonance imaging (hr-VW-MRI) at baseline and received intensive medical management within 90 days. The morphological features, such as minimal lumen area (MLA), and histogram parameters including entropy were assessed based on hr-VW-MR images. The recurrence of ischemic events after 6 months was defined as hyperintensity on diffusion-weighted images in the ipsilateral vascular territory. Cox regression analysis was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for recurrent events.

RESULTS

A total of 222 patients (age 59.5 ± 12.1; males 153) were finally included, and 38 had recurrent stroke after 6 months. After adjusting the age and gender, Cox regression demonstrated that smoking (HR = 4.321; 95% CI, 1.838-10.161; p = 0.001), taking exercise (HR = 0.409; 95% CI, 0.198-0.843; p = 0.015), blood pressure management (HR = 0.180; 95% CI, 0.073-0.443; p = 0.001), MLA (HR = 0.771; 95% CI, 0.625-0.951; p = 0.015) and entropy (HR = 0.274; 95% CI, 0.130-0.576; p = 0.001) were significant predictors of recurrent ischemic stroke. However, the area under curve value of MRI parameters was significantly higher than that of traditional clinical factors (0.86 vs 0.79; p = 0.01).

CONCLUSIONS

The plaque characteristics based on hr-VW-MRI may provide complementary values over traditional clinical features in predicting ischemic recurrence for ICAS.

KEY POINTS

Question The study addresses recurrent ischemic stroke in intracranial atherosclerosis patients, identifying high-risk plaque features that contribute to recurrence despite intensive medical management. Findings Plaque features on high-resolution vessel wall magnetic resonance imaging (hr-VW-MRI), such as minimal lumen area and entropy, improve prediction of stroke recurrence over clinical factors. Clinical relevance This two-center prospective study improves patient care by using hr-VW-MRI and histogram factors like entropy to better predict stroke recurrence, allowing for more personalized treatment strategies and potentially reducing ischemic events in patients with intracranial atherosclerosis.

Intracranial stenosis prediction using a small set of risk factors in the Tromsø Study

Intracranial atherosclerotic stenosis (ICAS) refers to a narrowing of intracranial arteries due to plaque buildup on the inside of the vessel walls restricting blood flow. Early detection of ICAS is crucial to prevent serious consequences such as stroke. Here we apply three different machine learning methods, such as support vector machines, multi-layer perceptrons and Kolmogorov-Arnold Networks to predict ICAS according to sparse risk factors from blood lipids and demographic data, including smoking habits, age, sex, diabetes, blood pressure lowering and cholesterol-lowering drugs and high-density lipoprotein. We achieved similar performance on classification compared to modern detection algorithms for ICAS in TOF-MRA (time-of-flight magnetic resonance angiography). The prevalence of ICAS in the population is relatively low, which is often case in medicine. While in the medical research community, the issue of low prevalence is established, machine learning-based research in medicine often does not take into account a critical viewpoint of the prevalence in clinical settings of their methods. We showed that with a balanced training/test set an accuracy up to 81% was achievable, while with the inclusion of prevalence, the positive predictive value was at 19% to the prevalence data, changes the performance metrics. Therefore, we highlighted the discrepancy that can arise between the results reported by the models and their clinical relevance. Furthermore, the results demonstrate the predictive potential of limited risk factors, highlighting its potential contribution to a multi-modular classification algorithm based on MRAs.

Local artery geometry characteristics associated with middle cerebral atherosclerotic stenosis

OBJECTIVES

The impact of artery geometry on intracranial atherosclerosis (ICAS) is unclear. To investigate the association between local artery geometry characteristics and middle cerebral atherosclerotic stenosis.

METHODS

This was a case-control study. ICAS patients with more than 50% stenosis in one M1 pre-bifurcation segment but no significant stenosis on the other side were included. The stenosis degree, diameter, length, angle, and morphology (straight-shape, U-shape, and S-shape) of the M1 pre-bifurcation segments were measured by using digital subtraction angiography (DSA) combined with computed tomography angiography (CTA) and 3D reconstruction imaging. The geometry characteristics on both sides were compared. The conditional multivariate Logistics regression was used to investigate the association between stenotic sides and the geometry characteristics.

RESULT

A total of 133 patients, 266 M1 pre-bifurcation segments, were included. Compared with non-stenotic sides, stenotic sides showed smaller diameters (2.873 ± 0.456 mm vs. 2.993 ± 0.360 mm, P = 0.002) and larger tortuosity index (7.61% vs. 6.45%, P = 0.048). The S-shape M1 pre-bifurcation segment was independently associated with the stenotic sides (OR = 3.509, 95% CI 1.176-10.468, P = 0.024). The stenotic side was worse fitted to Murray's law (mean square error 0.326 vs. 0.313).

CONCLUSIONS

The morphology of the M1 pre-bifurcation segment was associated with middle cerebral atherosclerotic stenosis.

Hemodynamics of distal cerebral arteries are associated with functional outcomes in symptomatic ischemic stroke in middle cerebral artery territory: A 4D flow CMR study

BACKGROUND

Cerebrovascular hemodynamics are believed to play an important role in the development of ischemic stroke (IS). However, the relationships between hemodynamics and prognosis are not fully understood. Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) enables comprehensive characteristics of cerebrovascular hemodynamics. This study aims to investigate the associations of the different hemodynamics derived from 4D flow CMR with IS functional outcomes.

METHODS

91 patients (median age 64 years, 62 males) with unilateral IS in middle cerebral artery (MCA) territory were included. All subjects underwent a CMR scan, including 4D flow, three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA), 3D whole brain black-blood high-resolution vessel wall imaging (HR-VWI) of the MCA. Six hemodynamics, including flow rate, velocity, pulsatility index, time-averaged WSS (TAWSS), oscillatory shear index and relative residence time (RRT) were calculated for the lesion site, pre-bifurcation M1 (pM1) segment and the distal M1 and/or first branches of M2 (dM1/M2) segments. Vessel characteristics such as lumen area, vessel area, wall area, maximum wall thickness and the degree of stenosis were calculated at the most stenotic lesion site. The modified Rankin Scale (mRS) scores were assessed at 90 days and one year, and a mRS >2 was considered as a poor functional outcome.

RESULTS

Lower segment-level TAWSS (OR:0.24, P=0.006 and OR: 0.29, P=0.014), higher RRT (OR: 2.74, P=0.007 and OR: 2.40, P=0.011) of dM1/M2 segments and lower segment- and lesion-level velocity (OR: 0.40, P=0.019 and OR: 0.41, P=0.025; OR: 0.41, P=0.030 and OR: 0.42, P=0.040) of pM1 segment were observed to be associated with poor functional outcome at both 90 days and one year. Using the cut-off value of 3.58Pa and 0.29, respectively, TAWSS and RRT of dM1/M2 segments showed moderate estimate performance in distinguishing poor functional outcome from favorable outcome (AUCs range from 0.642-0.687) both at 90 days and one year.

CONCLUSION

Distal segmental TAWSS and RRT of dM1/M2 segments were associated with poor functional outcomes. Such alterations of hemodynamics might help for the identification of patients with potential unfavorable prognosis.

High-risk plaque characteristics associated with recurrent stroke in patients with intracranial stenosis: a systematic review and meta-analysis

BACKGROUND

Risk stratification based on intracranial plaque characteristics is crucial for patients with intracranial atherosclerosis (ICAS). Nonetheless, there remains a significant deficit of validated imaging markers capable of predicting recurrent strokes. Consequently, we conducted a systematic review and meta-analysis to investigate the prognostic significance of high-risk plaque characteristics (HPCs) in relation to recurrent stroke.

METHODS

The systematic review was registered in PROSPERO (CRD420245820945). We systematically searched PubMed, Ovid Medline, and Web of Science for studies evaluating the association between HPCs and risk of stroke recurrence. Data were aggregated and pooled using a random-effects meta-analysis. Heterogenicity and publication bias were assessed, with subgroup and sensitivity analyses performed where appropriate.

RESULTS

Eighteen studies, comprising 13 prospective and 5 retrospective, involving a total of 4967 patients (3594 symptomatic, and 1373 asymptomatic), were included in the analysis. Among symptomatic patients, those with HPCs exhibited a higher incidence of stroke recurrence compared to those without HPCs (adjusted HR, 3.90 ([95% CI, 2.15-7.08]). ICAS patients with baseline plaque enhancement (adjusted HR, 5.20 [95% CI, 3.12-8.66]), calcification (adjusted HR, 2.92 [95% CI, 1.32-6.45]), high plaque steepness (adjusted HR, 110.27 [95% CI, 4.75-2559.74]), and progression in plaque burden (adjusted HR, 6.29 [95% CI, 1.62-24.45]) were identified as being at an increased risk of stroke recurrence. Subgroup analyses revealed that traditional cerebrovascular risk factors, including increasing age, hypertension, diabetes mellitus, and smoking, further elevated the risk of HPC-related stroke recurrence in ICAS patients.

CONCLUSION

The identification of HPCs confers independent prognostic value for the prediction of stroke recurrence in ICAS patients, which could be instrumental for patients risk stratification.

Tmax >4 s volume predicts stroke recurrence in symptomatic intracranial atherosclerotic stenosis with optimal medical treatment

BACKGROUND

The time to maximum (Tmax) profile based on computed tomography perfusion (CTP) provides a quantitative assessment of cerebral hemodynamic compromise. We aimed to delineate the Tmax profile in stroke patients with symptomatic intracranial atherosclerotic stenosis (ICAS) and to investigate its predictive role in stroke recurrence after optimal medical treatment.

METHODS

Consecutive patients with ischemic stroke within 30 days attributed to 50%-99% ICAS were prospectively enrolled. Baseline tissue volume at different perfusion parameter thresholds based on CTP was automatically calculated using the Rapid Processing of Perfusion and Diffusion (RAPID) software. All patients received optimal medical treatment. The primary outcome was a composite of stroke in the territory of qualifying artery or vascular death within 1 year.

RESULTS

Among 204 patients with symptomatic ICAS, the median volume of Tmax >4 s, Tmax >6 s, and relative cerebral blood flow (rCBF) <30% were 61 mL, 0 mL, and 0 mL, respectively. The 1 year rate of primary outcome was 16.2% (33/204). Tmax >4 s volume was significantly associated with the primary outcome (per 10 mL increase, adjusted hazard ratio (HR), 1.028 (1.008-1.049), P=0.005). The optimal cut-off value of Tmax >4 s volume for predicting the primary outcome was 83 mL. Patients with Tmax >4 s volume >83 mL had a higher risk of the 1 year primary outcome than those with Tmax >4 s volume ≤83 mL (adjusted HR, 7.346 (3.012-17.871), P<0.001), after adjusting for degree of stenosis and stroke mechanisms.

CONCLUSION

Tmax >4 s volume is a promising perfusion parameter to define hemodynamic compromise in patients with symptomatic ICAS. Patients with a larger volume of Tmax >4 s are likely to have a higher risk of stroke recurrence despite optimal medical treatment.

Vessel wall MRI evaluation for the safety of endovascular recanalization of non-acute intracranial anterior circulation artery occlusions

BACKGROUND

Vessel wall MRI (VWMRI) can reveal the morphological features of intracranial artery occlusion (ICAO). This study aimed to investigate the imaging features of ICAO on VWMRI and explore their correlation with perioperative complications of endovascular recanalization for non-acute ICAO.

METHODS

The study retrospectively included consecutive patients with recurrent ischemic stroke due to non-acute ICAO in the anterior circulation who underwent preoperative VWMRI evaluation and endovascular recanalization. Perioperative complications included ischemic and hemorrhagic strokes within 30 days after operation. Imaging features of the occluded segments were evaluated on precontrast and post-contrast VWMRI, including occlusion length and site, vessel wall area, signal intensity, angle, and shape of the occluded segment. The associations between the clinical and imaging features and perioperative complications were examined.

RESULTS

One hundred and four patients were included in the analysis, of whom 22.1% (23/104) had perioperative complications. After adjusting for multiple confounding variables, four imaging risk factors were identified that were independently associated with perioperative complications, that is, the angle between the occluded and pre-occluded artery segments (OR 11.60, 95% CI 2.73 to 49.29), occluded artery segment shape (OR 13.07, 95% CI 2.82 to 60.67), vessel wall collapse before occlusion (OR 2.91, 95% CI 0.96 to 8.77), and post-contrast mean signal intensity ratio at the ¼ point of the occluded artery segment <1.24 (OR 6.14, 95% CI 1.67 to 22.51). From no risk factors to four risk factors, the incidence of perioperative complications gradually increased (0, 6.2%, 23.5%, 52.9%, and 100% respectively; p<0.001).

CONCLUSIONS

VWMRI may be helpful to select patients with non-acute ICAO who are suitable for endovascular recanalization.

Effects of different endovascular treatments on cerebral perfusion changes and stroke recurrence in patients with intracranial atherosclerosis

BACKGROUND

In patients with refractory intracranial atherosclerotic disease (ICAD), percutaneous transluminal balloon angioplasty (PTBA) is less complex but typically results in higher postprocedural residual stenosis than percutaneous transluminal angioplasty with stenting (PTAS).

METHODS

This study included patients with symptomatic ICAD with 70-99% stenosis treated with either PTBA or PTAS. All patients underwent preprocedural and postprocedural CT perfusion, which was processed by automated RAPID software. The rate of cerebral perfusion change was defined as the ratio of the volume of perfusion change to the preprocedural perfusion volume. Perioperative complications within a 30-day follow-up period were documented. Baseline characteristics, degree of stenosis before and after procedures, perioperative complications, and the rates of cerebral perfusion change were compared between groups. Patients were followed up for stroke recurrence within 1 year postprocedure, with survival analysis used to examine the relationship between procedure type and recurrence.

RESULTS

Between March and December 2021, 107 patients were enrolled: 30 (28.0%) were treated with PTBA and 77 (72.0%) with percutaneous transluminal angioplasty with stenting (PTAS). The PTBA group showed higher postprocedural residual stenosis than the PTAS group (P<0.004). The cerebral perfusion change rates were not significantly different between the groups (P=0.891). Three (3.9%) complications occurred in the PTAS group and none in the PTBA group during the 30-day follow-up. Stroke recurrence did not significantly differ between the procedures (P=0.960).

CONCLUSIONS

Immediate cerebral perfusion changes and the rate of stroke recurrences have no significant difference between the two groups.

Prevalence of intracerebral thrombus detected by optical coherence tomography in patients with posterior circulation stroke or transient ischemic attack

BACKGROUND

The incidence of thrombosis in patients with intracranial atherosclerotic stenosis (ICAS) remains unclear. Optical coherence tomography (OCT) has the potential to explore the vessel wall structure of posterior-circulation ICAS because of its relatively straight anatomical structure compared with that of the anterior cerebral arteries. This study aimed to determine the prevalence and characteristics of thrombosis in the posterior-circulation ICAS using OCT.

METHODS

This prospective study was conducted on 135 patients with posterior-circulation arterial stenosis who underwent OCT. All patients were symptomatic and had a severely stenotic lesion (70-99%) in the vetebrobasilar artery. The enrolled patients were classified according to the presence of in situ thrombus as defined by OCT. Clinical data and OCT characteristics were compared.

RESULTS

Eighty-two patients diagnosed with posterior-circulation ICAS were enrolled. In situ thrombi were identified in 34 patients. Clinically, patients with in situ thrombus were more prone to cerebral infarctions than transient ischemic attacks. The percentage area of stenosis in the non-thrombus group was significantly lower than that in the thrombus group. The thrombus burden, mean flow area, mean thrombus area, maximum lipid arc, and mean lumen area were significantly different among white, red, and mixed thrombi.

CONCLUSIONS

We achieved in vivo vessel wall structural analysis of posterior-circulation ICAS with the largest sample size. We also revealed the true incidence of in situ thrombosis and potential corresponding clinical events of posterior-circulation ICAS for the first time.

Prognostic value of angiographic based quantitative flow ratio and anatomic features in intracranial atherosclerotic stenosis

BACKGROUND

Patients with intracranial atherosclerotic stenosis (ICAS) are prone to stroke recurrence despite aggressive medical treatment. Further assessment of the anatomy and physiology of ICAS is urgently needed to facilitate individualized therapy. We explored the predictive value of angiography based hemodynamic and anatomical features for ICAS patients.

METHODS

In this retrospective study, patients with moderate-to-severe stenosis of the middle cerebral artery (MCA) were enrolled. The hemodynamic assessment was performed using the single view Murray's law based quantitative flow ratio (μQFR) approach. The locations of lesions were categorized as perforator rich segments of the MCA (pMCA) and others. Multivariate Cox models were developed to identify significant predictors. The primary outcomes were defined as stroke and transient ischemic attack.

RESULTS

Among the 333 patients (median (IQR) age, 56 (49-63) years, 70.3% men) over a median follow-up period of 64.5 months, 50 (15.0%) had the primary outcomes, and 80.0% occurred within 5 years. Patients with lower μQFR values (dichotomized at 0.73) had a higher risk of the 5 year primary outcomes (log rank P=0.023), and good collateral circulation may have attenuated the risk. In the multivariate analyses, μQFR (adjusted HR=0.345; 95% CI 0.155 to 0.766; P=0.009), lesion located in pMCA (adjusted HR=0.377; 95% CI 0.190 to 0.749; P=0.005), and diameter ratio of the internal carotid artery (adjusted HR=4.187; 95% CI 1.071 to 16.370; P=0.040) were significantly associated with the 5 year primary outcomes.

CONCLUSIONS

Angiography based μQFR and anatomical features, namely plaque localization and internal carotid artery expansion, could serve as promising prognostic indexes for MCA atherosclerosis.

Evaluation of Intensive Statins and Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors on Intracranial Artery Plaque Stability: A Prospective Single-Arm Study

BACKGROUND

Intracranial atherosclerotic stenosis is a leading cause of ischemic stroke and recurrent events due to plaque instability. High-resolution magnetic resonance imaging identifies plaque enhancement as a key marker of instability. This study evaluated the efficacy of combined high-intensity statins and proprotein convertase subtilisin/kexin type 9 inhibitors in plaque stabilization.

METHODS

In this prospective, single-arm study, patients with acute stroke and intracranial atherosclerotic stroke in the M1 segment of the middle cerebral artery or basilar artery were enrolled. After 24 weeks of intensive statin and evolocumab therapy, high-resolution magnetic resonance imaging assessments of intracranial vessels were conducted at baseline and follow-up. The primary end point was the change in stenosis degree; secondary end points included changes in plaque enhancement (contrast ratio) and plaque burden.

RESULTS

Thirty-six patients (median age, 58 years) participated. After therapy, stenosis decreased from 75.9% (interquartile range, 69.5%-84.8%) to 65.3% (interquartile range, 53.8%-75.0%; P<0.001). Contrast ratio grades and contrast volume decreased significantly (P<0.001), and lumen area increased (from 1.03 mm2 [interquartile range, 0.59-1.72 mm2] to 2.08 mm2 [interquartile range, 1.00-3.10 mm2]; P<0.001). No significant changes were observed in wall area, wall area index, or remodeling index. A notable correlation between the decrease in low-density lipoprotein cholesterol/apolipoprotein B ratio and reduction in contrast volume was observed.

CONCLUSIONS

Combining proprotein convertase subtilisin/kexin type 9 inhibitors with high-intensity statins may improve plaque stability and reduce lumen stenosis in patients with intracranial atherosclerotic stenosis. Larger randomized controlled trials are needed to confirm these findings.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2200058029.

Hemodynamic evaluation of symptomatic and asymptomatic intracranial atherosclerotic stenosis using cerebral angiographic images: an exploratory study

BACKGROUND

Previous studies suggest that it may be inappropriate to determine treatment strategies solely based on the degree of stenosis for patients with intracranial atherosclerotic stenosis (ICAS). In order to better risk stratify patients with ICAS, we developed a novel non-invasive fractional flow (FF) calculation technique based on intracranial angiography (Angio-FF) to assess the hemodynamics for patients with ICAS. This study aims to investigate the difference in FF between symptomatic and asymptomatic patients with ICAS and its potential optimal threshold.

METHODS

A total of 124 patients with ICAS with severe intracranial stenosis who had undergone cerebral angiography were recruited. According to the time of onset, the patients were divided into a symptomatic ICAS group (n=78) and an asymptomatic ICAS group (n=46). The Angio-FF of each group was collected and compared. Receiver-operating characteristic curve (ROC) analysis was performed to assess the discriminative ability of Angio-FF to predict hemodynamics for ICAS.

RESULTS

Compared with the asymptomatic ICAS group, the symptomatic ICAS group had a significantly lower Angio-FF (0.75 (0.66-0.85) vs 0.85 (0.77-0.89), P<0.001). The optimal cut-off value of Angio-FF for distinguishing symptomatic ICAS from asymptomatic ICAS was 0.785 (sensitivity 71.74%, specificity 57.69%).

CONCLUSIONS

Patients with Angio-FF <0.7853 may be more prone to intracranial ischemic events. Angio-FF of 0.7853 can serve as a boundary for whether patients with ICAS exhibit clinical symptoms.

Intracranial Atherosclerotic Stenosis

BACKGROUND

Ischemic stroke is a significant global health problem associated with mortality and disability. Intracranial atherosclerotic stenosis (ICAS) is a leading cause of stroke and contributes to recurrent stroke, especially in the Asian population. ICAS should be distinguished from extracranial atherosclerotic stenosis (ECAS) due to differences in pathophysiology. Understanding the mechanisms of ICAS is crucial for stroke prevention in the Asian population. Traditional vascular risk factors and the degree of the stenosis play an important role in predicting stroke occurrence.

SUMMARY

In East Asia, non-atherosclerotic vasculopathies are also often observed in ischemic stroke patients caused by large artery disease, highlighting the importance of identifying the specific etiologies of intracranial artery stenosis. Advances in diagnostic neuroimaging, such as high-resolution MRI (HR-MRI), can be helpful in distinguishing between them. For stroke prevention in patients with both asymptomatic and symptomatic ICAS, intensive management, including strict control of modifiable risk factors and appropriate antiplatelet therapies, is essential. There are no clear guidelines regarding the duration and combination of antiplatelet therapies. However, current recommendations suggest short-term dual antiplatelet therapies for 90 days to reduce the recurrence of stroke in symptomatic severe ICAS (70-99%). Cilostazol is also proposed as a good second-line treatment option, following clopidogrel, which remains the most widely used. In addition, endovascular or surgical interventions could be considered alternatives for a limited subset of symptomatic severe ICAS cases that are hemodynamically unstable.

KEY MESSAGES

The key messages are as follows: (1) ICAS is a major cause of ischemic stroke, especially in Asian populations. Its distinct pathophysiology, compared to ECAS, requires different treatment strategies for secondary prevention; (2) differentiation of intracranial artery stenosis etiology is essential, and HR-MRI would be a valuable diagnostic tool; (3) stroke prevention includes strict vascular risk factor control and the use of antiplatelet therapies, with short-term DAPT recommended for symptomatic severe ICAS; (4) cilostazol may serve as an effective second-line option for preventing ischemic stroke, while endovascular or surgical interventions may be limited to hemodynamically unstable cases.

BACKGROUND

Ischemic stroke is a significant global health problem associated with mortality and disability. Intracranial atherosclerotic stenosis (ICAS) is a leading cause of stroke and contributes to recurrent stroke, especially in the Asian population. ICAS should be distinguished from extracranial atherosclerotic stenosis (ECAS) due to differences in pathophysiology. Understanding the mechanisms of ICAS is crucial for stroke prevention in the Asian population. Traditional vascular risk factors and the degree of the stenosis play an important role in predicting stroke occurrence.

SUMMARY

In East Asia, non-atherosclerotic vasculopathies are also often observed in ischemic stroke patients caused by large artery disease, highlighting the importance of identifying the specific etiologies of intracranial artery stenosis. Advances in diagnostic neuroimaging, such as high-resolution MRI (HR-MRI), can be helpful in distinguishing between them. For stroke prevention in patients with both asymptomatic and symptomatic ICAS, intensive management, including strict control of modifiable risk factors and appropriate antiplatelet therapies, is essential. There are no clear guidelines regarding the duration and combination of antiplatelet therapies. However, current recommendations suggest short-term dual antiplatelet therapies for 90 days to reduce the recurrence of stroke in symptomatic severe ICAS (70-99%). Cilostazol is also proposed as a good second-line treatment option, following clopidogrel, which remains the most widely used. In addition, endovascular or surgical interventions could be considered alternatives for a limited subset of symptomatic severe ICAS cases that are hemodynamically unstable.

KEY MESSAGES

The key messages are as follows: (1) ICAS is a major cause of ischemic stroke, especially in Asian populations. Its distinct pathophysiology, compared to ECAS, requires different treatment strategies for secondary prevention; (2) differentiation of intracranial artery stenosis etiology is essential, and HR-MRI would be a valuable diagnostic tool; (3) stroke prevention includes strict vascular risk factor control and the use of antiplatelet therapies, with short-term DAPT recommended for symptomatic severe ICAS; (4) cilostazol may serve as an effective second-line option for preventing ischemic stroke, while endovascular or surgical interventions may be limited to hemodynamically unstable cases.

Added value of artificial intelligence solutions for arterial stenosis detection on head and neck CT angiography: A randomized crossover multi-reader multi-case study

PURPOSE

The purpose of this study was to investigate the added value of artificial intelligence (AI) solutions for the detection of arterial stenosis (AS) on head and neck CT angiography (CTA).

MATERIALS AND METHODS

Patients who underwent head and neck CTA examinations at two hospitals were retrospectively included. CTA examinations were randomized into group 1 (without AI-washout-with AI) and group 2 (with AI-washout-without AI), and six readers (two radiology residents, two non-neuroradiologists, and two neuroradiologists) independently interpreted each CTA examination without and with AI solutions. Additionally, reading time was recorded for each patient. Digital subtraction angiography was used as the standard of reference. The diagnostic performance for AS at lesion and patient levels with four AS thresholds (30 %, 50 %, 70 %, and 100 %) was assessed by calculating sensitivity, false-positive lesions index (FPLI), specificity, and accuracy.

RESULTS

A total of 268 patients (169 men, 63.1 %) with a median age of 65 years (first quartile, 57; third quartile, 72; age range: 28-88 years) were included. At the lesion level, AI improved the sensitivity of all readers by 5.2 % for detecting AS ≥ 30 % (P < 0.001). Concurrently, AI reduced the FPLI of all readers and specifically neuroradiologists for detecting non-occlusive AS (all P < 0.05). At the patient level, AI improved the accuracy of all readers by 4.1 % (73.9 % [1189/1608] without AI vs. 78.0 % [1254/1608] with AI) (P < 0.001). Sensitivity for AS ≥ 30 % and the specificity for AS ≥ 70 % increased for all readers with AI assistance (P = 0.01). The median reading time for all readers was reduced from 268 s without AI to 241 s with AI (P< 0.001).

CONCLUSION

AI-assisted diagnosis improves the performance of radiologists in detecting head and neck AS, and shortens reading time.

Application of high-resolution MRI in evaluating statin efficacy on symptomatic intracranial atherosclerosis

OBJECTIVES

To investigate the efficacy of statins on symptomatic intracranial atherosclerotic plaques using high-resolution 3.0 T MR vessel wall imaging (HR-MRI).

METHODS

Patients with symptomatic intracranial atherosclerotic plaques (cerebral ischemic events within the last three months) confirmed by HR-MRI from July 2017 to August 2022 were retrospectively included in this study. The enrolled patients started statin therapy at baseline. All the patients underwent the follow-up HR-MRI examination after statin therapy for at least 3 months. A paired sample t-test and Wilcoxon rank sum test were used to evaluate the changes in plaque characteristics after statin therapy. Multivariate linear regression was further used to investigate the clinical factors associated with statin efficacy.

RESULTS

A total of 48 patients (37 males; overall mean age = 60.2 ± 11.7 years) were included in this study. The follow-up time was 7.0 (5.6-12.0) months. In patients treated with statins for > 6 months (n = 31), plaque length, wall thickness, plaque burden, luminal stenosis and plaque enhancement were significantly reduced. Similar results were found in patients with good lipid control (n = 21). Younger age, lower BMI and hypertension were associated with decreased plaque burden. Lower BMI, hypertension and longer duration of statin therapy were associated with decreased plaque enhancement. Younger age and hypertension were associated with decreased luminal stenosis (all p < 0.05).

CONCLUSION

HR-MRI can effectively evaluate plaques changes after statin therapy. Statins can reduce plaque burden and stabilize plaques. The effect of statin may have a relationship with age, BMI, hypertension, and duration of statin therapy.

CLINICAL RELEVANCE STATEMENT

High-resolution MRI can be applied to evaluate the efficacy of statins on symptomatic intracranial atherosclerotic plaques. Long-term statin use and well-controlled blood lipid levels can help reduce plaque burden and stabilize plaques.

KEY POINTS

High-resolution MRI provides great help evaluating the changes of plaque characteristics after statin therapy. Efficacy of statins is associated with duration of use, controlled lipid levels, and clinical factors. High-resolution MRI can serve as an effective method for following-up symptomatic intracranial atherosclerosis.

Association between atherosclerosis and the development of multi-organ pathologies

Atherosclerosis is a chronic inflammatory disease affecting the vascular system, characterised by the accumulation of modified lipoproteins, immune cell aggregation and the development of fibrous tissue within blood vessel walls. As atherosclerosis impacts blood vessels, its adverse effects may manifest across various tissues and organs. In this review, we examine the association of atherosclerosis with Alzheimer's disease, stroke, pancreatic and thyroid dysfunction, kidney stones and chronic kidney diseases. In several cases, the reciprocal causative effect of these diseases on the progression of atherosclerosis is also discussed. Particular attention is given to common risk factors, biomarkers and identified molecular mechanisms linking the pathophysiology of atherosclerosis to the dysfunction of multiple tissues and organs. Understanding the role of atherosclerosis and its associated microenvironmental conditions in the pathology of multi-organ disorders may unveil novel therapeutic avenues for the prevention and treatment of cardiovascular and associated diseases.

Atherosclerotic plaque evolution predicts cerebral ischemic events in patients with intracranial atherosclerosis: a multicentre longitudinal study using high-resolution MRI

BACKGROUND

Intracranial atherosclerosis (ICAS) is the leading cause of ischemic stroke in Asians and the recurrent rate remains high despite the optimal medical treatment. This study aimed to confirm that follow-up high-resolution magnetic resonance imaging (hrMRI) provided essential values in predicting subsequent cerebral ischemic events in patients with ICAS.

METHODS

Patients with moderate to severe stenosis in the middle cerebral artery (MCA) defined by magnetic resonance (MRA) or computed tomography angiography (CTA) were recruited from three centers retrospectively. Detailed plaque composition was analyzed on baseline and follow-up hrMRI. Multivariate Cox proportional hazards regression analysis was used to identify the key risk factors for predicting subsequent ischemic events.

RESULTS

Among 152 patients, a total of 86 patients with MCA atherosclerotic stenosis underwent follow-up hrMRI exams and ipsilateral cerebral ischemic events occurred in 12 patients during a 1-year follow-up. Analyses showed the predictors of ischemic events were age (adjusted Hazard ratio (HR) = 0.942; 95% Confidence Interval (CI), [0.903, 0.983]; p = 0.006), progression of plaque burden (HR = 3.818; 95% CI [1.117, 13.051]; p = 0.033), vessel expansion (HR = 5.173; 95% CI [1.077, 24.838]; p = 0.040) and enhancement ratio progression (HR = 6.144; 95% CI [1.480, 25.511]; p = 0.012). The combined model achieved a concordance index of 0.804 (95% CI [0.658, 0.950]).

CONCLUSION

Longitudinal hrMRI evaluation improved the accuracy in identifying higher-risk patients with intracranial atherosclerosis.

KEY POINTS

Question Can longitude high-resolution magnetic resonance imaging (hrMRI) help clinicians observe intracranial plaque evolution? Findings Compared with the baseline exam, intracranial plaque evolution distinguished by follow-up hrMRI exam showed a higher accuracy in predicting subsequent ischemic events. Clinical relevance Longitudinal high-resolution magnetic resonance vessel wall imaging enables dynamic observation and evaluation of the changes in plaque characteristics among intracranial atherosclerosis patients. Atherosclerotic plaque evolution revealed by repeated exams can strengthen the risk stratification of patients with intracranial atherosclerosis.

Prediction Value of High Serum Pentraxin-3 for Short-Term Recurrence of Cerebral Infarction in Patients Accompanied with Intracranial Atherosclerotic Stenosis Within One Year

Objective

Elevated serum pentraxin-3 levels are generally considered a risk factor for atherosclerosis. However, there is limited data on the relationship between pentraxin-3 and cerebral infarction (CI) accompanied by intracranial atherosclerotic stenosis (ICAS). This study aims to investigate the association between pentraxin-3 (PTX-3) and short-term recurrence in cerebral infarction caused by ICAS patients within one year.

Methods

A prospective observational study was conducted. Cerebral infarction accompanied by intracranial atherosclerotic stenosis (CI-ICAS) patients were selected from January 2020 to December 2023. Recurrent ischemic stroke (RIS) is defined as a new neurological deficit that appears after a period of clinical stabilization, lasting more than 24 hours, with an attributable new ischemic lesion that can be confirmed by CT or MRI. Serum pentraxin-3 levels were determined on admission. Multivariate logistic regression analysis was used to investigate the relationship between serum pentraxin-3 and RIS.

Results

Among 398 patients enrolled, 112 cases (28.1%) had recurrence within one year. The elevation of serum PTX-3 level in patients accompanied with ICAS was independently correlated with recurrent stroke. Therefore, it is worth considering the possibility of intervening in higher PTX-3 levels. Serum pentraxin-3 was significantly higher in patients with RIS (15.16 vs 10.21 µmol/L, P<0.001). Correlation analysis showed that PTX-3 was correlated with age, LDL, Hs-CRP, Baseline NIHSS score, and Hcy (P < 0.001). Univariate logistic regression analysis showed that pentraxin-3 remained an independent predictor of recurrent ischemic stroke after adjusting for major confounding factors (OR = 1.21, 95% CI: 1.06-1.39, P = 0.007).

Conclusion

The elevation of serum pentraxin-3 level in patients with ischemic stroke was independently correlated with the recurrence of stroke within one year. Therefore, intervention in serum pentraxin-3 levels may be worth considering.

Drug-eluting stents versus bare-metal stents for intracranial atherosclerotic stenosis: a systematic review and meta-analysis

BACKGROUND

In-stent restenosis (ISR) is the primary cause of stroke recurrence after intracranial stenting. Drug-eluting stents (DES) have recently shown great potential for reducing restenosis. This systematic review aimed to evaluate the efficacy and safety of DES compared with bare-metal stents (BMS) for intracranial atherosclerotic stenosis (ICAS).

METHODS

We systematically searched the MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, Embase (Ovid) and Web of Science databases for studies published from inception through 10 October 2023, comparing DES with BMS for the treatment of symptomatic severe ICAS. We included randomised controlled trials and cohort studies that compared DES and BMS in adult patients with ICAS. The primary outcomes were stroke or death within 30 days and ISR within 1 year. Secondary outcomes included procedure-related adverse events, technical success, functional evaluation findings, restenosis degree and other safety endpoints within 1 year. Subgroup analyses were conducted across different study types.

RESULTS

A total of 510 participants fulfilling all eligibility criteria were enrolled in four studies. DES had a similar rate of any stroke or death within 1 month (3 studies, 476 participants: risk ratio (RR): 1.00; 95% CI: 0.46 to 1.11; p=1.00; I2=31%) to that of the BMS group and had a significantly lower rate of ISR within 1 year (4 studies, 429 participants: RR: 0.23; 95% CI: 0.13 to 0.41; p<0.001; I2=0%). Moreover, a lower rate of stroke recurrence within 1 year was reported (3 studies, 436 participants: RR: 0.46; 95% CI: 0.24 to 0.88; p=0.02; I2=52%) in the DES group.

CONCLUSION

This review demonstrates that the application of DES for intracranial stenting is safe and can significantly reduce the rates of ISR and recurrent ischaemic events. Further research is required to validate these results.

PROSPERO REGISTRATION NUMBER

CRD42022338178.

Clinical efficacy of tirofiban in the endovascular therapy of patients with acute ischaemic stroke due to intracranial atherosclerotic disease: A meta-analysis

OBJECT

The treatment results of combination of arterial injection of tirofiban with endovascular therapy (EVT) for acute large vessel occlusion (LVO) stroke due to intracranial atherosclerotic disease (ICAD) were inconsistent. This meta-analysis aims to assess the safety and efficacy of ICAD-LVO treatment by intra-arterial injection of tirofiban combined with EVT.

METHODS

Relevant studies were identified through a systematic literature search in Pubmed, EMBASE, Web of Science and Cochrane Library databases, covering articles published from January 2010 to July 2024. The efficacy outcomes assessed in the meta-analysis included favorable functional outcome and recanalization rates. Safety outcomes included mortality and symptomatic intracranial haemorrhage (sICH).

RESULTS

The meta-analysis consisted of data from 11 studies, which included 1 randomised controlled trial (RCT), 5 prospective cohort studies, and 5 retrospective cohort studies, encompassing a total of 2869 patients. The findings showed that tirofiban+EVT for ICAD-LVO was associated with significant improvements in favorable functional outcomes (RR, 1.12; 95 %CI, 1.04-1.21; P=0.005) and reductions in mortality rates (RR, 0.72; 95 %CI, 0.62-0.83; P<0.0001), despite no significant differences in the incidence of sICH (RR, 0.75; 95 % CI, 0.55-1.02; P=0.07) and recanalization rates (RR, 1.02; 95 % CI, 0.99-1.05; P=0.15). Subgroup analysis showed that the application of tirofiban significantly increased favorable functional outcomes in patients with anterior circulation stroke (RR, 1.23; 95 % CI, 1.06-1.42; P=0.005), but there was no significant difference in posterior circulation stroke (RR, 1.08; 95 % CI, 0.83-1.41; P=0.55). In addition, the use of tirofiban in patients with posterior circulation stroke might reduce the incidence of sICH (RR, 0.50; 95 % CI, 0.26-0.96; P=0.04).

CONCLUSION

Tirofiban combined with EVT may be an effective treatment strategy for the treatment of ICAD-LVO, but only for patients with anterior circulation and remains unclear for patients with posterior circulation.

Hemodynamic assessment of intracranial atherosclerotic stenosis: comparison between invasive non-hyperemic pressure ratio and angiography-derived quantitative flow ratio

Objectives

To evaluate the diagnostic accuracy of the quantitative flow ratio (QFR) for hemodynamic exploration of intracranial atherosclerotic stenosis, using the invasive cerebrovascular pressure ratio (CVPR) and resting full-cycle ratio (RFR) as reference standards.

Materials and methods

Patients with symptomatic unifocal intracranial atherosclerotic stenosis were included. The CVPR was defined as the ratio of the proximal and distal pressures. All patients underwent angioplasty under general anesthesia. The QFR was calculated based on digital subtraction angiography. Using the CVPR as a reference, we compared its correlation with the QFR across different degrees and locations of stenosis.

Results

The CVPR and QFR were measured in 34 vessels of 32 patients. The QFR demonstrated a high correlation and excellent agreement(r = 0.8227, p < 0.001) with the CVPR in distal stenosis before intervention. In the subgroup with diameter stenosis >80%, the QFR showed a high correlation (r = 0.8812, p < 0.001) with the CVPR. In the anterior circulation subgroup, the QFR showed an excellent correlation (r = 0.9066, p < 0.001) with the CVPR. In the posterior circulation subgroup, the QFR showed a high correlation with the CVPR (r = 0.7706, p < 0.001). Diameter stenosis rates showed a moderate negative correlation with the CVPR.

Conclusion

There was a strong correlation between the QFR and wire-based CVPR, especially for anterior circulation lesions before intervention. The QFR may serve as a predictive factor for evaluating hemodynamic changes in intracranial atherosclerotic stenosis.

RNF213 p.Arg4810Lys Variant Is Associated with Higher Stenosis Progression in Asymptomatic Intracranial Artery Stenosis

Intracranial artery stenosis (ICAS) is a significant contributor to ischemic stroke, with the RNF213 p.Arg4810Lys variant identified as a related genetic factor. We explored the clinical outcomes of the RNF213 genotype in patients with asymptomatic ICAS. Between November 2011 and March 2019, 139 patients with asymptomatic ICAS were enrolled in this study. Genotyping for RNF213 p.Arg4810Lys was performed using Sanger sequencing. A comprehensive analysis was conducted to compare the RNF213 genotype with background characteristics and clinical outcomes such as ipsilateral ischemic cerebrovascular events and stenosis progression. RNF213 p.Arg4810Lys was found in 25% of cases, revealing distinct clinical features between carriers and non-carriers. The incidence of ipsilateral ischemic cerebrovascular events was 4.3% (6/139 cases), and stenosis progression was observed in 13% (18/139 cases) during a mean follow-up period of 58 months. Stenosis progression rates were notably higher in the RNF213 variant group (25.7%; 9/35 cases) than in the RNF213 wild-type group (8.7%; 9/104 cases). Cumulative stenosis progression rate was significantly higher in the RNF213 variant group than in the RNF213 wild-type group (log-rank test, P = 0.0004). Multivariate Cox regression analysis indicated a significant association between the RNF213 p.Arg4810Lys variant and an increased risk of stenosis progression (P = 0.03, odds ratio 3.2; 95% confidence interval, 1.1-9.0). The RNF213 p.Arg4810Lys variant exhibits clinical disparities in asymptomatic ICAS and is notably linked to a heightened risk of stenosis progression. These results suggest a distinct difference in the vascular stenosis mechanism associated with this variant, warranting further investigation into its clinical implications and potential mechanistic insights.

Surgical Outcomes of Low-Flow Bypass Surgery in Intracranial Atherosclerotic Steno-Occlusive Diseases

BACKGROUND AND OBJECTIVES

The role of bypass surgery in intracranial atherosclerotic steno-occlusive diseases (ICADs) remains controversial. We aimed to analyze the surgical outcomes of bypass surgery in patients with the ICADs in a single tertiary institution.

METHODS

Among 1018 cases of low-flow bypass surgery between 2003 and 2022, 215 patients with the ICAD refractory to medical treatment were finally enrolled in this study. Clinical and radiological outcomes were retrospectively evaluated, with survival analyses.

RESULTS

All strokes, cerebral infarctions, and intracranial hemorrhages occurred in 12.1% (n = 26), 9.8% (n = 21), and 2.3% (n = 5), respectively, during the clinical follow-up of 54.6 ± 47.6 months (range, 0.6-237.8 months). Among all stroke events, 84.6% (n = 22) occurred within 30 postoperative days. The 2-year and 5-year cumulative risks of all strokes were 12.1% each. The mean modified Rankin Scale scores were 1.6 ± 1.1 (range, 0-5) preoperatively and 0.8 ± 1.2 (range, 0-6) at last ( P < .01). The patency of direct bypass was 99.1% (n = 213) just before discharge and 96.3% (n = 184 of 191 patients with available tests) at the last angiographic follow-up of 27.0 ± 27.3 months (range, 2.3-97.3 months). All the patients with available data (n = 190) showed hemodynamic improvement on acetazolamide-challenged single-photon emission computed tomography with 99mTc-hexamethylpropyleneamine oxime during the follow-up of 38.6 ± 36.7 months (range, 2.3-158.6 months).

CONCLUSION

Low-flow bypass surgery showed acceptable treatment outcomes in the prevention of recurrent stroke.

Edge-Type Hyperintense Intracranial Artery Plaque: A Potential MRI Biomarker of Stroke Recurrence

BACKGROUND

Identifying patients at high risk of stroke recurrence is important for stroke prevention and treatment.

PURPOSE

To explore the characteristics of T1 hyperintense plaques (HIP) and their relationship with stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis (sICAS).

STUDY TYPE

Retrospective.

POPULATION

One hundred fifty-seven patients with moderate-to-severe (≥50%) nonocclusive sICAS and MRI studies (42 females and 115 males, mean age 58.69 ± 10.68 years).

FIELD STRENGTH/SEQUENCE

3D higher-resolution black-blood T1-weighted fast-spin-echo sequence at 3.0 T.

ASSESSMENT

HIP (signal intensity [SI] of plaque-to-adjacent gray matter >1.0 on non-contrast T1-weighted images) and non-HIP plaques were identified. HIP plaques were categorized as edge type (high SI adjacent to lumen) and non-edge type (high SI within plaque). Clinical and imaging features of different plaque types were compared. Stroke recurrence was assessed through telephone or medical records at 3 and 6 months, and then once a year post-MRI. The relationship between edge type and non-edge types HIP with stroke recurrence was analyzed.

STATISTICAL TESTS

Student's t test, Mann-Whitney U-test, chi square test and Fisher's exact test to compare features between plaque types. Kaplan-Meier curves (with log-rank tests) and Cox proportional hazards regression to assess relationship between stroke recurrence and different plaque types. A two-tailed P-value of <0.05 was considered statistically significant.

RESULTS

Of 157 culprit lesions, 87 (55%) were HIPs (43 edge type, 44 non-edge type) and 70 (45%) were non-HIPs. Plaque thickness, area, and volume were significantly higher for HIPs than for non-HIPs. Among patients with HIPs, edge type was significantly more likely in the posterior circulation (53.5% vs. 27.3%), and had significantly higher plaque thickness, length, area, volume, plaque burden, and remodeling index than non-edge type. Edge-type HIP was significantly more common than non-edge HIP in patients with diabetes mellitus (51.2% vs. 29.5%) and dyslipidemia (79.1% vs. 54.5%). During median follow-up of 27 months, 33 patients experienced stroke recurrence. Recurrence was associated with edge-type HIP (adjusted hazard ratio = 2.83; 95% confidence interval: 1.40-5.69), both in the overall cohort (34.9% vs. 15.8%) and in patients with HIP (34.9% vs. 9.0%). Age ≥60 years and edge-type HIP had a significant interaction.

DATA CONCLUSIONS

Hyperintense plaque may be categorized as edge type or non-edge type. Edge-type HIP may be a potential MRI biomarker of stroke recurrence.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Lipoprotein-associated phospholipase A2 activity levels is associated with artery to artery embolism in symptomatic intracranial atherosclerotic disease

BACKGROUND

Lipoprotein-associated phospholipase A2 activity (Lp-PLA2-A) is a pivotal enzyme involved in the inflammatory process and atherosclerotic plaque vulnerability. This study aimed to investigate the potential of Lp-PLA2-A as a biomarker for reflecting artery-to-artery embolism (AAE), a critical mechanism with high risk of stroke recurrence in symptomatic intracranial atherosclerotic disease (sICAD).

METHODS

The current analysis included a cohort of 1,908 patients with sICAD and baseline levels of Lp-PLA2-A from the Third China National Stroke Registry (CNSR-III). The baseline Lp-PLA2-A levels were quantified centrally using an automatic enzyme assay system. Diagnosis of sICAD was made by experienced stroke neurologists based on the presence of a cerebral infarction within the territory of a stenotic (>50 %) or occluded artery, or when clinical symptoms were consistent with the diagnosis. Infarct lesions affecting the cortex serve as imaging biomarkers for stroke mechanism involving AAE.The relationship between baseline Lp-PLA2-A quartile levels and the presence of cortical infarction was analyzed using multivariate logistic regression.

RESULTS

Compared to patients in the first Lp-PLA2-A quartile, those in the second, third and fourth quartiles demonstrated a significantly higher proportion of AAE. The proportion of patients with cortical infarction increased with rising Lp-PLA2-A quartiles, observed at 39.3 %, 47.1 %, 47.4 %, and 50.7 % for the first, second, third and fourth quartiles respectively (P for trend=0.004). Compared with the first quartile, the odds ratios (ORs) were 1.38 (95 % CI = 1.06-1.79) for the second, 1.33 (95 % CI = 1.02-1.72) for the third quartile and 1.48 (95 % CI = 1.14-1.92) for the fourth quartile. The association between higher Lp-PLA2-A and increased proportion of cortical infarction was also present in the subgroups defined by age <65 years, male, and high-sensitivity C-reactive protein ≥2 mg/L. In sensitivity analyses, the positive correlation between Lp-PLA2-A levels and proportion of cortical infarction remained consistent.

CONCLUSIONS

This research highlights the significance of Lp-PLA2-A as a biomarker for reflecting stroke mechanism in sICAD. Additional studies are warranted to explore the potential of targeting Lp-PLA2-associated inflammatory pathways as a pivotal approach in arresting the advancement of intracranial atherosclerotic stenosis and reducing the incidence of embolic strokes.

Rare RNF213 variants is related to early-onset intracranial atherosclerosis: A Chinese community-based study

BACKGROUND

The relationship between rare variants in Ring finger protein 213 (RNF213) and intracranial atherosclerosis (ICAS) remained unelucidated. Using whole-exome sequencing (WES) and high-resolution magnetic resonance imaging (HR-MRI), this study aimed at investigating the association between rare RNF213 variants and ICAS within a Chinese community-dwelling population.

METHODS

The present study included 821 participants from Shunyi cohort. Genetic data of rare RNF213 variants were acquired by WES and were categorized by functional domains. Intracranial and extracranial atherosclerosis were assessed by brain HR-MRI and carotid ultrasound, respectively. Logistic regression and generalized linear regression were applied to evaluate the effects of rare RNF213 variants on atherosclerosis. Stratification by age were conducted with 50 years old set as the cutoff value.

RESULTS

Ninety-five participants were identified as carriers of rare RNF213 variants. Carotid plaques were observed in 367 (44.7 %) participants, while ICAS was identified in 306 (37.3 %). Rare variants of RNF213 was not associated with ECAS. Employing HR-MRI, both the presence of rare variants (β = 0.150, P = 0.025) and numerical count of variants (β = 0.182, P = 0.003) were significantly correlated with ICAS within the group of age ≤50 years. Both variant existence (β = 0.154, P = 0.014) and variant count (β = 0.188, P = 0.003) were significantly associated with plaques in middle cerebral arteries within younger subgroup, rather than basilar arteries. Furthermore, a significant association was observed between variants that located outside the N-arm domain and ICAS in the younger subgroup (OR = 2.522, P = 0.030). Statistical results remained robust after adjusted for age, gender, and cardiovascular risk factors.

CONCLUSIONS

Rare variants of RNF213 is associated with age-related ICAS in general Chinese population, highlighting the potential role of RNF213 as a genetic contributor to early-onset ICAS.

Simulation analysis of different types of balloon dilatation catheters for the treatment of intracranial arterial stenosis

The application of balloon dilation catheters in the management of intracranial arterial stenosis has been gradually increasing. However, studies on the feasibility and effectiveness of different types of balloons remain relatively scarce. In this study, catheter models of three different materials were designed to simulate balloon crimping,splitting, and dilatation processes. A compliant balloon produces large deformations with poor dilatation and a stress concentration phenomenon. During dilatation, the shear stress generated in the intima and lesion area by the semi-compliant balloon was smaller than that generated by the non-compliant balloon. These results demonstrate the feasibility of using semi-compatible balloons.

Oral microbiome dysbiosis may be associated with intra cranial aneurysms

BACKGROUND

Although the etiology of aneurysms remains elusive, recent advances in high-throughput sequencing technology and ongoing human microbiome investigations suggest a potential link between microbiome composition and the onset of various human diseases.

OBJECTIVE

This study aimed to utilize high-throughput 16 S rRNA gene sequencing to analyze the oral flora bacterial profiles of individuals, comparing patients with intracranial aneurysms to a healthy control group. Importantly, we sought to identify differences in the oral microbiota and offer novel insights and methods for early diagnosis and identification of intracranial aneurysms.

METHOD

Saliva samples were collected from 60 patients with cerebral aneurysms (case group) and 130 healthy individuals (control group). The V3-V4 region of the bacterial 16 S rRNA gene was amplified and sequenced using the HiSeq high-throughput sequencing platform to establish the bacterial profile. Sequencing data were analyzed using QIIME2 and Metastats software to compare composition differences and relative abundance at the phylum and genus levels in the oral microbiota of the two groups.

RESULTS

Significant differences in oral microbiota composition were observed between patients in the case and control groups (P < 0.05). Genus-level identification highlighted key positions occupied by Eubacterium, Saccharimonadaceae, Rothia, Gemella, Streptococcus, Lactobacillales, Phocaeicola, Bacteroides, Saccharimonadales, and Abiotrophia.

CONCLUSION

This study revealed noteworthy distinctions in the composition, abundance, and diversity of oral microbiota between intracranial aneurysm patients and healthy controls. These disparities suggest a potential correlation between oral microbiota and the development of intracranial aneurysms, offering new avenues for early diagnosis and intervention. However, limitations such as a small sample size, lack of prospective design, and absence of causal inference warrant further validation and exploration.

Nomogram for predicting asymptomatic intracranial atherosclerotic stenosis in a neurologically healthy population

Asymptomatic intracranial atherosclerotic stenosis (aICAS) is a major risk factor for cerebrovascular events. The study aims to construct and validate a nomogram for predicting the risk of aICAS. Participants who underwent health examinations at our center from September 2019 to August 2023 were retrospectively enrolled. The participants were randomly divided into a training set and a testing set in a 7:3 ratio. Firstly, in the training set, least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were performed to select variables that were used to establish a nomogram. Then, the receiver operating curves (ROC) and calibration curves were plotted to assess the model's discriminative ability and performance. A total of 2563 neurologically healthy participants were enrolled. According to LASSO-Logistic regression analysis, age, fasting blood glucose (FBG), systolic blood pressure (SBP), hypertension, and carotid atherosclerosis (CAS) were significantly associated with aICAS in the multivariable model (adjusted P < 0.005). The area under the ROC of the training and testing sets was, respectively, 0.78 (95% CI: 0.73-0.82) and 0.65 (95% CI: 0.56-0.73). The calibration curves showed good homogeneity between the predicted and actual values. The nomogram, consisting of age, FBG, SBP, hypertension, and CAS, can accurately predict aICAS risk in a neurologically healthy population.

Distribution of Arteriosclerotic Vessels in Patients with Arteriosclerosis and the Differences of Serum Lipid Levels Classified by Different Sites

Objective

To investigate the distribution of arteriosclerotic vessels of arteriosclerosis, differential serum lipid profiles, and differences in the proportion of dyslipidaemia between patients with single-site arteriosclerosis and multi-site arteriosclerosis (significant hardening of ≥2 arteries).

Methods

The data of 6581 single-site arteriosclerosis patients and 5940 multi-site arteriosclerosis patients were extracted from the hospital medical record system. Serum total cholesterol (TC), triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein (Apo) A1, ApoB concentrations and C-reactive protein (CRP) between patients with single-site arteriosclerosis and multi-site arteriosclerosis were collected and analyzed.

Results

The most diseased arteries were coronary arteries (n=7099, 33.7%), limb arteries (n=6546, 31.1%), and carotid arteries (n=5279, 25.1%). TC, LDL-C, TC/HDL-C, and LDL-C/HDL-C levels were higher and CRP level was lower in multi-site arteriosclerosis patients than those in single-site arteriosclerosis patients. The TC, LDL-C levels in non-elderly (<65 years old) female patients were higher and TG/HDL-C, TC/HDL-C, LDL-C/HDL-C levels were lower than those in non-elderly male patients, while the TG, TC, LDL-C, and TG/HDL-C levels in elderly (≥65 years old) female patients were higher and LDL-C/HDL-C level was lower than those in elderly male patients. The proportion of dyslipidemia in descending order was as follows: low HDL-C (31.9%), elevated TG (16.9%), elevated TC (9.0%), and elevated LDL-C (4.2%). The levels of TC, LDL-C, TC/HDL-C, and LDL-C/HDL-C in patients with peripheral arteriosclerosis were higher than those in patients with cardio-cerebrovascular arteriosclerosis.

Conclusion

There were differences in serum lipid levels in patients with arteriosclerosis with different age, gender and distribution of arteriosclerotic vessels.

Identification of middle cerebral artery stenosis in transcranial Doppler using a modified VGG-16

Objectives

The diagnosis of intracranial atherosclerotic stenosis (ICAS) is of great significance for the prevention of stroke. Deep learning (DL)-based artificial intelligence techniques may aid in the diagnosis. The study aimed to identify ICAS in the middle cerebral artery (MCA) based on a modified DL model.

Methods

This retrospective study included two datasets. Dataset1 consisted of 3,068 transcranial Doppler (TCD) images of the MCA from 1,729 patients, which were assessed as normal or stenosis by three physicians with varying levels of experience, in conjunction with other medical imaging data. The data were used to improve and train the VGG16 models. Dataset2 consisted of TCD images of 90 people who underwent physical examination, which were used to verify the robustness of the model and compare the consistency between the model and human physicians.

Results

The accuracy, precision, specificity, sensitivity, and area under curve (AUC) of the best model VGG16 + Squeeze-and-Excitation (SE) + skip connection (SC) on dataset1 reached 85.67 ± 0.43(%),87.23 ± 1.17(%),87.73 ± 1.47(%),83.60 ± 1.60(%), and 0.857 ± 0.004, while those of dataset2 were 93.70 ± 2.80(%),62.65 ± 11.27(%),93.00 ± 3.11(%),100.00 ± 0.00(%), and 0.965 ± 0.016. The kappa coefficient showed that it reached the recognition level of senior doctors.

Conclusion

The improved DL model has a good diagnostic effect for MCV stenosis in TCD images and is expected to help in ICAS screening.

3D-Printed Stents Loaded with Panax notoginseng Saponin for Promoting Re-endothelialization and Reducing Local Inflammation in the Carotid Artery of Rabbits

Endovascular treatment (EVT) using stents has become the primary option for severe cerebrovascular stenosis. However, considerable challenges remain to be addressed, such as in-stent restenosis (ISR) and late thrombosis. Many modified stents have been developed to inhibit the hyperproliferation of vascular smooth muscle cells (SMCs) and protect vascular endothelial cells (VECs), thereby reducing such complications. Some modified stents, such as those infused with rapamycin, have improved in preventing acute thrombosis. However, ISR and late thrombosis, which are long-term complications, remain unavoidable. Panax notoginseng saponin (PNS), a traditional Chinese medicine consisting of various compounds, is beneficial in promoting the proliferation and migration of VECs and inhibiting the proliferation of SMCs. Herein, a 3D-printed polycaprolactone (PCL) stent loaded with PNS (PNS-PCL stent) was developed based on a previous study. In vitro studies confirmed that PNS promotes the migration and proliferation of VECs, which were damaged, by increasing the expression levels of microRNA-126, p-AKT, and endothelial nitric oxide synthase. In vivo, the PNS-PCL stents maintained the patency of the carotid artery in rabbits for up to three months, outperforming the PCL stents. The PNS-PCL stents may present a new solution for the EVT of cerebrovascular atherosclerotic stenosis in the future.

Prognostic Value of Mild Asymptomatic Intracranial Atherosclerotic Stenosis in Patients With Hypertension

BACKGROUND

Mild asymptomatic intracranial atherosclerotic stenosis (aICAS) is common in Chinese patients with hypertension. However, there are no data on its prognostic value in this population. The aim of the present study was to clarify the prevalence and associated cardiovascular risk factors of mild aICAS and determine its prognostic value for overall and cardiovascular mortality in patients with hypertension.

METHODS

In total, 1,813 participants were evaluated for aICAS using computed tomographic angiography. The predictive effect of mild to severe aICAS on all-cause and cardiovascular mortality was evaluated using Kaplan-Meier survival curves and Cox regression analyses.

RESULTS

The prevalence rate of mild aICAS was 35.7%. Poorly controlled hypertension, in combination with diabetes and dyslipidemia, was associated with aICAS. Patients with aICAS had an independently significant increase in the risk of all-cause and cardiovascular death, with adjusted hazard ratios (HRs) for mild to severe stenosis ranging from 1.56 to 3.30 for all-cause death and from 2.48 to 6.38 for cardiovascular death. Among the patients with mild aICAS, only those with more than two stenoses had increased mortality after adjustment, with an HR of 2.44 (95% CI: 1.42-4.18) for total death and 4.49 (95% CI: 1.82-11.05) for cardiovascular death.

CONCLUSIONS

A significant association between mild aICAS and mortality in stroke-free patients with hypertension was revealed. The results indicate that mild aICAS might be an imaging marker for cerebrovascular lesions in patients with hypertension and poor control of blood pressure and lipids in this population requires further research.

A case report of effective treatment of intracranial atherosclerotic stenosis treated with the integration of traditional Chinese medicine and Western medicine

RATIONALE

Intracranial atherosclerotic stenosis (ICAS) represents a prevalent global cause of stroke, posing a notably higher risk of stroke recurrence than other stroke etiologies. Herein, we report a case of a 39-year-old male patient diagnosed with ICAS, treated through an integrated approach incorporating Chinese and Western medicine with significant efficacy and satisfied clinical safety.

PATIENT CONCERNS

This patient presented with 1 transient ischemic attack and prolonged headache, dizziness and poor sleep quality. In addition, the patient refused to undergo surgery due to the high cost and postoperative risks.

DIAGNOSES

Diagnostic methods used to identify ICAS include conventional cerebral angiography, magnetic resonance angiography (MRA), CT angiography (CTA), transcranial Doppler ultrasound (TCD), and High-Resolution Magnetic resonance imaging. Considering the cost and risks associated with conventional angiography, noninvasive imaging has emerged as the method of choice for diagnosing ICAS. After a series of noninvasive examinations (CTA, TCD, and HR-MRI), the patient was diagnosed with ICAS.

INTERVENTIONS

The western medical regimen includes antiplatelet coagulation, blood pressure control, lipid regulation, plaque stabilization, and lifestyle modifications such as exercise, weight loss, and adherence to low-salt, low-fat diets. Complementing this, traditional Chinese medicine (TCM) treatment was guided by the principle of strengthening the spleen, resolving dampness, nourishing blood and harmonizing ying, resolving blood stasis and clearing collaterals. This involved the administration oral Chinese medicine such as modified Shenling Baizhu powder and modified Si Wu decoction.

OUTCOMES

The efficacy of the treatment was assessed by evaluating the degree of luminal stenosis and peak systolic blood flow velocity in the M1 segment of the left middle cerebral artery (MCA) before and after the intervention. Encouragingly, posttreatment results demonstrated the disappearance of the plaque in the left MCA-M1 segment, with no significant lumen stenosis observed. Moreover, a notable and smooth reduction in blood flow velocity was achieved in the left MCA, indicating positive outcomes from the integrated traditional Chinese and Western medicine approach.

CONCLUSION

This case report shows that a combination of traditional Chinese and Western medicine is safe and effective in the treatment of ICAS and is worthy of promotion in the clinic.

A Long-Term Outcome of Symptomatic Middle Cerebral Artery Undergoing Intracranial Angioplasty or Stenting

OBJECTIVE

For symptomatic stenosis in the middle cerebral artery (MCA), intracranial angioplasty and stenting are frequently employed. However, limited data exist regarding their long-term impact. Our study demonstrates the long-term advantages in preventing ischemic events through a 5-year follow-up period.

METHODS

A set of 41 individuals with symptomatic stenosis in the MCA who underwent angioplasty or stenting procedures between October 2004 and April 2018 at various hospitals in Southwest China were prospectively enrolled in the study. The rates of successful revascularization, complications, imaging observations, and clinical outcomes were systematically assessed.

RESULTS

A total of 41 individuals successfully underwent stenting, respectively. After stenting, the extent of stenosis was decreased from 71.8% (56-87.8%) to 24.9% (0-45%). The mean follow-up period is 36.9 ± 13.68 months (range, 11-67 months). There was no deterioration of neurological function or a new ischemic event. A DSA or CT angiography was conducted after the procedure and demonstrated no in-stent restenosis. No patient experienced restenosis below 50% during the mean follow-up period. The morbidity and mortality rates of the case series were 7.3% and 2.4%, respectively.

CONCLUSIONS

In the treatment of symptomatic MCA atherosclerotic stenoses, intracranial angioplasty and stenting are demonstrated to be technically feasible and safe. Its early and long-term efficacy on ischemic event prevention is acceptable, with a reduced level of restenosis, although the representative sample is tiny.

Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis: The BASIS Randomized Clinical Trial

Importance

Previous randomized clinical trials did not demonstrate the superiority of endovascular stenting over aggressive medical management for patients with symptomatic intracranial atherosclerotic stenosis (sICAS). However, balloon angioplasty has not been investigated in a randomized clinical trial.

Objective

To determine whether balloon angioplasty plus aggressive medical management is superior to aggressive medical management alone for patients with sICAS.

Design, Setting, and Participants

A randomized, open-label, blinded end point clinical trial at 31 centers across China. Eligible patients aged 35 to 80 years with sICAS defined as recent transient ischemic attack (<90 days) or ischemic stroke (14-90 days) before enrollment attributed to a 70% to 99% atherosclerotic stenosis of a major intracranial artery receiving treatment with at least 1 antithrombotic drug and/or standard risk factor management were recruited between November 8, 2018, and April 2, 2022 (final follow-up: April 3, 2023).

Interventions

Submaximal balloon angioplasty plus aggressive medical management (n = 249) or aggressive medical management alone (n = 252). Aggressive medical management included dual antiplatelet therapy for the first 90 days and risk factor control.

Main Outcomes and Measures

The primary outcome was a composite of any stroke or death within 30 days after enrollment or after balloon angioplasty of the qualifying lesion or any ischemic stroke in the qualifying artery territory or revascularization of the qualifying artery after 30 days through 12 months after enrollment.

Results

Among 512 randomized patients, 501 were confirmed eligible (mean age, 58.0 years; 158 [31.5%] women) and completed the trial. The incidence of the primary outcome was lower in the balloon angioplasty group than the medical management group (4.4% vs 13.5%; hazard ratio, 0.32 [95% CI, 0.16-0.63]; P < .001). The respective rates of any stroke or all-cause death within 30 days were 3.2% and 1.6%. Beyond 30 days through 1 year after enrollment, the rates of any ischemic stroke in the qualifying artery territory were 0.4% and 7.5%, respectively, and revascularization of the qualifying artery occurred in 1.2% and 8.3%, respectively. The rate of symptomatic intracranial hemorrhage in the balloon angioplasty and medical management groups was 1.2% and 0.4%, respectively. In the balloon angioplasty group, procedural complications occurred in 17.4% of patients and arterial dissection occurred in 14.5% of patients.

Conclusions and Relevance

In patients with sICAS, balloon angioplasty plus aggressive medical management, compared with aggressive medical management alone, statistically significantly lowered the risk of a composite outcome of any stroke or death within 30 days or an ischemic stroke or revascularization of the qualifying artery after 30 days through 12 months. The findings suggest that balloon angioplasty plus aggressive medical management may be an effective treatment for sICAS, although the risk of stroke or death within 30 days of balloon angioplasty should be considered in clinical practice.

Trial Registration

ClinicalTrials.gov Identifier: NCT03703635.

Characteristics of Atherosclerotic Plaques and Stroke Mechanism in Patients with Border-Zone Infarcts: A High-resolution Magnetic Resonance Imaging Study

BACKGROUND

Relatively little is known about the plaque characteristics of border-zone infarcts and how they differ between cortical border-zone (CBZ) and internal border-zone (IBZ) infarcts.

METHODS

We conducted a retrospective observational cohort study of patients with intracranial atherosclerotic disease who underwent high-resolution magnetic resonance imaging (HR-MRI) examination. Individuals with border-zone infarcts in the middle cerebral artery (MCA) territory, detected by diffusion-weighted imaging, were enrolled. Plaque morphological and compositional parameters of both IBZ and CBZ groups were compared. Independent predictors were identified using a binary logistic regression model, and the sensitivity and specificity of the model were assessed using a receiver operating characteristic curve. Kaplan-Meier survival analysis further explored differences in stroke recurrence between BZ patients with mono or dual antiplatelet therapy.

RESULTS

We reviewed 101 symptomatic patients with border-zone infarcts (BZ) within the MCA territory in the study. Out of the patients meeting the imaging eligibility criteria, we detected 34 cases with isolated IBZ, 23 cases with isolated CBZ, and six cases with both IBZ and CBZ infarcts. Those with IBZ infarcts had a higher plaque burden than those without (p < 0.001), and those with CBZ infarcts exhibited a complicated plaque less frequently than those without (37.9% vs 67.6%, p = 0.018). In those with isolated IBZ or CBZ infarcts, plaque burden was independently associated with isolated IBZ infarcts (odd ratio=1.08; 95% CI, 1.02-1.15; p = 0.023). During the median follow-up period of 37 (27, 50) months, 13.8% of patients receiving early dual antiplatelet treatment and 30.4% of those on single antiplatelet therapy experienced stroke recurrence (p = 0.182).

CONCLUSION

Intracranial atherosclerotic plaque morphology and composition differ between patients with IBZ and those with CBZ infarcts. Higher plaque burden is more associated with IBZ infarcts.

PCSK9 Inhibitor with Statin Therapy for Intracranial Artery Stenosis ( PISTIAS): Rationale and design of a multicenter randomized controlled trial

RATIONALE

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors enable an additional 54-75% reduction in low-density lipoprotein cholesterol (LDL-C) in statin-treated patients, demonstrating plaque regression in coronary artery disease. However, the impact of achieving an extremely low level of LDL-C with PCSK9 inhibitors (e.g. Evolocumab) on symptomatic intracranial atherosclerosis remains unexplored.

AIM AND HYPOTHESIS

To determine whether combining Evolocumab and statins achieves a more significant symptomatic intracranial plaque regression than statin therapy alone.

SAMPLE SIZE ESTIMATES

With a sample size of 1000 subjects, a two-sided α of 0.05, and 20% lost to follow-up, the study will have 83.3% power to detect the difference in intracranial plaque burden.

METHODS AND DESIGN

This is an investigator-initiated multicenter, randomized, open-label, outcome assessor-blinded trial, evaluating the impact of combining Evolocumab and statins on intracranial plaque burden assessed by high-resolution magnetic resonance imaging at baseline in patients undergoing a clinically indicated acute stroke or transient ischemic attack due to intracranial artery stenosis, and after 24 weeks of treatment. Subjects (n = 1000) were randomized 1:1 into two groups to receive either Evolocumab 140 mg every 2 weeks with statin therapy or statin therapy alone.

STUDY OUTCOMES

The primary endpoint is the change in intracranial plaque burden assessed by high-resolution magnetic resonance imaging, performed at baseline and at the end of the 24-week treatment period.

DISCUSSION

This trial will explore whether more significant intracranial plaque regression is achievable with the treatment of combining Evolocumab and statins, providing information about efficacy and safety data.

TRIAL REGISTRATION NUMBER

ChiCTR2300068868; https://www.chictr.org.cn/.

Diagnostic accuracy of hemodynamic assessment of intracranial atherosclerotic stenosis from a single angiographic view: a validation study

BACKGROUND

The aim of this study is to assess the feasibility of identifying the hemodynamic status of intracranial atherosclerotic stenosis (ICAS) using angio-based fractional flow (FF) calculated from a single angiographic view, with wire-based FF as the reference standard.

METHOD

The study retrospectively recruited 100 ICAS patients who underwent pressure wire measurement and digital subtraction angiography. The AccuICAD software was used to calculate angio-based FF, with the wire-measured value serving as the reference standard for evaluating the accuracy, consistency, and diagnostic performance of angio-based FF.

RESULTS

The mean±SD value of wire-based FF was 0.77±0.18, while the mean value of angio-based FF was 0.77±0.19. A good correlation between angio-based FF and wire-based FF was evident (r=0.90, P<0.001), with good agreement (mean difference 0.00±0.08). The diagnostic accuracy of angio-based FF and percent diameter stenosis (DS%) were 93.23% versus 72.18%, 91.73% versus 72.93%, and 89.47% versus 78.95% for predicted wire-based FF thresholds of 0.70, 0.75, and 0.80, respectively. The area under the curve (AUC) values for angio-based FF and DS% were 0.975 versus 0.822, 0.970 versus 0.814, and 0.943 versus 0.826 at the respective thresholds, respectively.

CONCLUSION

The FF calculated from a single angiographic view can be considered an effective tool for functional assessment of cerebral arterial stenosis.

Dual Antiplatelet Therapy and Outcomes in Acute Mild to Moderate Stroke With Versus Without Large-Artery Atherosclerosis Post Hoc Analysis of ATAMIS

BACKGROUND

We conducted a post hoc analysis of the ATAMIS (Antiplatelet Therapy in Acute Mild to Moderate Ischemic Stroke) trial to investigate whether the priority of clopidogrel plus aspirin to aspirin alone was consistent between patients with and without stroke pathogenesis of large-artery atherosclerosis (LAA).

METHODS AND RESULTS

Patients with stroke classification randomized to a clopidogrel-plus-aspirin group and aspirin-alone group in a modified intention-to-treat analysis set of ATAMIS were classified into LAA and non-LAA subtypes. The primary outcome was early neurologic deterioration at 7 days, defined as a >2-point increase in National Institutes of Health Stroke Scale score compared with baseline, and safety outcomes were bleeding events and intracranial hemorrhage. We compared treatment effects in each stroke subtype and investigated the interaction. Among 2910 patients, 225 were assigned into the LAA subtype (119 in the clopidogrel-plus-aspirin group and 106 in the aspirin-alone group) and 2685 into the non-LAA subtype (1380 in the clopidogrel-plus-aspirin group and 1305 in the aspirin-alone group). Median age was 66 years, and 35% were women. A lower proportion of early neurologic deterioration was found to be associated with dual antiplatelet therapy in the LAA subtype (adjusted risk difference, -10.4% [95% CI, -16.2% to -4.7%]; P=0.001) but not in the non-LAA subtype (adjusted risk difference, -1.4% [95% CI, -2.6% to 0.1%]; P=0.06). No significant interaction was found (P=0.11).

CONCLUSIONS

Compared with the non-LAA subtype, patients with stroke of the LAA subtype may get more benefit from dual antiplatelet therapy with clopidogrel plus aspirin with respect to early neurologic deterioration at 7 days.

REGISTRATION

URL: clinicaltrials.gov; UnIque identifier: NCT02869009.

Association between cerebral artery stenosis and depressive symptoms in elderly patients

OBJECTIVE

To examine the association between cerebral artery stenosis and depressive symptoms in elderly patients.

METHODS

The study participants were 365 patients aged ≥65 years who visited the psychiatric outpatient clinic, Samsung Medical Center between January 1, 2000, and December 31, 2019, and were diagnosed with depressive disorder. They had brain imaging tests including magnetic resonance angiography (MRA), psychological evaluations including the 15-item Geriatric Depression Scale (GDS-15), and lab tests. Individuals' cerebral artery stenosis was identified and the association with significant depressive symptoms was examined.

RESULTS

Of the 365 subjects, 108 had at least one location of cerebral artery stenosis (29.6 %). The mean score of GDS-15 in the stenosis group was 8.1 (SD, 3.8), higher than the mean GDS-15 score of 6.5 (SD, 4.0) for the group without stenosis (p < 0.001). Compared to no middle cerebral artery (MCA) stenosis, having MCA stenosis was associated with significant depressive symptoms (p = 0.005). Compared to no posterior cerebral artery (PCA) stenosis, having left PCA stenosis was associated with significant depressive symptoms (p = 0.022). In the multivariable linear regression analysis, only bilateral MCA stenosis had a positive association with the score of GDS-15 (p = 0.013).

CONCLUSION

Bilateral MCA stenosis and left PCA stenosis are associated with significant depressive symptoms among elderly patients, with bilateral MCA stenosis positively associated with the severity of depression.

Intracranial Atherosclerotic Disease and Incident Dementia: The ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Studies of the neurovascular contribution to dementia have largely focused on cerebral small vessel disease (CSVD), but the role of intracranial atherosclerotic disease (ICAD) remains unknown in the general population. The objective of this study was to determine the risk of incident dementia from ICAD after adjusting for CSVD and cardiovascular risk factors in a US community-based cohort.

METHODS

We acquired brain magnetic resonance imaging examinations from 2011 through 2013 in 1980 Black and White participants in the ARIC study (Atherosclerosis Risk in Communities), a prospective cohort conducted in 4 US communities. Magnetic resonance imaging examinations included high-resolution vessel wall magnetic resonance imaging and magnetic resonance angiography to identify ICAD. Of these participants, 1590 without dementia, without missing covariates, and with adequate magnetic resonance image quality were followed through 2019 for incident dementia. Associations between ICAD and incident dementia were assessed using Cox proportional hazard ratios adjusted for CSVD (characterized by white matter hyperintensities, lacunar infarctions, and microhemorrhages), APOE4 genotype (apolipoprotein E gene ε4), and cardiovascular risk factors.

RESULTS

The mean age (SD) of study participants was 77.4 (5.2) years. ICAD was detected in 34.6% of participants. After a median follow-up of 5.6 years, 286 participants developed dementia. Compared with participants without ICAD, the fully adjusted hazard ratios (95% CIs) for incident dementia in participants with any ICAD, with ICAD only causing stenosis ≤50%, and with ICAD causing stenosis >50% in ≥1 vessel were 1.57 (1.17-2.11), 1.41 (1.02-1.95), and 1.94 (1.32-2.84), respectively. ICAD was associated with dementia even among participants with low white matter hyperintensities burden, a marker of CSVD.

CONCLUSIONS

ICAD was associated with an increased risk of incident dementia, independent of CSVD, APOE4 genotype, and cardiovascular risk factors. The increased risk of dementia was evident even among participants with low CSVD burden, a group less likely to be affected by vascular dementia, and in participants with ICAD causing only low-grade stenosis. Our results suggest that ICAD may partially mediate the effect that cardiovascular risk factors have on the brain leading to dementia. Both ICAD and CSVD must be considered to understand the vascular contributions to cognitive decline.

Risk factor differences in five-year progression of Intracranial artery stenosis and cerebral small vessel disease in general population

BACKGROUND

Intracranial artery stenosis (ICAS) and cerebral small vessel disease (CSVD) are associated with a heavy socioeconomic burden; however, their longitudinal changes remain controversial.

METHODS

We conducted a longitudinal analysis on 756 participants of Shunyi Cohort who underwent both baseline and follow-up brain magnetic resonance imaging (MRI) and MR angiography in order to investigate the risk factors for ICAS and CSVD progression in community population. Incident ICAS was defined as new stenosis occurring in at least one artery or increased severity of the original artery stenosis. CSVD markers included lacunes, cerebral microbleeds (CMB), and white matter hyperintensities (WMH).

RESULTS

After 5.58 ± 0.49 years of follow-up, 8.5% of the 756 participants (53.7 ± 8.0 years old, 65.1% women) had incident ICAS. Body mass index (BMI) (OR = 1.09, 95% CI = 1.01-1.17, p = 0.035) and diabetes mellitus (OR = 2.67, 95% CI = 1.44-4.93, p = 0.002) were independent risk factors for incident ICAS. Hypertension was an independent risk factor for incident lacunes (OR = 2.12, 95% CI = 1.20-3.77, p = 0.010) and CMB (OR = 2.32, 95% CI = 1.22-4.41, p = 0.011), while WMH progression was primarily affected by BMI (β = 0.108, SE = 0.006, p = 0.002). A higher LDL cholesterol level was found to independently protect against WMH progression (β = -0.076, SE = 0.027, p = 0.019).

CONCLUSIONS

Modifiable risk factor profiles exhibit different in patients with ICAS and CSVD progression. Controlling BMI and diabetes mellitus may help to prevent incident ICAS, and antihypertensive therapy may conduce to mitigate lacunes and CMB progression. LDL cholesterol may play an inverse role in large arteries and small vessels.

Potential of BMI as a screening indicator for extracranial-intracranial bypass surgery in patients with symptomatic artery occlusion: a post-hoc analysis of the CMOSS trial

BACKGROUND

To investigate the association between BMI and the incidence of ischemic stroke in patients with symptomatic artery occlusion, and further to evaluate the utility of BMI as a screening tool for identifying candidates for extracranial-intracranial bypass surgery.

MATERIALS AND METHODS

The authors analyzed the relationship between BMI and the occurrence of ipsilateral ischemic stroke (IIS) among patients receiving only medical management in the Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS). Additionally, the authors compared the primary endpoint of CMOSS-stroke or death within 30 days, or IIS after 30 days up to 2 years-among patients with varying BMIs who underwent either surgery or medical treatment.

RESULTS

Of the 165 patients who treated medically only, 16 (9.7%) suffered an IIS within 2 years. BMI was independently associated with the incidence of IIS (hazard ratio: 1.16 per kg/m 2 ; 95% CI: 1.06-1.27). The optimal BMI cutoff for predicting IIS was 24.5 kg/m 2 . Patients with BMI ≥24.5 kg/m 2 experienced a higher incidence of IIS compared to those with BMI <24.5 kg/m 2 (17.4 vs. 0.0%, P <0.01). The incidence of the CMOSS primary endpoint was significantly different between the surgical and medical groups for patients with BMI ≥24.5 kg/m 2 (5.3 vs. 19.8%, P <0.01) and those with BMI <24.5 kg/m 2 (10.6 vs. 1.4%; P =0.02). Surgical intervention was independently associated with a reduced rate of the CMOSS primary endpoint in patients with BMI ≥24.5 kg/m 2 .

CONCLUSION

Data from the CMOSS trial indicate that patients with BMI ≥24.5 kg/m 2 are at a higher risk of IIS when treated medically only and appear to derive greater benefit from bypass surgery compared to those with lower BMIs. Given the small sample size and the inherent limitations of retrospective analyses, further large-scale, prospective studies are necessary to confirm these findings.

Burden of intracranial artery calcification in white patients with ischemic stroke

INTRODUCTION

The diagnostic workup of stroke doesn't identify an underlying cause in two-fifths of ischemic strokes. Intracranial arteriosclerosis is acknowledged as a cause of stroke in Asian and Black populations, but is underappreciated as such in whites. We explored the burden of Intracranial Artery Calcification (IAC), a marker of intracranial arteriosclerosis, as a potential cause of stroke among white patients with recent ischemic stroke or TIA.

PATIENTS AND METHODS

Between December 2005 and October 2010, 943 patients (mean age 63.8 (SD ± 14.0) years, 47.9% female) were recruited, of whom 561 had ischemic stroke and 382 a TIA. CT-angiography was conducted according to stroke analysis protocols. The burden of IAC was quantified on these images, whereafter we assessed the presence of IAC per TOAST etiology underlying the stroke and assessed associations between IAC burden, symptom severity, and short-term functional outcome.

RESULTS

IAC was present in 62.4% of patients. Furthermore, IAC was seen in 84.8% of atherosclerotic strokes, and also in the majority of strokes with an undetermined etiology (58.5%). Additionally, patients with larger IAC burden presented with heavier symptoms (adjusted OR 1.56 (95% CI [1.06-2.29]), but there was no difference in short-term functional outcome (1.14 [0.80-1.61]).

CONCLUSION

IAC is seen in the majority of white ischemic stroke patients, aligning with findings from patient studies in other ethnicities. Furthermore, over half of patients with a stroke of undetermined etiology presented with IAC. Assessing IAC burden may help identify the cause in ischemic stroke of undetermined etiology, and could offer important prognostic information.

High-resolution MR vessel wall imaging and cardiovascular health for evaluating the occurrence of ischemic stroke

OBJECTIVES

To explore the value of high-resolution MR vessel wall imaging (HR-VWI) based plaque characteristics combined with cardiovascular health (CVH) metrics in the risk evaluation of ischemic stroke attributed to middle cerebral artery (MCA) atherosclerotic stenosis.

METHODS

Retrospective analysis of 209 participants with middle cerebral atherosclerosis, 146 patients with high signal in the MCA area on DWI were included in the symptomatic group, and 63 patients were included in the asymptomatic group. The degree of stenosis, enhancement ratio, plaque burden, remodeling index, and intraplaque hemorrhage were measured and compared between groups. Seven CVH metrics and other clinical data were obtained. The association between these factors and ischemic stroke was investigated by univariate and multivariate analysis.

RESULTS

The degree of stenosis [OR, 1.036 (95 % CI, 1.014-1.058); P = 0.001], plaque burden [OR, 0.958 (95 % CI, 0.928-0.989); P = 0.009], intraplaque hemorrhage [OR, 3.530 (95 % CI, 1.233-10.110); P = 0.019], physical activity [OR, 4.321 (95 % CI, 1.526-12.231); P = 0.006], and diet [OR, 8.986 (95 % CI, 2.747-29.401); P < 0.001] were the independent characteristics associated with the occurrence of ischemic stroke. ROC curve showed that the combination of plaque characteristics, diet, and physical activity achieved the highest AUC of 0.828 (95 % CI 0.770-0.877; P < 0.001), with sensitivity and specificity being 86.30 % and 66.67 %, respectively.

CONCLUSION

Plaque characteristics combined with CVH metrics may identify high-risk populations for ischemic stroke and offer novel insights into risk evaluation and stratification.

Calcification is a risk factor for intracranial in-stent restenosis: an optical coherence tomography study

BACKGROUND

The frequent occurrence of calcification in intracranial artery stenosis increases the risk of ischemic stroke. In previous cases, we have observed a possible relationship between calcification and intracranial in-stent restenosis (ISR) using optical coherence tomography (OCT). Therefore, our study aimed to demonstrate the relationship between intracranial calcification and ISR with a larger sample size.

METHODS

For our study patients who underwent OCT for intracranial artery stenosis before stenting were included from May 2020 to October 2022. Follow-up assessments were performed using transcranial color-coded duplex (TCCD) sonography ultrasonography to detect cases of ISR.

RESULTS

We recruited 54 patients, 15 of them were excluded as they did not meet the study criteria. Our study included 39 patients, of whom 21 had calcification, and 18 did not. The results of our study revealed a significant association between calcification and intracranial ISR (9 (42.86) vs 2 (11.11), p=0.0375). Notably, patients with macrocalcification were more likely to undergo ISR than patients with spotty calcification (77.78% vs 22.22%, p=0.03).

CONCLUSION

OCT imaging demonstrates that calcification is an essential risk factor for intracranial ISR. These findings have important implications for individualized treatment. They provide valuable insights for optimizing stent design and exploring potential mechanisms of intracranial ISR.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05550077.