1
|
Alexander MJ, Yu W. Intracranial atherosclerosis update for neurointerventionalists. J Neurointerv Surg 2024; 16:522-528. [PMID: 37295944 DOI: 10.1136/jnis-2022-019628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
The management of intracranial atherosclerotic disease (ICAD) has been evolving with advanced imaging, refinements of best medical treatment, and the development of endovascular options. There has been a significant increase in the use of endovascular therapy for symptomatic ICAD in the USA over the past 6 years. The rationale for this review is to update neurointerventionalists in these areas so that evidence-based decisions can be considered when counseling potential patients regarding their risks, benefits, and potential complications. The landmark SAMMPRIS trial demonstrated superiority of aggressive medical management (AMM) over intracranial stenting as an initial treatment. However, the risk of disabling or fatal stroke remains high in patients presenting with stroke treated with AMM. Recent studies showed a significantly lower rate of periprocedural complications from intracranial stenting. Patients who have failed medical treatment may therefore benefit from intracranial stenting, particularly in those with hemodynamic compromise and large vessel embolic stroke. Drug coated angioplasty balloons and drug eluting stents may potentially reduce the risk of in-stent re-stenosis. Large vessel occlusion (LVO) due to underlying ICAD is seen in a subset of thrombectomy-eligible patients. The use of stenting as a rescue therapy in LVO thrombectomy has also shown promising early results.
Collapse
Affiliation(s)
| | - Wengui Yu
- Neurology, University of California Irvine, Irvine, California, USA
| |
Collapse
|
2
|
Wu Y, Gao F, Feng H. Hemodynamic Impairments of Evaluating Symptomatic Intracranial Atherosclerotic Stenosis using Quantitative Flow Ratio on Digital Subtraction Angiography : A Comparison with Computed Tomography Perfusion, MRI and Fractional Flow Reserve. Clin Neuroradiol 2024:10.1007/s00062-024-01395-2. [PMID: 38489035 DOI: 10.1007/s00062-024-01395-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/31/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE Cerebral hemodynamics are important for the management of intracranial atherosclerotic stenosis (ICAS). The quantitative flow ratio (QFR) is a novel angiography-derived index for assessing the functional relevance of ICAS without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to FFR are scarce. METHODS In this prospective study 56 patients with anterior circulation symptomatic ICAS who received endovascular treatment were included. The new method of computing QFR from a single angiographic view, i.e., the Murray law-based QFR (μQFR), was applied to the examined vessels. An artificial intelligence algorithm was developed to realize the automatic delineation of vascular contour. Pressure gradients were measured before and after treatment within the lesion vessel using a pressure guidewire and the FFR was calculated. RESULTS There was a good correlation between μQFR and FFR. Preoperative FFR predicted DWI watershed infarction (FFR optimal cut-off level: 0.755). Preoperative μQFR predicted DWI watershed infarction (μQFR optimal cut-off level: 0.51). Preoperative FFR predicted CTP hypoperfusion (FFR best predictive value: 0.62). Preoperative μQFR predicted CTP hypoperfusion (μQFR best predictive value: 0.375). CONCLUSION The μQFR based on DSA images can be used as an indicator to assess the functional status of the lesion in patients with ICAS.
Collapse
Affiliation(s)
- Yingchun Wu
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, 150001, Harbin, China
- Department of Neurology, Ordos Central Hospital, Ordos, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Honglin Feng
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, 150001, Harbin, China.
| |
Collapse
|
3
|
Yaghi S, Albin C, Chaturvedi S, Savitz SI. Roundtable of Academia and Industry for Stroke Prevention: Prevention and Treatment of Large-Vessel Disease. Stroke 2024; 55:226-235. [PMID: 38134259 DOI: 10.1161/strokeaha.123.043910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Shadi Yaghi
- Alpert Medical School at Brown University, Providence, RI (S.Y.)
| | | | | | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston (S.I.S.)
| |
Collapse
|
4
|
Liu Y, Li S, Tian X, Leung TW, Liu L, Liebeskind DS, Leng X. Cerebral haemodynamics in symptomatic intracranial atherosclerotic disease: a narrative review of the assessment methods and clinical implications. Stroke Vasc Neurol 2023; 8:521-530. [PMID: 37094991 PMCID: PMC10800270 DOI: 10.1136/svn-2023-002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a common cause of ischaemic stroke and transient ischaemic attack (TIA) with a high recurrence rate. It is often referred to as intracranial atherosclerotic stenosis (ICAS), when the plaque has caused significant narrowing of the vessel lumen. The lesion is usually considered 'symptomatic ICAD/ICAS' (sICAD/sICAS) when it has caused an ischaemic stroke or TIA. The severity of luminal stenosis has long been established as a prognostic factor for stroke relapse in sICAS. Yet, accumulating studies have also reported the important roles of plaque vulnerability, cerebral haemodynamics, collateral circulation, cerebral autoregulation and other factors in altering the stroke risks across patients with sICAS. In this review article, we focus on cerebral haemodynamics in sICAS. We reviewed imaging modalities/methods in assessing cerebral haemodynamics, the haemodynamic metrics provided by these methods and application of these methods in research and clinical practice. More importantly, we reviewed the significance of these haemodynamic features in governing the risk of stroke recurrence in sICAS. We also discussed other clinical implications of these haemodynamic features in sICAS, such as the associations with collateral recruitment and evolution of the lesion under medical treatment, and indications for more individualised blood pressure management for secondary stroke prevention. We then put forward some knowledge gaps and future directions on these topics.
Collapse
Affiliation(s)
- Yuying Liu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Shuang Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Xuan Tian
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core, University of California Los Angeles, Los Angeles, California, USA
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| |
Collapse
|
5
|
Sabayan B, Goudarzi R, Ji Y, Borhani‐Haghighi A, Olson‐Bullis BA, Murray AM, Sedaghat S. Intracranial Atherosclerosis Disease Associated With Cognitive Impairment and Dementia: Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e032506. [PMID: 37955546 PMCID: PMC10727275 DOI: 10.1161/jaha.123.032506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Intracranial atherosclerosis disease (ICAD) alters cerebrovascular hemodynamics and brain structural integrity. Multiple studies have evaluated the link between ICAD and cognitive impairment, with mixed results. This study aims to systematically review and summarize the current evidence on this link. METHODS AND RESULTS PubMed, EMBASE, PsycInfo, and Web of Science were searched from 2000 to 2023 without language restriction. Cross-sectional and prospective cohort studies as well as postmortem studies were included. Studies containing data on the link between ICAD, defined as at least 50% stenosis in 1 intracranial vessel, and cognitive impairment and dementia were screened by 2 independent reviewers. A total of 22 (17 observational and 5 postmortem) unique studies, comprising 11 184 individuals (average age range, 59.8-87.6 years; 45.7% women; 36.5% Asian race), were included in the systematic review. Seven of 10 cross-sectional studies and 5 of 7 prospective studies showed a significant association between ICAD and cognitive impairment. In the pooled analysis, ICAD was associated with greater cognitive impairment (measure of association, 1.87 [95% CI, 1.49-2.35]). Meta-regression analyses did not show a significant impact of age, sex, and race. All postmortem studies showed that patients with Alzheimer disease and vascular dementia had a higher burden of ICAD compared with controls. CONCLUSIONS This study shows that ICAD is associated with cognitive impairment and dementia across age, sex, and race groups. Our findings may underscore the need to develop individualized dementia preventive care plans in patients with ICAD.
Collapse
Affiliation(s)
- Behnam Sabayan
- Department of Neurology, Hennepin Healthcare Research InstituteHennepin County Medical CenterMinneapolisMN
- Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisMN
| | - Roham Goudarzi
- Faculty of ScienceUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Yuekai Ji
- Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisMN
| | | | | | - Anne M. Murray
- Berman Center for Outcomes and Clinical Research and Geriatrics Division, Department of MedicineHennepin Healthcare Research InstituteMinneapolisMN
| | - Sanaz Sedaghat
- Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisMN
| |
Collapse
|
6
|
Wang M, Leng X, Wu J, Gao Y, Fiehler J, Siddiqui AH, Xiang J, Koduri S, Wan S. Cerebral Fractional Flow Reserve for Functional Evaluation of Intracranial Atherosclerotic Stenosis. Transl Stroke Res 2023; 14:678-680. [PMID: 35644817 DOI: 10.1007/s12975-022-01034-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Ming Wang
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, No. 1229 Gudun Road, Hangzhou, 310030, Zhejiang, China
| | | | - Jiong Wu
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, No. 1229 Gudun Road, Hangzhou, 310030, Zhejiang, China
| | - Yuhai Gao
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, No. 1229 Gudun Road, Hangzhou, 310030, Zhejiang, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | | | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Shu Wan
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, No. 1229 Gudun Road, Hangzhou, 310030, Zhejiang, China.
| |
Collapse
|
7
|
Gao J, Zhang L, Lin J, Yang J, Yao M, Cheng Z, Cai X, Huang L. Stroke recurrence is associated with unfavorable intracranial venous outflow in patients with symptomatic intracranial atherosclerotic large vessel severe stenosis or occlusion. Front Neurol 2023; 14:1156315. [PMID: 37228413 PMCID: PMC10203233 DOI: 10.3389/fneur.2023.1156315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Objective The purpose of this study was to investigate the predictive value of intracranial venous outflow for recurrent cerebral ischemic events (RCIE) in patients with symptomatic intracranial atherosclerotic large-vessel severe stenosis or occlusion (sICAS-S/O). Methods This retrospective study included sICAS-S/O patients with anterior circulation who underwent dynamic computed tomography angiography (dCTA) and computed tomography perfusion (CTP). Arterial collaterals were evaluated using the pial arterial filling score for dCTA data, tissue-level collaterals (TLC) were assessed using the high-perfusion intensity ratio (HIR, Tmax >10 s/Tmax >6 s), and cortical veins were evaluated using the multi-phase venous score (MVS) for the vein of Labbé (VOL), sphenoparietal sinus (SPS), and superficial cerebral middle vein (SCMV). The relationships between multi-phase venous outflow (mVO), TLC, and 1-year RCIE were analyzed. Results Ninety-nine patients were included, 37 of whom had unfavorable mVO (mVO-) and 62 of whom had favorable mVO (mVO+). Compared with the mVO+ patients, mVO- patients had a higher admission National Institutes of Health Stroke Scale (NIHSS) score (median, 4 [interquartile range (IQR), 0-9] vs. 1 [IQR, 0-4]; p = 0.048), larger ischemic volume (median, 74.3 [IQR, 10.1-177.9] vs. 20.9 [IQR, 5-86.4] mL; p = 0.042), and worse tissue perfusion (median, 0.04 [IQR, 0-0.17] vs. 0 [IQR, 0-0.03]; p = 0.007). Multivariate regression analysis showed that mVO- was an independent predictor of 1-year RCIE. Conclusion For patients with sICAS-S/O of the anterior circulation, unfavorable intracranial venous outflow is a potential imaging indicator for predicting higher 1-year RCIE risk.
Collapse
Affiliation(s)
- Jiali Gao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Liang Zhang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiaxin Lin
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiajie Yang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Mingzheng Yao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhongyuan Cheng
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Xiangran Cai
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Li’an Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| |
Collapse
|
8
|
Das S, Shu L, Morgan RJ, Shah A, Fayad FH, Goldstein ED, Chahien D, Maglinger B, Bokka SK, Owens C, Abbasi M, Kvernland A, Siegler JE, Grory BM, Nguyen TN, Furie K, Khatri P, Mistry E, Prabhakaran S, Liebeskind DS, Romano JG, de Havenon A, Palaiodimou L, Tsivgoulis G, Yaghi S. Borderzone Infarcts and Recurrent Cerebrovascular Events in Symptomatic Intracranial Arterial Stenosis: A Systematic Review and Meta-Analysis. J Stroke 2023; 25:223-232. [PMID: 37282372 PMCID: PMC10250880 DOI: 10.5853/jos.2023.00185] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Intracranial arterial stenosis (ICAS)-related stroke occurs due to three primary mechanisms with distinct infarct patterns: (1) borderzone infarcts (BZI) due to impaired distal perfusion, (2) territorial infarcts due to distal plaque/thrombus embolization, and (3) plaque progression occluding perforators. The objective of the systematic review is to determine whether BZI secondary to ICAS is associated with a higher risk of recurrent stroke or neurological deterioration. METHODS As part of this registered systematic review (CRD42021265230), a comprehensive search was performed to identify relevant papers and conference abstracts (with ≥20 patients) reporting initial infarct patterns and recurrence rates in patients with symptomatic ICAS. Subgroup analyses were performed for studies including any BZI versus isolated BZI and those excluding posterior circulation stroke. The study outcome included neurological deterioration or recurrent stroke during follow-up. For all outcome events, corresponding risk ratios (RRs) and 95% confidence intervals (95% CI) were calculated. RESULTS A literature search yielded 4,478 records with 32 selected during the title/abstract triage for full text; 11 met inclusion criteria and 8 studies were included in the analysis (n=1,219 patients; 341 with BZI). The meta-analysis demonstrated that the RR of outcome in the BZI group compared to the no BZI group was 2.10 (95% CI 1.52-2.90). Limiting the analysis to studies including any BZI, the RR was 2.10 (95% CI 1.38-3.18). For isolated BZI, RR was 2.59 (95% CI 1.24-5.41). RR was 2.96 (95% CI 1.71-5.12) for studies only including anterior circulation stroke patients. CONCLUSION This systematic review and meta-analysis suggests that the presence of BZI secondary to ICAS may be an imaging biomarker that predicts neurological deterioration and/or stroke recurrence.
Collapse
Affiliation(s)
- Saurav Das
- Department of Neurology, University of Kentucky, Louisville, KY, USA
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI, USA
| | | | - Asghar Shah
- Department of Neurology, Brown University, Providence, RI, USA
| | - Fayez H. Fayad
- Department of Neurology, Brown University, Providence, RI, USA
| | | | | | - Benton Maglinger
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Cory Owens
- Department of Neurology, University of Kentucky, Louisville, KY, USA
| | - Mehdi Abbasi
- Department of Neurology, Yale University, New Haven, CT, USA
| | | | - James E. Siegler
- Department of Neurology, Cooper University Hospital, Camden, NJ, USA
| | | | - Thanh N. Nguyen
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI, USA
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | | | - David S. Liebeskind
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Lina Palaiodimou
- Second Department of Neurology, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| |
Collapse
|
9
|
Yaghi S, Shu L, Goldstein ED, Chang A, Kala N, Stretz C, Burton TM, Perelstein E, Furie K, Jayaraman M, Torabi R, Moldovan K, de Havenon A, Khatri P, Gebregziabher M, Liebeskind DS, Prabhakaran S. Recurrence risk in symptomatic intracranial stenosis treated medically in the real world. J Stroke Cerebrovasc Dis 2023; 32:107086. [PMID: 37030126 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107086] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND The risk of early recurrence in medically treated patients with intracranial atherosclerotic stenosis (ICAS) may differ in clinical trials versus real-world settings. Delayed enrollment may contribute to lower event rates in ICAS trials. We aim to determine the 30-day recurrence risk in a real-world setting of symptomatic ICAS. METHODS We used a comprehensive stroke center stroke registry to identify hospitalized patients with acute ischemic stroke or TIA due to symptomatic 50-99% ICAS. The outcome was recurrent stroke within 30 days. We used adjusted Cox regression models to identify factors associated with increased recurrence risk. We also performed a comparison of 30-day recurrent stroke rates in real world cohorts and clinical trials. RESULTS Among 131 hospitalizations with symptomatic 50-99% ICAS over 3 years, 80 hospitalizations of 74 patients (mean age 71.6 years, 55.41% men) met the inclusion criteria. Over 30 days, 20.6 % had recurrent stroke; 61.5% (8/13) occurred within first 7 days. The risk was higher in patients not receiving dual antiplatelet therapy (HR 3.92 95% CI 1.30-11.84, p = 0.015) and hypoperfusion mismatch volume >3.5 mL at a T max>6 s threshold (HR 6.55 95% CI 1.60-26.88, p < 0.001). The recurrence risk was similar to another real world ICAD cohort (20.2%), and higher than that seen in clinical trials (2.2%-5.7%), even in those treated with maximal medical treatment or meeting inclusion criteria for trials. CONCLUSIONS In patients with symptomatic ICAS, the real-world recurrence of ischemic events is higher than that seen in clinical trials, even in subgroups receiving the same pharmacological treatment strategies.
Collapse
Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States.
| | - Liqi Shu
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Eric D Goldstein
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Allison Chang
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Narendra Kala
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Christoph Stretz
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Tina M Burton
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Elizabeth Perelstein
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Karen Furie
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States
| | - Mahesh Jayaraman
- Department of Neurology, Brown University, Brown Medical School, 593 Eddy Street APC 5, Providence, RI 02903, United States; Department of Radiology, Brown University, Providence, RI, United States; Department of Neurosurgery, Brown University, Providence, RI, United States
| | - Radhmer Torabi
- Department of Neurosurgery, Brown University, Providence, RI, United States
| | - Krisztina Moldovan
- Department of Neurosurgery, Brown University, Providence, RI, United States
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, United States
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA, United States
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, IL, United States
| |
Collapse
|
10
|
Wang M, Leng X, Mao B, Zou R, Lin D, Gao Y, Wang N, Lu Y, Fiehler J, Siddiqui AH, Wu J, Xiang J, Wan S. Functional evaluation of intracranial atherosclerotic stenosis by pressure ratio measurements. Heliyon 2023; 9:e13527. [PMID: 36852079 PMCID: PMC9958418 DOI: 10.1016/j.heliyon.2023.e13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/09/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
Background Fractional flow reserve is widely used for the functional evaluation of coronary artery stenosis. Some studies have similarly used the translesional pressure ratio measurements for the functional evaluation of intracranial atherosclerotic stenosis. In this paper, we aimed to investigate the relationship between pressure ratio and cerebral tissue perfusion by MR perfusion imaging and provided a non-invasive method for evaluating the functional significance of intracranial atherosclerotic stenosis. Methods A total of 18 consecutive patients with intracranial atherosclerotic stenosis patients including 19 stenotic vessels were recruited. The pressure was measured using a pressure guidewire, the pressure ratio before and after the endovascular intervention was calculated and compared with the severity of diameter stenosis and perfusion-derived MR (the time to maximum tissure residue function (Tmax)). Moreover, the DSA-derived pressure ratio was computed using a novel computational fluid dynamics-based model, termed CFD-PR, and was compared with the actual pressure ratio to assess its diagnostic accuracy. Results The pressure ratio increased after percutaneous transluminal angioplasty or stenting, while the correlation between pressure ratio and diameter stenosis was not significant. The pressure ratio was negatively correlated with Tmax (r = -0.73, P < 0.01), and a 95% confidence interval for the cutoff value of pressure ratio = 0.67 (95% confidence interval: 0.58-0.76) was suggested. There was a good correlation (mean = 0.02, Spearman's correlation coefficient r = 0.908, P < 0.001) and agreement (limits of agreement: -0.157 to 0.196, P = 0.954) between CFD-PR and the actual pressure ratio. Conclusions This exploratory study indicates the pressure ratio may correlate with the perfusion status. The pressure ratio can be calculated through a non-invasive method using a computational fluid dynamics-based method.
Collapse
Affiliation(s)
- Ming Wang
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | | | - Baojie Mao
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Rong Zou
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Dongdong Lin
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | - Yuhai Gao
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | - Ning Wang
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | - Yuning Lu
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - Jiong Wu
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | | | - Shu Wan
- Brain Center, Zhejiang Hospital, Hangzhou, China
| |
Collapse
|
11
|
Surgical Management of Intracranial Atherosclerotic Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023. [DOI: 10.1007/s11936-022-00974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
12
|
Kvernland A, Torres J, Raz E, Nossek E, de Havenon A, Gebregziabher M, Khatri P, Prabhakaran S, Liebeskind DS, Yaghi S. Borderzone infarction and recurrent stroke in intracranial atherosclerosis. J Stroke Cerebrovasc Dis 2023; 32:106897. [PMID: 36402094 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/10/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intracranial stenosis (ICAS) is a common cause of stroke worldwide and patients with symptomatic ICAS exhibit a high rate of recurrence, particularly in the early period after the initial event. In this study, we aimed to study the association between borderzone infarct and recurrent ischemic stroke in patients hospitalized with symptomatic ICAS. METHODS This is a retrospective single center study that included patients hospitalized with acute ischemic stroke in the setting of intracranial stenosis (50% or more and an acute ischemic stroke in the territory supplied by the stenosed artery) over a 32-month period. We excluded patients who did not receive a brain MRI or did not have an infarct on brain imaging. The primary predictor is infarct pattern (any borderzone vs. no borderzone infarct) and the primary outcome was recurrent cerebrovascular events (RCVE) within 90 days. We used unadjusted, and age and sex adjusted logistic regression models to determine associations between infarct pattern and RCVE at 90-days. RESULTS Among 99 patients who met the inclusion criteria (4 tandem), the mean age was 70.1 ± 11.2 years and 41.4% were women; 43 had borderzone infarcts and 19 had RCVE. In adjusted binary logistic regression analysis, borderzone infarct was associated with increased risk of RCVE (adjusted OR 4.00 95% CI 1.33-11.99, p=0.013). The association between borderzone infarction and RCVE was not different among anterior circulation ICAD (adjusted HR 2.85 95% CI 0.64-12.76, p=0.172) vs. posterior circulation ICAD (adjusted HR 6.69 95% CI 1.06-42.11, p=0.043), p-value for interaction = 0.592. CONCLUSION In real world post-SAMMPRIS medically treated patients with ICAD, the borderzone infarct pattern was associated with 90-day RCVE. Borderzone infarcts are likely a surrogate marker of impaired distal blood flow, highlighting the importance of targeting stroke mechanisms and developing alternative treatment strategies for high-risk cohorts.
Collapse
Affiliation(s)
| | - Jose Torres
- Department of Neurology, New York Langone Health, New York, NY, USA.
| | - Eytan Raz
- Department of Radiology, New York Langone Health, New York, NY, USA.
| | - Erez Nossek
- Department of Neurosurgery, New York Langone Health, New York, NY, USA.
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, USA.
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA.
| | | | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA.
| |
Collapse
|
13
|
Yan L, Hou Z, Fu W, Yu Y, Cui R, Miao Z, Lou X, Ma N. Association of periprocedural perfusion non-improvement with recurrent stroke after endovascular treatment for Intracranial Atherosclerotic Stenosis. Ther Adv Neurol Disord 2022; 15:17562864221143178. [PMID: 36601085 PMCID: PMC9806435 DOI: 10.1177/17562864221143178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/17/2022] [Indexed: 12/28/2022] Open
Abstract
Background Predictors of recurrent stroke after endovascular treatment for symptomatic intracranial atherosclerotic stenosis (ICAS) remain uncertain. Objectives Among baseline characteristics, lesion features, and cerebral perfusion changes, we try to explore which factors are associated with the risk of recurrent stroke in symptomatic ICAS after endovascular treatment. Design Consecutive patients with symptomatic ICAS of 70-99% receiving endovascular treatment were enrolled. All patients underwent whole-brain computer tomography perfusion (CTP) within 3 days before and 3 days after the endovascular treatment. Baseline characteristics, lesion features, and cerebral perfusion changes were collected. Methods Cerebral perfusion changes were evaluated with RAPID software and calculated as preprocedural cerebral blood flow (CBF) < 30%, time to maximum of the residue function (Tmax) > 6 s, and Tmax > 4 s volumes minus postprocedural. Cerebral perfusion changes were divided into periprocedural perfusion improvement (>0 ml) and non-improvement (⩽ 0 ml). Recurrent stroke within 180 days was collected. The Cox proportional hazards analysis analyses were performed to evaluate factors associated with recurrent stroke. Results From March 2021 to December 2021, 107 patients with symptomatic ICAS were enrolled. Of the 107 enrolled patients, 30 (28.0%) patients underwent balloon angioplasty alone and 77 patients (72.0%) underwent stenting. The perioperative complications occurred in three patients. Among CBF < 30%, Tmax > 6 s, and Tmax > 4 s volumes, Tmax > 4 s volume was available to evaluate cerebral perfusion changes. Periprocedural perfusion improvement was found in 77 patients (72.0%) and non-improvement in 30 patients (28.0%). Nine patients (8.4%) suffered from recurrent stroke in 180-day follow-up. In Cox proportional hazards analysis adjusted for age and sex, perfusion non-improvement was associated with recurrent stroke [hazards ratio (HR): 4.472; 95% CI: 1.069-18.718; p = 0.040]. Conclusion In patients with symptomatic ICAS treated with endovascular treatment, recurrent stroke may be related to periprocedural cerebral perfusion non-improvement. Registration http://www.chictr.org.cn. Unique identifier: ChiCTR2100052925.
Collapse
Affiliation(s)
- Long Yan
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Zhikai Hou
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Weilun Fu
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Ying Yu
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Rongrong Cui
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General
Hospital, Beijing, China
| | | |
Collapse
|
14
|
Rennert RC, Russin JJ. Rethinking Cerebral Bypass Surgery. Neurosurg Clin N Am 2022; 33:403-417. [DOI: 10.1016/j.nec.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
15
|
Ballout AA, Liebeskind DS. Recurrent stroke risk in intracranial atherosclerotic disease. Front Neurol 2022; 13:1001609. [PMID: 36119685 PMCID: PMC9475064 DOI: 10.3389/fneur.2022.1001609] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Recurrent stroke risk secondary to intracranial atherosclerotic disease remains high despite aggressive medical treatment. This risk is further amplified in subgroups possessing biomarkers of hemodynamic insufficiency and potential for embolization, which have been shown to be independently and synergistically predictive of recurrent stroke. Luminal stenosis was predominantly used as entry criteria in major treatment trials, discounting the potential role of hemodynamics from primary analyses, limiting the strength of evidence and conclusions of these biomarkers to post-hoc analyses and other natural history studies. Future treatment trials should consider stratifying patients using a combination of these high-risk biomarkers. In the absence of trials, risk stratifying patients based on the presence of these markers may lend to more individualized clinical decisions. We aimed to summarize the studies that have investigated the relationship between biomarkers and their role in predicting recurrent stroke risk in intracranial atherosclerotic disease.
Collapse
Affiliation(s)
- Ahmad A. Ballout
- Department of Neurology, Northwell Health, and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, United States
| | - David S. Liebeskind
- Department of Neurology, University of California in Los Angeles, Los Angeles, CA, United States
- *Correspondence: David S. Liebeskind
| |
Collapse
|
16
|
Kim SJ, Schneider DJ, Feldmann E, Liebeskind DS. Intracranial atherosclerosis: Review of imaging features and advances in diagnostics. Int J Stroke 2022; 17:599-607. [PMID: 34983259 DOI: 10.1177/17474930211066427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intracranial atherosclerotic disease is one of the leading causes of ischemic strokes and poses a moderate risk of recurrence. Diagnosis is currently limited to stenosis on luminal imaging, which likely underestimates the true prevalence of the disease. Detection of non-stenosing intracranial atherosclerosis is important in order to optimize secondary stroke prevention strategies. This review collates findings from the early seminal trials and the latest studies in advanced radiological techniques that characterize symptomatic intracranial atherosclerotic disease across various imaging modalities. While computed tomography angiography (CTA) and magnetic resonance angiography (MRA) comprise diagnostic mainstays in identifying stenotic changes secondary to atherosclerosis, emerging techniques such as high-resolution MRA, quantitative MRA, and computational fluid dynamics may reveal a myriad of other underlying pathophysiological mechanisms.
Collapse
Affiliation(s)
- Song J Kim
- Vascular Neurology and Neurocritical Care, Sutter Health Comprehensive Stroke Care Center, San Francisco, CA, USA
| | - David J Schneider
- Cardiovascular Research Institute of Vermont, The University of Vermont, Colchester, VT, USA
| | - Edward Feldmann
- Neurosciences and Rehabilitation, Baystate Health, Springfield, MA, USA
| | - David S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, CA, USA
| |
Collapse
|
17
|
Xiao J, Liang H, Wang Y, Wang S, Wang Y, Bi Y. Risk Factors of Hypoperfusion on MRI of Ischemic Stroke Patients Within 7 Days of Onset. Front Neurol 2021; 12:668360. [PMID: 34025571 PMCID: PMC8137898 DOI: 10.3389/fneur.2021.668360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Hypoperfusion is an important factor determining the prognosis of ischemic stroke patients. The present study aimed to investigate possible predictors of hypoperfusion on MRI of ischemic stroke patients within 7 days of stroke onset. Methods: Ischemic stroke patients, admitted to the comprehensive Stroke Center of Shanghai Fourth People's Hospital affiliated to Tongji University within 7 days of onset between January 2016 and June 2017, were recruited to the present study. Magnetic resonance imaging (MRI), including both diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI), was performed within 7 days of the symptom onset. Time to maximum of the residue function (Tmax) maps were automatically evaluated using the RAPID software. The volume of hypoperfusion was measured outside the infarct area based on ADC < 620 × 10−6 mm2/s. The 90 d mRS score was assessed through either clinic visits or telephone calls. Multivariate step-wise analysis was used to assess the correlation between MR findings and clinical variables, including the demographic information, cardio-metabolic characteristics, and functional outcomes. Results: Among 635 patients admitted due to acute ischemic stroke within 7 days of onset, 241 met the inclusion criteria. Hypoperfusion volume of 38 ml was the best cut-off value for predicting poor prognosis of patients with cerebral infarction (90 d-mRS score ≥ 2). The incidences of MR perfusion Tmax > 4–6 s maps with a volume of 0–38 mL or >38 mL were 51.9% (125/241) and 48.1% (116/241), respectively. Prior stroke and vascular stenosis (≥70%) were associated with MR hypoperfusion. Multivariate step-wise analysis showed that prior stroke and vascular stenosis (≥70%) were risk factors of Tmax > 4–6 s maps, and the odds ratios (OR) were 3.418 (adjusted OR 95% CI: 1.537–7.600), and 2.265 (adjusted OR, 95% CI: 1.199–4.278), respectively. Conclusion: Our results suggest that prior stroke and vascular stenosis (≥70%) are strong predictors of hypoperfusion in patients with acute ischemic stroke within 7 days of stroke onset.
Collapse
Affiliation(s)
- Jingjing Xiao
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Huazheng Liang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China.,Department of Neurology, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yue Wang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Shaoshi Wang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yi Wang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China.,College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yong Bi
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| |
Collapse
|
18
|
Kim SJ, Morales JM, Yaghi S, Honda T, Scalzo F, Hinman JD, Raychev R, Sharma LK, Feldmann E, Romano JG, Prabhakaran S, Liebeskind DS. Intracranial atherosclerotic disease mechanistic subtypes drive hypoperfusion patterns. J Neuroimaging 2021; 31:686-690. [PMID: 33930227 DOI: 10.1111/jon.12863] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE In symptomatic intracranial atherosclerotic stenosis (ICAS), borderzone infarct pattern and perfusion mismatch are associated with increased risk of recurrent strokes, which may reflect the shared underlying mechanism of hypoperfusion distal to the intracranial atherosclerosis. Accordingly, we hypothesized a correlation between hypoperfusion volumes and ICAS infarct patterns based on the respective underlying mechanistic subtypes. METHODS We conducted a retrospective analysis of consecutive symptomatic ICAS cases, acute strokes due to subocclusive (50%-99%) intracranial stenosis. The following mechanistic subtypes were assigned based on the infarct pattern on the diffusion-weighted imaging: Branch occlusive disease (BOD), internal borderzone (IBZ), and thromboembolic (TE). Perfusion parameters, obtained concurrently with the MRI, were studied in each group. RESULTS A total of 42 patients (57% women, mean age 71 ± 13 years old) with symptomatic ICAS received MRI within 24 h of acute presentation. Fourteen IBZ, 11 BOD, and 17 TE patterns were identified. IBZ pattern yielded higher total Tmax > 4 s and Tmax > 6 s perfusion delay volumes, as well as corresponding Tmax > 4 s and Tmax > 6 s mismatch volume, compared to BOD. TE pattern exhibited greater median Tmax > 6 s hypoperfusion delay in volume compared to BOD. In IBZ versus TE, the volume difference between Tmax > 4 s and Tmax > 6 s (Δ Tmax > 4 s - Tmax > 6 s) was substantially greater. CONCLUSION ICAS infarct patterns, in keeping with their respective underlying mechanisms, may correlate with distinct perfusion profiles.
Collapse
Affiliation(s)
- Song J Kim
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jose M Morales
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Tristan Honda
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Fabien Scalzo
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jason D Hinman
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Radoslav Raychev
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Latisha K Sharma
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Edward Feldmann
- Department of Neurology, Baystate Health, University of Massachusetts, Springfield, Massachusetts, USA
| | - Jose G Romano
- Department of Neurology, University of Miami, Miami, Florida, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
19
|
Prabhakaran S, Liebeskind DS, Cotsonis G, Nizam A, Feldmann E, Sangha RS, Campo-Bustillo I, Romano JG. Predictors of Early Infarct Recurrence in Patients With Symptomatic Intracranial Atherosclerotic Disease. Stroke 2021; 52:1961-1966. [PMID: 33866818 DOI: 10.1161/strokeaha.120.032676] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE While prior studies identified risk factors for recurrent stroke in patients with symptomatic intracranial atherosclerotic disease, few have assessed risk factors for early infarct recurrence. METHODS We performed a post hoc analysis of the MYRIAD study (Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease) of intracranial atherosclerotic disease patients with recent (<21 days) stroke/transient ischemic attack, 50% to 99% stenosis and who underwent 6- to 8-week magnetic resonance imaging (MRI) per protocol. Infarct recurrence was defined as new infarcts in the territory of the symptomatic artery on brain MRI at 6 to 8 weeks compared to index brain MRI. Qualifying events and clinical and imaging outcomes were centrally ascertained by 2 independent reviewers. We assessed the association between baseline clinical and imaging variables and recurrent infarct in bivariate models and multivariable logistic regression to identify independent predictors of infarct recurrence. RESULTS Of 105 enrolled patients in MYRIAD, 89 (84.8%) were included in this analysis (mean age, 64±12 years, 54 [60.7%] were male, and 53 [59.6%] were White). The median time from qualifying event to MRI was 51+16 days, on which 22 (24.7%) patients had new or recurrent infarcts. Younger age (57.7 versus 66.0 years; P<0.01), diabetes (32.6% versus 14.6%, P=0.05), index stroke (31.3% versus 4.6%, P=0.01), anterior circulation location of stenosis (29.7% versus 12.0%, P=0.08), number of diffusion-weighted imaging lesions (>1: 40.0%, 1: 26.9% versus 0: 4.4%, P<0.01), and borderzone infarct pattern (63.6% versus 25.0%, P=0.01) on baseline MRI were associated with new or recurrent infarcts. Age (adjusted odds ratio, 0.93 [95% CI, 0.89-0.98], P<0.01) and number of diffusion-weighted imaging lesions (adjusted odds ratio, 3.24 [95% CI, 1.36-7.71], P<0.01) were independently associated with recurrent infarct adjusting for hypertension, diabetes, and stenosis location (anterior versus posterior circulation). CONCLUSIONS An index multi-infarct pattern is associated with early recurrent infarcts, a finding that might be explained by plaque instability and artery-to-artery embolism. Further investigation of plaque vulnerability in intracranial atherosclerotic disease is needed. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02121028.
Collapse
Affiliation(s)
| | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles (D.S.L.)
| | - George Cotsonis
- Department of Bioinformatics and Biostatistics, Emory University, Atlanta, GA (G.C., A.N.)
| | - Azhar Nizam
- Department of Bioinformatics and Biostatistics, Emory University, Atlanta, GA (G.C., A.N.)
| | - Edward Feldmann
- Department of Neurology, The University of Massachusetts Medical School-Baystate, Springfield (E.F.)
| | - Rajbeer S Sangha
- Department of Neurology, University of Alabama at Birmingham (R.S.S.)
| | | | - Jose G Romano
- Department of Neurology, University of Miami, FL (I.C.-B., J.G.R.)
| | | |
Collapse
|
20
|
Yaghi S, Havenon AD, Honda T, Hinman JD, Raychev R, Sharma LK, Kim S, Feldmann E, Romano JG, Prabhakaran S, Liebeskind DS. Impaired Distal Perfusion Predicts Length of Hospital Stay in Patients with Symptomatic Middle Cerebral Artery Stenosis. J Neuroimaging 2021; 31:475-479. [PMID: 33565162 DOI: 10.1111/jon.12839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Perfusion imaging can risk stratify patients with symptomatic intracranial stenosis. We aim to determine the association between perfusion delay and length of hospital stay (LOS) in symptomatic middle cerebral artery (MCA) stenosis patients. METHODS This is a retrospective study of consecutive patients admitted to a comprehensive stroke center over 5 years with ischemic stroke or transient ischemic attack (TIA) within 7 days of symptom onset due to MCA stenosis (50-99%) and underwent perfusion imaging. Patients were divided into three groups: mismatch volume ≥ 15 cc based on T max > 6 second delay, T max 4-6 second delay, and <4 second delay. The outcome was LOS, both as a continuous variable and categorical (≥7 days [prolonged LOS] vs. <7 days). We used adjusted regression analyses to determine the association between perfusion categories and LOS. RESULTS One hundred and seventy eight of 194 patients met the inclusion criteria. After adjusting for age and NIHSS, T max >6 second mismatch was associated with prolonged LOS (OR 2.94 95% CI 1.06-8.18; P = .039), but T max 4-6 second was not (OR 1.45 95% CI .46-4.58, P = .528). We found similar associations when LOS was a continuous variable for T max > 6 second (β coefficient = 2.01, 95% CI .05-3.97, P = .044) and T max 4-6 second (β coefficient = 1.24, 95% CI -.85 to 3.34, P = .244). CONCLUSION In patients with symptomatic MCA stenosis, T max > 6 second perfusion delay is associated with prolonged LOS. Prospective studies are needed to validate our findings.
Collapse
Affiliation(s)
- Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - Tristan Honda
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - Jason D Hinman
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - Radoslav Raychev
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - Latisha K Sharma
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - Song Kim
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - Edward Feldmann
- Department of Neurology, University of Massachusetts Medical School, Baystate, MA
| | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL
| | | | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| |
Collapse
|