Baseline vessel wall magnetic resonance imaging characteristics associated with in-stent restenosis for intracranial atherosclerotic stenosis

Evaluation of paclitaxel-coated balloon angioplasty for the treatment of symptomatic intracranial in-stent restenosis

Background

Symptomatic intracranial in-stent restenosis (sISR) poses a major challenge in the management of cerebrovascular diseases, often requiring effective and safe treatment options.

Objectives

This study aims to evaluate the efficacy and safety of paclitaxel-coated balloon (PCB) angioplasty for treating sISR.

Methods

We conducted a retrospective analysis of five patients aged 49-74 years, who were treated with PCB angioplasty between January 2017 and June 2022. Treatment procedures included pre-operative digital subtraction angiography, antiplatelet therapy, and the use of the SeQuent Please balloon. Patients received aspirin and clopidogrel prior to and after the procedure.

Results

The procedure achieved a 100% success rate. The degree of ISR was significantly reduced from an average pre-operative rate of 72±18.9% to a post-operative rate of 34±8.22%. Long-term follow-up showed that the majority of patients did not experience restenosis, confirming the long-term effectiveness of the treatment.

Conclusions

PCB angioplasty demonstrates significant potential as an effective and safe treatment option for patients with sISR, especially those considered to be at high risk. This study supports further investigation into PCB angioplasty as a standard treatment for sISR.

Intracranial atherosclerosis update for neurointerventionalists

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.

High-resolution magnetic resonance vessel wall imaging in ischemic stroke and carotid artery atherosclerotic stenosis: A review

Ischemic stroke is a significant burden on human health worldwide. Carotid Atherosclerosis stenosis plays an important role in the comprehensive assessment and prevention of ischemic stroke patients. High-resolution vessel wall magnetic resonance imaging has emerged as a successful technique for assessing carotid atherosclerosis stenosis. This advanced imaging modality has shown promise in effectively displaying a wide range of characteristics associated with the condition, leading to a comprehensive evaluation. High-resolution vessel wall magnetic resonance imaging not only enables a comprehensive evaluation of the instability of carotid atherosclerosis stenosis plaques but also provides valuable information for understanding the pathogenesis and predicting the prognosis of ischemic stroke patients. The purpose of this article is to review the application of high-resolution magnetic resonance imaging in ischemic stroke and carotid atherosclerotic stenosis.

Vessel wall MRI characteristics associated with intraprocedural stent thrombosis during angioplasty for intracranial atherosclerotic stenosis

BACKGROUND

Few studies have so far explored plaque characteristics on high-resolution magnetic resonance vessel wall imaging (HR-VWI) associated with intraprocedural stent thrombosis (IPST) during angioplasty for intracranial atherosclerotic stenosis (ICAS). We aimed to investigate the plaque features on HR-VWI associated with IPST during stenting for ICAS.

METHODS

This study recruited 77 patients with ICAS who underwent intracranial stenting using the Gateway-Wingspan system, and were performed with enhanced pre- and post-contrast T1-weighted HR-VWI on a 3.0T MRI scanner before angioplasty. During stenting for ICAS, eight patients (male: 100%, age mean ± standard deviation (SD): 58.7±2.47) developed IPST within 30 minutes after stenting. To ensure comparability, 16 patients who had undergone intracranial stenting but did not develop IPST were matched as controls for this study. Univariable and binary logistic models were used to explore the plaque characteristics on HR-VWI associated with IPST.

RESULTS

Patients who developed IPST had less plaque diffusion (37.50% vs 81.25%, p=0.036), a more severe degree of area stenosis (median 96.30% vs 81.65%, p<0.01), and a higher plaque enhancement index (median 37.99 vs 13.12, p<0.01) compared with those who did not. After multivariate adjustment, IPST was independently associated with a more severe degree of area stenosis (adjusted odds ratio (OR) 1.20, 95% confidence interval (CI) 1.01-1.43, p=0.044) and a higher plaque enhancement index (adjusted OR 1.17, 95% CI 1.01 to 1.36, p=0.036).

CONCLUSION

Intraprocedural stent thrombosis during intracranial angioplasty for patients with ICAS may be independently associated with a higher plaque enhancement index and a more severe degree of area stenosis on HR-VWI.

Complications and long-term in-stent restenosis of endovascular treatment of severe symptomatic intracranial atherosclerotic stenosis and relevant risk factors

To investigate the complications and in-stent restenosis of endovascular treatment of severe symptomatic intracranial atherosclerotic stenosis and relevant risk factors. Three hundred and fifty-four consecutive patients with intracranial atherosclerotic stenosis (70%-99%) were retrospectively enrolled. The clinical data, treatment outcomes, complications and in-stent restenosis at follow-up were analyzed. The endovascular treatment was composed of balloon dilatation only in 21 (5.93%) patients, and deployment of self-expandable stents in 232 (65.54%), balloon-expandable stents in 75 (21.19%), and both balloon- and self-expandable stents in 26 (7.34%), with a total of 359 stents being successfully deployed at the stenotic location. After treatment, the residual stenosis ranged 9.2%±1.5% (range 7%-19%), which was significantly (P < .05) smaller than that before treatment. Periprocedural complications occurred in 43 patients with a complication rate of 12.15% including arterial dissection in 4 (1.13%) patients, new cerebral infarction in 21 (5.93%), cerebral hemorrhage in 12 (3.3%), and subarachnoid hemorrhage in 6 (1.69%). Hyperlipidemia [odds ratio (OR) 10.35, 95% confidence interval (CI) 4.42-24.28, and P < .0001] and location at the middle cerebral artery (MCA) (OR 4.15, 95% CI 1.92-8.97, and P < .001) were significant (P < .05) risk factors for periprocedural complications, whereas hyperlipidemia (OR 11.28, 95% CI 4.65-30.60, and P < .0001), location at the MCA (or 5.26, 95% CI 2.03-15.08, and P < .001), and angulation (OR 1.02, 95% CI 1.00-1.04, and P = .02) were significant (P < .05) independent risk factors for periprocedural complications. Follow-up was performed in 287 (81.07%) patients at 6 to 36 (28 ± 6.7) months. In-stent restenosis was present in 36 (12.54%), and female sex (OR 2.53, and 95% CI 1.27-5.06) and periprocedural complications (OR 9.18, and 95% CI 3.52-23.96) were significant (P < .05) risk factors for in-stent restenosis, with periprocedural complication (OR 9.61, and 95% CI 3.48-27.23) as the only significant (P < .0001) independent risk factor for in-stent restenosis. A certain rate of periprocedural complications and in-stent stenosis may occur in endovascular treatment of severe intracranial stenosis, and the relevant risk factors may include hyperlipidemia, MCA location, angulation at the stenosis and female sex.

Refined imaging features of culprit plaques improve the prediction of recurrence in intracranial atherosclerotic stroke within the middle cerebral artery territory

Recurrence is a significant adverse outcome of ischemic stroke (IS), particularly in cases of intracranial arteriosclerosis (ICAS). In this study, we investigated the impact of imaging features of culprit plaque using high-resolution magnetic resonance vessel wall imaging (HR-MR-VWI) on the prediction of IS recurrence. A total of 86 patients diagnosed with ICAS-related IS within the middle cerebral artery (MCA) territory were included, of which 23.25% experienced recurrent IS within one year. Our findings revealed significant differences between the recurrence and non-recurrence groups in terms of age (p = 0.007), diabetes mellitus (p = 0.031), hyperhomocysteinemia (p = 0.021), artery-artery embolism (AAE) infarction (p = 0.019), prominent enhancement (p = 0.013), and surface irregularity of the culprit plaque (p = 0.009). Age (HR = 1.063, p = 0.005), AAE infarction (HR = 5.708, p = 0.008), and prominent enhancement of the culprit plaque (HR = 4.105, p = 0.025) were identified as independent risk factors for stroke recurrence. The areas under the receiver operating characteristic curve (AUCs) for predicting IS recurrence using clinical factors, conventional imaging findings, HR-MR-VWI plaque features, and a combination of clinical and conventional imaging models were 0.728, 0.645, 0.705, and 0.814, respectively. Notably, the combination model demonstrated superior predictive performance with an AUC of 0.870. Similarly, AUC of combination model for predicting IS recurrence in validation cohort which enrolled another 37 patients was 0.865. In conclusion, the presence of obvious enhancement in culprit plaque on HR-MR-VWI is a valuable factor in predicting IS recurrence in ICAS-related strokes within the MCA territory. Furthermore, our combination model, incorporating plaque features, exhibited improved prediction accuracy.

Qualitative and quantitative plaque enhancement on high-resolution vessel wall imaging predicts symptomatic intracranial atherosclerotic stenosis

BACKGROUND AND PURPOSE

Intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke (IS), and high-resolution vessel wall imaging (HR-VWI) can be used to assess the plaque characteristics of ICAS. This study aimed to qualitatively and quantitatively assess plaque enhancement of ICAS and to investigate the relationship between plaque enhancement, plaque morphological features, and IS.

METHODS

Data from adult patients with ICAS from April 2018 to July 2022 were retrospectively collected, and all patients underwent HR-VWI examination. Plaque enhancement was qualitatively and quantitatively assessed, and the plaque-to-pituitary stalk contrast ratio (CR) indicated the degree of plaque enhancement. Plaque characteristics, such as plaque burden and area, were quantitatively measured using HR-VWI. Furthermore, receiver-operating characteristic (ROC) analysis was performed to assess the ability of CR to discriminate plaque enhancement. The patients were divided into a symptomatic ICAS group and an asymptomatic ICAS group according to the clinical and imaging characteristics. Univariate and multivariate analyses were performed to investigate which factors were significantly associated with plaque enhancement and symptomatic ICAS. The plaque burden and CR were compared using linear regression.

RESULTS

A total of 91 patients with ICAS were enrolled in this study. ICAS plaque burden was significantly associated with plaque enhancement (p = .037), and plaque burden was linearly positively correlated with CR (R = 0.357, p = .001). ROC analysis showed that the cutoff value of CR for plaque enhancement was 0.56 (specificity of 81.8%). Both plaque enhancement and plaque burden were significantly associated with symptomatic ICAS, and only plaque enhancement was an independent risk factor after multivariate analysis.

CONCLUSION

Plaque burden was an independent risk factor for plaque enhancement and showed a linear positive correlation with CR. The cutoff value of CR for plaque enhancement was 0.56, and CR ≥ 0.56 was significantly associated with symptomatic ICAS, which was independently associated with plaque enhancement.

Vessel Wall Imaging in Cryptogenic Stroke

Cryptogenic strokes are symptomatic cerebral ischemic infarcts without a clear etiology identified following standard diagnostic evaluation and currently account for 10% to 40% of stroke cases. Continued research is needed to identify and bridge gaps in knowledge of this stroke grouping. Vessel wall imaging has increasingly shown its utility in the diagnosis and characterization of various vasculopathies. Initial promising evidence suggests rational use of vessel wall imaging in stroke workup may unravel pathologies that otherwise would have been occult and further improve our understanding of underlying disease processes that can translate into improved patient outcomes and secondary stroke prevention.

High-Resolution Vessel Wall MRI in Assessing Postoperative Restenosis of Intracranial Atherosclerotic Disease Before Drug-Coated Balloon Treatment: An Outcome Prediction Study

BACKGROUND

Postoperative restenosis frequently occurs in intracranial atherosclerotic disease (ICAD) patients after drug-coated balloon (DCB) treatment. However, high-risk plaques associated with postoperative restenosis remain to be explored.

PURPOSE

To assess whether high-resolution vessel wall MRI (HR-VWI) contributes to the identification of high-risk plaques associated with postoperative restenosis before DCB treatment.

STUDY TYPE

Retrospective.

SUBJECTS

A total of 70 patients with ICAD who underwent DCB treatment.

FIELD STRENGTH/SEQUENCE

3.0 T; magnetic resonance angiography, HR-VWI.

ASSESSMENT

All patients underwent HR-VWI examination prior to DCB treatment. Digital subtraction angiography (DSA) measurement was assessed 6 months (±1 month) after operation to determine the vessel restenosis, classifying patients into three groups of no stenosis, mild stenosis (<50%), and restenosis (>50%). Clinical factors and HR-VWI characteristics, including vessel and lumen area at maximal lumen narrowing (MLN), plaque area and length, degree of stenosis, plaque burden, remodeling index, and enhancement amplitude, were compared among three groups. Clinical factors and HR-VWI characteristics were separately evaluated for the association with postoperative restenosis.

STATISTICAL TESTS

Kolmogorov-Smirnov test, intra-class correlation coefficient, Kruskal Wallis H test, Mann-Whitney U test, receiver operating characteristic (ROC) curve, multivariable linear regression analysis. P-values <0.05 was considered statistically significant.

RESULTS

During the follow-up DSA measurement, 13 lesions (18.5%) showed restenosis. With HR-VWI, significant differences among three groups were observed in plaque length, lumen area of MLN, degree of stenosis, enhancement amplitude, and plaque burden. In ROC analysis, plaque length (area under the curve [AUC] = 0.809), and enhancement amplitude (AUC = 0.880) provided higher efficacy in identification of high-risk plaques associated with postoperative restenosis than degree of stenosis (AUC = 0.746) and plaque burden (AUC = 0.759). Multivariable linear regression analysis showed that plaque length and enhancement amplitude were independent prognostic factors of postoperative restenosis.

DATA CONCLUSION

HR-VWI has the potential to identify high-risk plaques in ICAD patients before DCB treatment.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.