Long-term mortality and recurrent stroke risk among Chinese stroke patients with predominant intracranial atherosclerosis

Self-expanding intracranial drug-eluting stent system in patients with symptomatic intracranial atherosclerotic stenosis: initial experience and midterm angiographic follow-up

BACKGROUND

Symptomatic intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide. In patients undergoing endovascular treatment for ICAS, in-stent restenosis (ISR) is associated with ischemic stroke recurrence.

OBJECTIVE

Intracranial drug-eluting self-expanding stent systems (COMETIU; Sinomed Neurovita Technology Inc., CHN) are new devices for treating ICAS. This study evaluated the perioperative experience and medium-term outcomes of COMETIU in 16 patients.

METHODS

We prospectively analyzed 16 patients with ICAS (≥ 70% stenosis) who underwent intravascular therapy between September 4, 2022, and February 1, 2023. The primary outcome was the incidence of ISR at 6 months postoperatively. The secondary efficacy outcomes were device and technical success rates. The secondary safety outcomes included stroke or death within 30 days after the procedure and the cumulative annual rate of recurrent ischemic stroke in the target-vessel territory from 31 days to 6 months and 1 year.

RESULTS

A total of 16 patients with 16 intracranial atherosclerotic lesions were treated with 16 COMETIUs. All procedures were performed under general anesthesia with 100% device and technical success rates, with no cases of periprocedural stroke or death. The mean radiographic follow-up duration was at least 6 months postoperatively, and all patients presented for radiographic and clinical follow-up. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for all patients revealed no cases of ISR.

CONCLUSION

COMETIU is safe and effective for treating ICAS, with minimal risk during the procedure and a low rate of ISR during medium-term follow-up.

A Review of Post-Stroke Cognitive Impairment and the Potential Benefits of Stingless Bee Honey Supplementation

Post-stroke cognitive impairment (PSCI) is a common decline in cognitive abilities that occurs within 3 months after a stroke. During recovery, stroke survivors often experience varying degrees of cognitive decline, with some patients experiencing permanent cognitive deficits. Thus, it is crucial to prioritise recovery and rehabilitation after a stroke to promote optimal protection of and improvement in cognitive function. Honey derived from stingless bees has been linked to various therapeutic properties, including neuroprotective effects. However, scientific evidence for the mechanisms through which these honey supplements enhance cognitive function remains limited. This narrative review aims to provide an overview of the causes of PSCI, current treatments, the biomarkers influencing cognition in post-stroke patients and the potential of stingless bee honey (SBH) as a neuroprotective agent against the progression of PSCI.

Remote ischemic conditioning after stroke: Research progress in clinical study

BACKGROUND AND PURPOSE

Stroke is a leading cause of global morbidity and mortality, indicating the necessity and urgency of effective prevention and treatment. Remote ischemic conditioning (RIC) is a convenient, simple, non-intrusive, and effective method that can be easily added to the treatment regime of stroke patients. Animal experiments and clinical trials have proved the neuroprotective effects of RIC on brain injury including (examples of neuroprotective effects). This neuroprotection is achieved by raising brain tolerance to ischemia, increasing local cerebral blood perfusion, promoting collateral circulations, neural regeneration, and reducing the incidence of hematomas in brain tissue. This current paper will summarize the studies within the last 2 years for the comprehensive understanding of the use of RIC in the treatment of stroke.

METHODS

This paper summarizes the clinical research progress of RIC on stroke (ischemic stroke and hemorrhagic stroke (HS)). This paper is a systematic review of research published on registered clinical trials using RIC in stroke from inception through November 2022. Four major databases (PUBMED, WEB OF SCIENCE, EMBASE, and ClinicalTrials.gov) were searched.

RESULTS

Forty-eight studies were identified meeting our criteria. Of these studies, 14 were in patients with acute ischemic stroke with onset times ranging from 6 h to 14 days, seven were in patients with intravenous thrombolysis or endovascular thrombectomy, 10 were in patients with intracranial atherosclerotic stenosis, six on patients with vascular cognitive impairment, three on patients with moyamoya disease, and eight on patients with HS. Of the 48 studies, 42 were completed and six are ongoing.

CONCLUSIONS

RIC is safe, feasible, and effective in the treatment of stroke. Large-scale research is still required to explore the optimal treatment options and mechanisms of RIC in the future to develop a breakthrough in stroke prevention and treatment.

A bibliometric analysis of the 100 most-cited clinical articles in the research of intracranial artery stenosis and intracranial atherosclerosis

Background

Intracranial arterial stenosis (ICAS), caused by intracranial atherosclerosis, is one of the major causes of ischemic stroke. This study identified the top 100 most-cited publications on ICAS through a bibliometric analysis.

Methods

Two independent authors conducted a search in the Web of Science database for clinical articles on ICAS published between 1993 and 2022. The top 100 most-cited articles were then extracted. For each article, the analysis covered the title, author, country of origin/affiliation, journal, total number of citations, number of citations per year, and type of study.

Results

The top 100 most-cited papers in the ICAS were authored by 565 authors from 12 countries and published in 29 journals. In terms of the 5-year trend, the largest number of papers were published between 2003 and 2007 (n = 31). The median number of citations for the 100 papers was 161 (range 109-1,115). The journal with the highest proportion of the 100 most published articles was Stroke, accounting for 41% of articles and 37% of the citations. According to country of origin, the United States of America accounted for the largest number of articles, followed by China, Japan, and South Korea, with these four countries together accounting for 81% of the total number of articles and 88% of the citations. Trends in the past five years included the use of terms such as acute ischemic stroke and mechanical thrombectomy.

Conclusion

The findings of this study provide novel insight into this field and will facilitate future research endeavors.

Plaque features of the middle cerebral artery are associated with periprocedural complications of intracranial angioplasty and stenting

PURPOSE

The identification of plaque features in the middle cerebral artery (MCA) may help minimize periprocedural complications and select patients suitable for percutaneous transluminal angioplasty and stenting (PTAS). However, relevant research is lacking.

METHODS

We retrospectively included patients with symptomatic MCA stenosis who received PTAS. All patients underwent intracranial vessel wall MRI (VWMRI) before surgery. Periprocedural complications (PC) included ischemic and hemorrhagic stroke within 30 days. Stenosis location, MCA shape, plaque eccentricity and distribution, plaque thickness and length, and enhancement ratio were compared between patients with and without PC.

RESULTS

Sixty-six patients were included in the study, of which 12.1% (8/66) had PC. Of the eight patients with PC, seven (87.5%) had superior wall plaques. In the non-PC group (n = 58), nine (17%) patients had superior wall plaques. Compared with patients without PC, those with PC had more frequent superior wall plaques (17% vs 87.5%, p < 0.001) and s-shaped MCAs (19% vs 50%, p = 0.071), different stenosis locations (p = 0.012), thicker plaques (1.58 [1.35, 2.00] vs 1.98 [1.73, 2.43], p = 0.038), and less frequent inferior wall plaques (79.2% vs 12.5%, p < 0.001). Multivariate analysis showed that only the presence of superior wall plaques (OR = 41.54 [2.31, 747.54]) was independently associated with PC.

CONCLUSION

MCA plaque features were highly correlated with PC in patients with symptomatic MCA stenosis who underwent PTAS.

Cost-effectiveness of treatment in adults with blood pressure of 130-139/80-89 mmHg and high cardiovascular risk in China: a modelling study

Background

The most recent updated hypertension guidelines recommend individuals with systolic blood pressure (SBP)/diastolic blood pressure (DBP) of 130-139/80-89 mmHg and high cardiovascular risk should receive antihypertensive drug treatment. This study aimed to assess the benefits and cost-effectiveness of medication for people aged ≥35 years with this blood pressure stratum and high cardiovascular risk in China.

Methods

The benefits of drug treatment in adults aged ≥35 years with SBP/DBP of 130-139/80-89 mmHg and high cardiovascular risk were evaluated in decision-analytic simulation models. Decreasing numbers of cardiovascular disease (CVD) events and premature deaths from all causes and increasing quality-adjusted life-years (QALYs) from drug treatment were estimated in 10-year and lifetime horizons. The incremental cost-effectiveness ratios (ICER) for drug treatment were calculated.

Findings

Among approximately 106.60 million Chinese adults aged ≥35 years with this blood pressure stratum and high cardiovascular risk, drug treatment was estimated to prevent 2,060,000 strokes and 660,000 myocardial infarctions over a 10-year time horizon. Adults prescribed antihypertensive drugs could gain 0.034 incremental QALYs. Over a lifetime horizon, adults who start treatment earlier could benefit more in preventing CVD and gaining incremental QALYs. The medication treatment is cost-effective either over a 10-year time horizon with an ICER of Int$13321.29 per QALY gained or over the remaining lifetime.

Interpretation

Antihypertensive treatment of adults with SBP/DBP of 130-139/80-89 mmHg and high cardiovascular risk would gain substantial benefits with cost-effectiveness. The young and middle-aged population would derive the most benefit.

Funding

National Natural Science Foundation of China, and Beijing Natural Science Foundation.

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

BACKGROUND

Data on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce.

OBJECTIVE

To compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT).

METHODS

We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy.

RESULTS

Among 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).

CONCLUSION

Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.

Poststroke neutrophil count is predictive of the outcomes of large-artery atherosclerotic stroke and associated with craniocervical atherosclerosis

Elevation of the neutrophil count is detrimental to the outcome of patients with stroke. The effect of poststroke neutrophil count on the outcome of patients with large-artery atherosclerosis (LAA) stroke is unclear. This study aims to explore the relationship of poststroke neutrophil count with the functional outcome of patients with LAA stroke, and the relationship of poststroke neutrophil count and craniocervical atherosclerotic stenosis (AS) number in these patients. The AS was defined as ≥ 50% stenosis or occlusion attributed to atherosclerosis on craniocervical large arteries. A total of 297 participants were enrolled in the cohort. In multivariable analyses, neutrophil count [adjusted relative risk (aRR) = 1.23, 95% confidence interval (CI) 1.09-1.40, p = 0.001] was an independent predictor of 90-day poor functional outcome [modified Rankin Scale (mRS) > 2 points]. The neutrophil count was significantly associated with the craniocervical AS number in a multivariable ordinal logistic regression analysis [adjusted odds ratio (aOR) = 1.41, 95% CI 1.16-1.72, p = 0.001]. The poststroke neutrophil count is a valuable predictor of 90-day poor functional outcome of patients with LAA stroke. The poststroke neutrophil count is positively correlated with the craniocervical AS number in these patients.

Correlation of sLOX-1 Levels and MR Characteristics of Culprit Plaques in Intracranial Arteries with Stroke Recurrence

(1) Background: Symptomatic intracranial artery atherosclerosis (sICAS) is an important cause of acute ischaemic stroke (AIS) and is associated with a high risk of stroke recurrence. High-resolution magnetic resonance vessel wall imaging (HR-MR-VWI) is an effective method for evaluating atherosclerotic plaque characteristics. Soluble lectin-like oxidised low-density lipoprotein receptor-1 (sLOX-1) is closely associated with plaque formation and rupture. We aim to explore the correlation between sLOX-1 levels and culprit plaque characteristics, based on HR-MR-VWI, with stroke recurrence in patients with sICAS. (2) Methods: A total of 199 patients with sICAS underwent HR-MR-VWI between June 2020 and June 2021 in our hospital. The culprit vessel and plaque characteristics were assessed according to HR-MR-VWI, and sLOX-1 levels were measured by ELISA (enzyme linked immunosorbent assay). Outpatient follow-up was performed 3, 6, 9, and 12 months after discharge. (3) Results: sLOX-1 levels were significantly higher in the recurrence group than in the non-recurrence group (p < 0.001). The culprit plaque thickness, degree of stenosis and plaque burden were higher in the recurrence group than in the non-recurrence group (p = 0.003, p = 0.014 and p = 0.010, respectively). The incidence of hyperintensity on T1WI, positive remodelling and significant enhancement (p < 0.001, p = 0.003 and p = 0.027, respectively) was higher in the recurrence group than in the non-recurrence group. Kaplan-Meier curves showed that patients with sLOX-1 levels > 912.19 pg/mL and hyperintensity on T1WI in the culprit plaque had a higher risk of stroke recurrence (both p < 0.001). Multivariate Cox regression analysis showed that sLOX-1 > 912.19 pg/mL (HR = 2.583, 95%CI 1.142, 5.846, p = 0.023) and hyperintensity on T1WI in the culprit plaque (HR = 2.632, 95% CI 1.197, 5.790, p = 0.016) were independent risk factors for stroke recurrence. sLOX-1 levels were significantly associated with the culprit plaque thickness (r = 0.162, p = 0.022), degree of stenosis (r = 0.217, p = 0.002), plaque burden (r = 0.183, p = 0.010), hyperintensity on T1WI (F = 14.501, p < 0.001), positive remodelling (F = 9.602, p < 0.001), and significant enhancement (F = 7.684, p < 0.001) (4) Conclusions: sLOX-1 levels were associated with vulnerability of the culprit plaque and can be used as a supplement to HR-MR-VWI to predict stroke recurrence.

Effect of Mid-Basilar Artery Angle and Plaque Characteristics on Pontine Infarction in Patients with Basilar Artery Plaque

AIMS

The basilar artery (BA) geometry and plaque characteristics may play an important role in the development of atherosclerosis. This study was performed to explore the relationship between the mid-BA angle and plaque characteristics and its effect on pontine infarction using high-resolution magnetic resonance imaging and three-dimensional time-of-flight magnetic resonance angiography.

METHODS

In total, 77 patients with BA plaques were included in this study. According to the presence of acute pontine infarction on diffusion-weighted imaging, the patients were divided into a pontine infarction group and pontine non-infarction group. The mid-BA angle, plaque burden, stenosis ratio, positive remodeling, and intraplaque hemorrhage were evaluated to investigate their effects on stroke.

RESULTS

The pontine infarction group had a greater plaque burden, stenosis ratio, positive remodeling, and mid-BA angle than the pontine non-infarction group. The correlation between the plaque burden and mid-BA angle was the highest (r=0.441, P＜0.001). Multivariate logistic regression analysis showed that the plaque burden (odds ratio, 1.164; 95% confidence interval, 1.093-1.241; P＜0.001) was an independent risk factor for pontine infarction.

CONCLUSION

The mid-BA angle may increase the incidence of pontine infarction by increasing the plaque burden.

Diagnostic Errors in Cerebrovascular Pathology: Retrospective Analysis of a Neuroradiology Database at a Large Tertiary Academic Medical Center

BACKGROUND AND PURPOSE

Diagnostic errors affect 2%-8% of neuroradiology studies, resulting in significant potential morbidity and mortality. This retrospective analysis of a large database at a single tertiary academic institution focuses on diagnostic misses in cerebrovascular pathology and suggests error-reduction strategies.

MATERIALS AND METHODS

CT and MR imaging reports from a consecutive database spanning 2015-2020 were searched for errors of attending physicians in cerebrovascular pathology. Data were collected on missed findings, study types, and interpretation settings. Errors were categorized as ischemic, arterial, venous, hemorrhagic, and "other."

RESULTS

A total of 245,762 CT and MR imaging neuroradiology examinations were interpreted during the study period. Vascular diagnostic errors were present in 165 reports, with a mean of 49.6 (SD, 23.3) studies on the shifts when an error was made, compared with 34.9 (SD, 19.2) on shifts without detected errors (P < .0001). Seventy percent of examinations occurred in the hospital setting; 93.3% of errors were perceptual; 6.7% were interpretive; and 93.9% (n = 155) were clinically significant (RADPEER 2B or 3B). The distribution of errors was arterial and ischemic each with 33.3%, hemorrhagic with 21.8%, and venous with 7.5%. Most errors involved brain MR imaging (30.3%) followed by head CTA (27.9%) and noncontrast head CT (26.1%). The most common misses were acute/subacute infarcts (25.1%), followed by aneurysms (13.7%) and subdural hematomas (9.7%).

CONCLUSIONS

Most cerebrovascular diagnostic errors were perceptual and clinically significant, occurred in the emergency/inpatient setting, and were associated with higher-volume shifts. Diagnostic errors could be minimized by adjusting search patterns to ensure vigilance on the sites of the frequently missed pathologies.

Identification of immune-related key genes in the peripheral blood of ischaemic stroke patients using a weighted gene coexpression network analysis and machine learning

Background

The immune system plays a vital role in the pathological process of ischaemic stroke. However, the exact immune-related mechanism remains unclear. The current research aimed to identify immune-related key genes associated with ischaemic stroke.

Methods

CIBERSORT was utilized to reveal the immune cell infiltration pattern in ischaemic stroke patients. Meanwhile, a weighted gene coexpression network analysis (WGCNA) was utilized to identify meaningful modules significantly correlated with ischaemic stroke. The characteristic genes correlated with ischaemic stroke were identified by the following two machine learning methods: the support vector machine-recursive feature elimination (SVM-RFE) algorithm and least absolute shrinkage and selection operator (LASSO) logistic regression.

Results

The CIBERSORT results suggested that there was a decreased infiltration of naive CD4 T cells, CD8 T cells, resting mast cells and eosinophils and an increased infiltration of neutrophils, M0 macrophages and activated memory CD4 T cells in ischaemic stroke patients. Then, three significant modules (pink, brown and cyan) were identified to be significantly associated with ischaemic stroke. The gene enrichment analysis indicated that 519 genes in the above three modules were mainly involved in several inflammatory or immune-related signalling pathways and biological processes. Eight hub genes (ADM, ANXA3, CARD6, CPQ, SLC22A4, UBE2S, VIM and ZFP36) were revealed to be significantly correlated with ischaemic stroke by the LASSO logistic regression and SVM-RFE algorithm. The external validation combined with a RT‒qPCR analysis revealed that the expression levels of ADM, ANXA3, SLC22A4 and VIM were significantly increased in ischaemic stroke patients and that these key genes were positively associated with neutrophils and M0 macrophages and negatively correlated with CD8 T cells. The mean AUC value of ADM, ANXA3, SLC22A4 and VIM was 0.80, 0.87, 0.91 and 0.88 in the training set, 0.85, 0.77, 0.86 and 0.72 in the testing set and 0.87, 0.83, 0.88 and 0.91 in the validation samples, respectively.

Conclusions

These results suggest that the ADM, ANXA3, SLC22A4 and VIM genes are reliable serum markers for the diagnosis of ischaemic stroke and that immune cell infiltration plays a crucial role in the occurrence and development of ischaemic stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03562-w.

Prevalence and Risk Factors Comparison of Anterior and Posterior Intracranial Arterial Stenosis

The prevalence and risk factors of intracranial atherosclerotic stenosis (ICAS) located in the anterior circulation (AC) and posterior circulation (PC) has been scarcely noted in the general population. We aimed to determine ICAS prevalence and risk factor profile of AC and PC in a representative population. Data were from the China Hypertension Survey of Beijing. In total, 4800 people aged 35 years or older were enrolled in this subsurvey for ICAS, and 3954 participants were eligible for analysis. ICAS was assessed by transcranial Doppler. The prevalence of ICAS in AC was much greater than that in PC (11.9% vs. 4.2%), and subjects with ICAS in PC were 3.9 years older than those with ICAS in AC. Multivariable logistics regression showed that the odds of hypertension and diabetes increased by 79% (OR: 1.79, 95% CI: 1.40-2.27) and 35% (OR: 1.35, 95% CI: 1.04-1.75) in those with AC vascular lesions and by 3.35 times (OR: 3.35, 95% CI: 2.49-4.50) and 71% (OR: 1.71, 95% CI: 1.19-2.46) in those with PC vascular lesions compared with those without vascular lesions. Most modifiable vascular risk factors for ICAS appeared to exert similar magnitudes of risk for PC to AC lesions.

Dyslipidemias and stroke prevention: recommendations of the Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology

OBJECTIVE

We present an update of the Spanish Society of Neurology's recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.

DEVELOPMENT

We performed a systematic review to evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.

CONCLUSIONS

In primary prevention, the patient's vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.

Dyslipidemias and stroke prevention: Recommendations of the Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology

OBJECTIVE

We present an update of the Spanish Society of Neurology's recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.

DEVELOPMENT

We performed a systematic review to evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.

CONCLUSIONS

In primary prevention, the patient's vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55 mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.

Posterior Circulation Ischemia in the Endovascular Era

BACKGROUND AND OBJECTIVES

To perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes.

METHODS

Review of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO.

RESULTS

PCI accounts for 15%-20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%-60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate.

DISCUSSION

PCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.

Simultaneous Stenting for Symptomatic Tandem Extracranial and Intracranial Posterior Circulation Stenoses: Long-Term Outcomes and Procedural Experience

Few studies have reported on simultaneous endovascular stenting for tandem posterior circulation (PC) stenoses and its long-term outcomes. Thus, our aim was to investigate the safety and efficacy of simultaneous stenting in patients with symptomatic tandem extra- and intracranial PC stenoses. From September 2014 to June 2018, 16 such patients with symptomatic stenoses who underwent simultaneous stent placement were analyzed. The primary outcome was occurrence of any stroke, TIA, or death within 30 days after the procedure. The secondary outcomes were technical success, clinical success, and the occurrence of in-stent restenosis ≥50% during follow-up. Technical success was defined as stent coverage of all tandem lesions and residual stenosis <30%. Clinical success was determined based on any occurrence of neurological events or death within 3 months after the procedure. All stents (19 intracranial and 14 extracranial) were placed with a technical success rate of 100%. One patient experienced a pontine ischemic stroke 2 days after the procedure and had recovered well at discharge. One patient experienced a minor complication of groin hematoma. The clinical success rate was 93.75% (15/16). During a median follow-up of 36.0 ± 11.0 months, two patients developed ISR ≥50% at the 1-year follow-up. None of the patients experienced stroke, TIA, or death after discharge during follow-up. Simultaneous stenting for symptomatic tandem extra- and intracranial PC stenoses is safe and feasible. Its impact on long-term stroke prevention is promising, and further study of a larger patient population is needed.

[Management of ischemic stroke in the acute phase]

Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.

Long term clinical outcomes of patients with ischemic stroke in primary care - a 9-year retrospective study

Background

We aim to document the long-term outcomes of ischemic stroke patients and explore the potential risk factors for recurrent cardiovascular events and all-cause mortality in primary care.

Methods

A retrospective cohort study performed at two general out-patient clinics (GOPCs) under Hospital Authority (HA) in Hong Kong (HK). Ischemic stroke patients with at least two consecutive follow-up visits during the recruitment period (1/1–30/6/2010) were included. Patients were followed up regularly till the date of recurrent stroke, cardiovascular event, death or 31/12/2018. The primary outcome was the occurrence of recurrent cerebrovascular event including transient ischemic stroke (TIA), ischemic stroke or hemorrhagic stroke. The secondary outcomes were all-cause mortality and coronary artery disease (CAD). We fit cox proportional hazard model adjusting death as competing risk factor to estimate the cause-specific hazard ratio (csHR).

Results

A total of 466 patients (mean age, 71.5 years) were included. During a median follow-up period of 8.7 years, 158 patients (33.9%) died. Eighty patients (17.2%) had recurrent stroke and 57 (12.2%) patients developed CAD. Age was an independent risk factor for recurrent stroke, CAD and death. Statin therapy at baseline had a protective effect for recurrent stroke (csHR = 0.476; 95% confidence interval [CI] 0.285–0.796, P = 0.005) after adjusting death as a competing risk factor and all-cause mortality (HR = 0.693, 95% CI 0.486–0.968, P = 0.043). In addition, female sex, antiplatelet and a higher diastolic blood pressure (DBP) at baseline were also independent predictors for survival.

Conclusions

Long term prognosis of ischemic stroke patients in primary care is favorable. Use of statin was associated with a significant decrease in stroke recurrence and mortality. Patients who died had a significant lower DBP at baseline, highlighted the need to consider both systolic and diastolic blood pressure in our daily practice.

Determinants and Outcomes of Asymptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide and confers a high risk of stroke recurrence, despite aggressive management of risk factors.

OBJECTIVES

This study identified the role of risk factors and risk of vascular events in subjects with asymptomatic ICAS for improved risk stratification.

METHODS

Stroke-free participants in the NOMAS (Northern Manhattan Study) trial, prospectively followed since 1993, underwent a brain magnetic resonance angiogram from 2003 to 2008. The study rated stenosis in 11 brain arteries as: 0: no stenosis; 1: <50% or luminal irregularities; 2: 50%-69%; and 3: ≥70% stenosis or flow gap. The study ascertained vascular events during the post-magnetic resonance imaging (MRI) period. Proportional odds regression quantified the association of pre-MRI exposures, and proportional hazard adjusted models were built to identify the risk of events in the post-MRI period.

RESULTS

The included sample included 1,211 participants from NOMAS (mean age: 71 ± 9 years; 59% women; 65% Hispanic; 45% had any stenosis). Older age (OR: 1.02 per year; 95% CI: 1.01 to 1.04), hypertension duration (OR: 1.01 per year; 95% CI: 1.00 to 1.02), higher number of glucose-lowering drugs (OR: 1.64 per each medication; 95% CI: 1.24 to 2.15), and high-density lipoprotein (OR: 0.96 per mg/dL; 95% CI: 0.92 to 0.99) were associated with ICAS. The highest event risk was noted among participants with ICAS ≥70% (5.5% annual risk of vascular events; HR: 2.1; 95% CI:1.4 to 3.2; compared with those with no ICAS).

CONCLUSIONS

ICAS is an imaging marker of established atherosclerotic disease in stroke-free subjects, and incidental diagnosis of ICAS should trigger a thorough assessment of vascular health.

Neutrophil-to-Lymphocyte Ratio as a Predictive Biomarker for Stroke Severity and Short-Term Prognosis in Acute Ischemic Stroke With Intracranial Atherosclerotic Stenosis

Background: Neutrophil-to-lymphocyte ratio (NLR) is an indicator of poor prognosis in acute ischemic stroke (AIS), but associations between NLR with stroke severity and prognosis of intracranial atherosclerotic stenosis (ICAS)-related ischemic events have not been well-elucidated; therefore, we aimed to evaluate whether admission NLR levels correlate with the early stroke severity and short-term functional prognosis in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). Methods: This retrospective study enrolled 899 consecutive patients with AIS attributed to ICAS at Xiangya Hospital stroke center between May 2016 and September 2020. The initial stroke severity was rated by the admission National Institutes of Health Stroke Scale (NIHSS) scores, and the short-term prognosis was evaluated using the 14-day modified Rankin Scale (mRS) scores after stroke onset. A severe stroke was defined as NIHSS >8; an unfavorable functional outcome was defined as mRS scores of 3-6. Admission NLR was determined based on circulating neutrophil and lymphocyte counts. Results: The median admission NLR of all patients was 2.80 [interquartile range (IQR), 2.00-4.00]. In univariate analysis, admission NLR was significantly elevated in patients with severe stroke and poor short-term prognosis. After multivariate adjustment, admission NLR levels were significantly correlated with severe stroke [odds ratio (OR), 1.132; 95% confidence interval (95% CI), 1.038-1.234; P = 0.005] and unfavorable short-term prognosis (OR, 1.102; 95% CI, 1.017-1.195; P = 0.018) in Model 1. In Model 2, the highest NLR tertile (≥3.533) remained an independent predictor of severe stroke (OR, 2.736; 95% CI, 1.590-4.708; P < 0.001) and unfavorable functional outcome (OR, 2.165; 95% CI, 1.416-3.311; P < 0.001) compared with the lowest NLR tertile (<2.231). The receiver operating characteristic (ROC) curves showed the predictability of NLR regarding the stroke severity [area under the curve (AUC), 0.659; 95% CI, 0.615-0.703; P < 0.001] and short-term prognosis (AUC, 0.613; 95% CI, 0.575-0.650; P < 0.001). The nomograms were constructed to create the predictive models of the severity and short-term outcome of sICAS. Conclusions: Elevated admission NLR levels were independently associated with the initial stroke severity and could be an early predictor of severity and poor short-term prognosis in AIS patients with ICAS, which might help us identify a target group timely for preventive therapies.

Non-High-Density Lipoprotein Cholesterol Predicts Adverse Outcomes in Acute Ischemic Stroke

[Figure: see text].

Weighted gene co expression network analysis (WGCNA) with key pathways and hub-genes related to micro RNAs in ischemic stroke

Ischemic stroke (IS) is one of the major causes of death and disability worldwide. However, the specific mechanism of gene interplay and the biological function in IS are not clear. Therefore, more research into IS is necessary. Dataset GSE110993 including 20 ischemic stroke (IS) and 20 control specimens are used to establish both groups and the raw RNA‐seq data were analysed. Weighted gene co‐expression network analysis (WGCNA) was used to screen the key micro‐RNA modules. The centrality of key genes were determined by module membership (mm) and gene significance (GS). The key pathways were identified by enrichment analysis with Kyoto Protocol Gene and Genome Encyclopedia (KEGG), and the key genes were validated by protein‐protein interactions network. Result: Upon investigation, 1185 up‐ and down‐regulated genes were gathered and distributed into three modules in response to their degree of correlation to clinical traits of IS, among which the turquoise module show a trait‐correlation of 0.77. The top 140 genes were further identified by GS and MM. KEGG analysis showed two pathways may evolve in the progress of IS. Discussion: CXCL12 and EIF2a may be important biomarkers for the accurate diagnosis and treatment in IS.

Prevalence, prognosis, and treatment of atherosclerotic intracranial stenosis in Caucasians

BACKGROUND

Intracranial atherosclerotic stenosis is a highly prevalent cause of stroke worldwide with important ethnic disparities. Widely considered to be a common cause of stroke in Asian and Afro-Caribbean populations, relatively less is known about the burden and significance of intracranial atherosclerotic stenosis in Caucasians.

AIMS

We aim to highlight recent insights and advances into the prevalence, prognosis, and treatment of symptomatic and asymptomatic atherosclerotic intracranial atherosclerotic stenosis in Caucasian patients.

SUMMARY OF REVIEW

We identified 48 articles studying intracranial atherosclerotic stenosis in Caucasian patients with ischemic stroke or transient ischemic attack. Most studies were on hospital-based cohorts of consecutive patients and half were graded as "fair" quality. There was significant variation between studies in the definition of intracranial atherosclerotic stenosis and in the imaging modalities used to detect intracranial atherosclerotic stenosis. Overall, 12.1% of Caucasian patients were found to have any intracranial atherosclerotic stenosis, 6.4% symptomatic intracranial atherosclerotic stenosis and 11.1% asymptomatic intracranial atherosclerotic stenosis, with higher rates at older ages. In studies reporting prognosis, there were 61 and 10 same-territory ischemic strokes in 1000 person-years in patients with symptomatic and asymptomatic intracranial atherosclerotic stenosis, respectively. Percutaneous stenting and angioplasty have not proven superior to intensive medical management in patients with symptomatic intracranial atherosclerotic stenosis.

CONCLUSIONS

Intracranial atherosclerotic stenosis has previously been neglected as a cause of stroke in Caucasians but is highly prevalent at older ages and frequently discovered with the growing use of noninvasive angiography. Intensive medical therapy is the treatment of choice, but there is a need to develop novel treatments or therapeutic approaches to lower the risk of stroke in higher risk patients.

Drug-Coated Balloon Dilation Compared With Conventional Stenting Angioplasty for Intracranial Atherosclerotic Disease

BACKGROUND

Conventional stent-based angioplasty was challenged for the high incidence of perioperative complications and follow-up in-stent restenosis (ISR) in treating intracranial atherosclerotic disease (ICAD). Currently, the drug-coated balloon (DCB) has shown promise in preventing and treating ISR.

OBJECTIVE

To compare the efficacy and safety of DCB dilation (with or without stenting) with conventionally only stenting angioplasty for symptomatic ICAD in routine clinical practice.

METHODS

From January 2016 to January 2019, consecutive patients treated with endovascular therapy for symptomatic ICAD were identified and dichotomized by whether DCB was used. The efficacy and safety endpoints, including periprocedural complications, clinical, and imaging follow-up outcomes between the 2 groups, were compared by propensity score matching.

RESULTS

A total of 42 patients in the DCB group and 73 patients in the non-DCB group were enrolled. Propensity score matching analysis selected 76 matched patients. Angiographic follow-up was completed at 185 ± 33 d. The median stenosis degree (0 [0%-20.0%] vs 15.0 [0%-62.5%], P = .005) and total restenosis incidence (5.3% [2/38] vs 34.2% [13/38], P = .003) in the DCB group were significantly lower than those in the non-DCB group. The periprocedural complications (2.6% vs 10.5%, P = .375), recurrent ischemic events (2.6% vs 13.2%, P = .219), and symptomatic restenosis (2.6% vs 10.5%, P = .375) were not statistically different between the 2 groups.

CONCLUSION

Compared with conventionally only stenting angioplasty, DCB dilation can effectively lower restenosis degree and total restenosis risk, with no superiority in symptomatic restenosis at 6-mo follow-up.

Cerebral autoregulation is heterogeneous in different stroke mechanism of ischemic stroke caused by intracranial atherosclerotic stenosis

BACKGROUND AND PURPOSE

Intracranial atherosclerotic stenosis (ICAS) is the most common cause of ischemic stroke (IS) and is associated with stroke recurrence. It results in IS due to a variety of mechanisms. However, the influence of brain reserve mechanism on different stroke mechanism is still unclear. Cerebral autoregulation (CA) is an important brain reserve mechanism and is impaired after IS. This study aimed to explore the impaired pattern of CA and assess the association between CA and stroke risk factors in different stroke mechanism caused by ICAS.

METHODS

IS patients with ICAS (50%-99% stenosis/occlusion) in middle cerebral artery (MCA) or internal carotid artery were enrolled to receive CA examinations within 7 days after onset. Healthy volunteers were also recruited as controls. CA was recorded from spontaneous fluctuations of blood pressure and MCA flow velocity. Transfer function analysis was used to derive CA parameters, including phase difference (PD) and coherence in the low-frequency range (0.06-0.12 Hz).

RESULTS

A total of 89 IS patients and 90 healthy controls were included. Compared with controls, CA was impaired ipsilaterally in patients with parent artery atherosclerosis occluding penetrating artery (POPA) while CA was bilaterally impaired in other stroke mechanisms. And CA on ipsilateral hemisphere was correlated with hypertension/hyperlipidemia in patients with POPA (r = -0.481, p = .008; r = -0.484, p = .008). While CA on ipsilateral hemisphere was correlated with perfusion parameter including the arterial spin-labeling (ASL) parameter cerebral blood flow (CBF) (r = 0.893, p = .007) and collateral circulation status the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) (r = 0.610, p = .021) in patients with hypoperfusion mechanism.

CONCLUSION

In IS patients, CA was impaired heterogeneously and was correlated with different risk factors in varied stroke mechanism. CA can be as an informative determinant of stroke risk in patients with ICAS and to help improving individualized treatment strategies in the presence of ischemic stroke caused by ICAS.

Endovascular stenting of medically refractory intracranial arterial stenotic (ICAS) disease (clinical and sonographic study)

Background

Atherosclerotic intracranial arterial stenosis (ICAS) is one of the most common causes of stroke worldwide and is associated with a high risk of recurrent stroke. Patients with a recent transient ischemic attack (TIA) or stroke and severe stenosis (70 to 99% of the diameter of a major intracranial artery) are at particularly high risk for recurrent stroke in the territory of the stenotic artery (approximately 23% at 1 year) despite medical treatment. Therefore, alternative therapies are urgently needed for these patients.

Objective

To determine the efficacy and safety of angioplasty with stenting in medically refractory ICAS and to compare its effectiveness with optimal medical treatment.

Subjects and methods

Fifty patients with symptomatic ICAS despite medical treatment (i.e, recurrent stroke or TIA) were enrolled and equally randomized in a prospective study where twenty-five patients underwent angioplasty with stenting and twenty-five patients received optimal medical treatment. Clinical assessment with NIHSS and mRS were done at 0, 3, and 6 months, and transracial Doppler (TCD) assessment of ICAS was done at 0 and 3 months after treatment.

Results

The interventional group had a better clinical outcome with mean NIHSS scores (5.2 ± 4.2, 4.43 ± 4.28 and 3.9 ± 4.7) at baseline, 3 and 6 months, respectively, in comparison to the medical group with mean NIHSS (4.5 ± 4.2, 11.42 ± 6.3, and 8.5 ± 5.1) and better functional outcome with mean mRS scores (1.3 ± 0.96, 1.2 ± 1.13, and 1.0 ± 1.13) at baseline, 3 and 6 months, respectively, in comparison to the medical group (0.84 ± 0.75, 2.28 ± 1.2, and 2 ± 1.24). TCD assessment of ICAS showed a marked reduction of the percentage of stenosis on 3 months of follow-up among the interventional groups (only 5.6% had > 70% stenosis) in comparison to the medical group (85.7% had > 70% stenosis). Recurrent ischemic events on 6 months of follow-up were 16% among interventional groups in comparison to 84% among medical groups. The mortality rate was 8% among interventional groups due to subarachnoid hemorrhages (SAH) related to procedure in comparison to 28% among medical groups secondary to ischemic events. The intraoperative success rate was 96% with the failure of stent deployment in 1 patient due to the tortuous anatomy of vessels. Early post interventional complication rate, i.e, SAH was 8%. Late post interventional restenosis and occlusion rates were 8% on 3 months of follow-up.

Conclusion

Endovascular stenting of medically refractory ICAS is more efficacious and effective with better clinical and functional outcomes than optimal medical treatment; however, its safety is still debatable.

Trial registration

Done at ClinicalTrials.gov. Trial ID (NCT Number) NCT04393025.

Prevalence, predictors, and prognosis of symptomatic intracranial stenosis in patients with transient ischaemic attack or minor stroke: a population-based cohort study

BACKGROUND

Symptomatic intracranial stenosis was perceived to convey a high risk of recurrent stroke, but two previous trials (SAMMPRIS and VISSIT) did not show superiority of intracranial stenosis stenting over intensive medical management alone. These findings were partly due to a lower than expected risk of recurrent stroke without stenting, possibly reflecting the young age of recruits (median age <60 years), and raise questions about generalisability to routine clinical practice. We therefore studied the age-specific prevalence, predictors, and prognosis of symptomatic intracranial stenosis in a population-based cohort of patients with transient ischaemic attack and minor stroke on intensive medical management.

METHODS

The Oxford Vascular Study (OXVASC) is a prospective incidence cohort study of all vascular events in a population of 92 728 people residing in Oxfordshire, UK. All patients, irrespective of age, with transient ischaemic attack and minor ischaemic stroke occurring between March 1, 2011, and March 1, 2018 (follow-up to Sept 28, 2018), were ascertained with multiple methods, including assessment in a dedicated daily emergency clinic and daily review of all hospital admissions. Imaging was by MR angiography of the intracranial and cervicocranial arteries, by CT angiography if MR angiography was contraindicated, and by transcranial Doppler and carotid ultrasound if CT angiography was contraindicated. All patients received intensive medical treatment without stenting, and those with intracranial vascular imaging were analysed in our study, which assessed the age-specific prevalence of 50-99% intracranial stenosis and the associated stroke risk of 50-99% and 70-99% stenosis (adjusted for age and vascular risk factors) during follow-up to Sept 28, 2018.

FINDINGS

Of 1368 eligible patients with intracranial vascular imaging, 241 (17·6%) had 385 50-99% symptomatic or asymptomatic intracranial stenosis. The prevalence of symptomatic 50-99% intracranial stenosis increased from 29 (4·9%) of 596 at younger than 70 years to 10 (19·6%) of 51 at 90 years or older (p_trend<0·0001). Of 94 patients with 50-99% symptomatic intracranial stenosis, 14 (14·9%) had recurrent strokes (12 ischaemic and two haemorrhagic) during a median follow-up of 2·8 years (IQR 1·5-4·6). Although symptomatic intracranial stenosis conveyed an increased risk of ischaemic stroke compared with no intracranial stenosis (adjusted hazard ratio 1·43, 95% CI 1·04-1·96), the risk of same-territory ischaemic stroke in patients with 70-99% symptomatic intracranial stenosis tended to be less than those reported in the non-stenting groups of the previous trials (1-year risk 5·6% [95% CI 0·0-13·0] vs 9·4% [3·1-20·7] in VISSIT; 2-year risk 5·6% [0·0-13·0] vs 14·1% [10·1-19·4] in SAMMPRIS).

INTERPRETATION

The prevalence of 50-99% symptomatic intracranial stenosis increases steeply with age in predominantly Caucasian patients with transient ischaemic attack and minor ischaemic stroke. However, the risk of recurrent stroke on intensive medical treatment of symptomatic intracranial stenosis is consistent with the two previous randomised controlled trials in younger cohorts, supporting the generalisability of the trial results to routine practice.

FUNDING

Wellcome Trust, Wolfson Foundation, British Heart Foundation, National Institute for Health Research, National Institute for Health Research Oxford Biomedical Research Centre, Association of British Neurologists.

Sirt3 Protects Against Ischemic Stroke Injury by Regulating HIF-1α/VEGF Signaling and Blood-Brain Barrier Integrity

Sirtuin 3 (Sirt3) is a member of the Sirtuin family proteins and known to regulate multiple physiological processes such as metabolism and aging. As stroke is an aging-related disease, in this work, we attempt to examine the role and potential mechanism of Sirt3 in regulating ischemic stroke by using a permanent middle cerebral artery occlusion (pMCAO) model in wild type (WT) and Sirt3 knockout (KO) mice, coupled with oxygen glucose deprivation (OGD) experiments in cultured primary astrocytes. Sirt3 deficiency aggravated neuronal cell apoptosis and neurological deficits after brain ischemia. In addition, Sirt3 KO mice showed more severe blood-brain barrier (BBB) disruption and inflammatory responses compared with WT group in the acute phase. Furthermore, specific overexpression of Sirt3 in astrocytes by injecting glial fibrillary acidic protein (GFAP)::Sirt3 virus in ischemic region showed protective effect against stroke-induced damage. Mechanistically, Sirt3 could regulate vascular endothelial growth factor (VEGF) expression by inhibiting hypoxia inducible factor-1α (HIF-1α) signaling after ischemia (OGD). Our results have shown that Sirt3 plays a protective role in ischemic stroke via regulating HIF-1α/VEGF signaling in astrocytes, and reversal of the Sirt3 expression at the acute phase could be a worthy direction for stroke therapy.

MiRNA: a potential target for gene diagnosis and treatment of atherosclerotic stroke

Stroke is one of the major diseases that endanger the physical health life of middle-aged and old people. It has the characteristics of high incidence, mortality and disability rate. Atherosclerosis is the main intervention target for stroke prevention and treatment. MiRNAs are highly expressed in the cerebral vasculature and play an important regulatory role in the pathogenesis of neuronal damage and ischemic stroke. This article reviews the mechanism of action between miRNAs and atherosclerosis, stroke, ischemia-reperfusion injury, collateral circulation and circRNA molecular networks, providing theoretical support for miRNA in gene diagnosis and drug therapy of atherosclerotic stroke.

A novel technique for stenting in cases of refractory intracranial stenosis

Endovascular management of intracranial stenosis is one of the most controversial subjects in neurointervention. Previous level 1 evidence shows superiority of medical management but more recent studies have shown improved outcomes in selective patients. We describe a case demonstrating a new method for stenting of intracranial stenosis using a single system with Coyote angioplasty balloon (Boston Scientific) and the Atlas stent (Stryker).

Cerebral blood flow territory instability in patients with atherosclerotic intracranial stenosis

BACKGROUND

Stroke risk stratification in patients with symptomatic intracranial atherosclerotic arterial disease (ICAD) remains an important clinical objective owing to the high 14-19% recurrent stroke rate in these patients on standard-of-care medical management. There thus remains a need for hemodynamic markers that may allow for the selection of personalized therapies for high-risk symptomatic patients.

PURPOSE

To determine if shifting of cerebral blood flow (CBF) territories in response to changes in cerebral perfusion pressure (CPP) may provide a marker for stroke risk in ICAD patients.

STUDY TYPE

Prospective.

POPULATION

Twenty ICAD patients who experienced a stroke within 45 days of study enrollment and 10 healthy controls.

SEQUENCE

3.0T MRI including anatomical imaging (T1 -weighted, T2 -weighted/FLAIR), 3D MR angiography, and normocapnic and hypercapnic vessel-encoded CBF-weighted arterial spin labeling.

ASSESSMENT

Patients were scanned within 45 days of overt stroke and monitored (duration = 13.2 ± 4.4 months) for the endpoint of non-cardioembolic stroke or transient ischemic attack. Flow territory shifting (shifting index) was calculated from the first scan by determining whether a voxel shifted from its primary arterial source from normocapnia to hypercapnia.

STATISTICAL TESTS

A Mann-Whitney U-test (significance: P < 0.05) was performed to determine whether patients meeting the endpoint had greater shifting indices relative to controls or patients not meeting the endpoint.

RESULTS

Shifting indices (mean ± standard error) were significantly higher in patients meeting endpoint criteria relative to controls (P = 0.0057; adjusted P = 0.036) and patients not meeting endpoint criteria (P = 0.0047; adjusted P = 0.036).

DATA CONCLUSION

Flow territory shifting may provide a marker of recurrent stroke risk in symptomatic ICAD patients on standard-of-care medical management therapies.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1441-1451.

Regression of asymptomatic intracranial arterial stenosis by aggressive medical management with a lipid-lowering agent

Objective

The incidence rate of stroke as a result of intracranial arterial stenosis (ICAS) is higher in Asian countries than in the West. We aimed to analyze the regression, lack of change, or progression of asymptomatic ICAS after the administration of rosuvastatin and associated factors.

Methods

The patients who had undergone computed tomography angiography (CTA) at our hospital and had been diagnosed with ICAS with no ischemic event in the stenosed vascular territory were included in the study. They were administered 20mg of rosuvastatin per day. After a follow-up period of at least 6 months after treatment, the patients were examined using CTA again and the clinical information and imaging results were analyzed.

Results

In total, 48 patients were diagnosed with asymptomatic ICAS. During the final follow-up examination, it was found that the stenotic lesion regressed in 30 patients, whereas it remained unchanged or progressed without any adverse effects in 18 patients. In univariate analysis, the regressed group showed significantly higher differences in the levels of total cholesterol and low-density lipoprotein (LDL) between their initial and final values (both, p=0.031 for both). In the multivariate analysis, a significantly higher difference in the levels of LDL between its initial and final measurement was seen in the regressed group (p=0.035, odds ratio(OR) 3.9).

Conclusions

Rosuvastatin was found to have better lipid-lowering effects for total cholesterol and particularly LDL in patients whose ICAS had regressed. We concluded that rosuvastatin administration can be recommended for the treatment of patients with asymptomatic ICAS.

Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease

Importance

Patients who have experienced stroke with intracranial atherosclerotic disease (ICAD) may also have concomitant atherosclerosis in different arterial beds and other possible causes for ischemic stroke. However, little is known about the frequency and prognostic effect of such overlapping diseases.

Objectives

To describe the prevalence of systemic atherosclerotic burdens and overlapping stroke etiologies and their contributions to long-term prognoses among patients who have experienced stroke with ICAD.

Design, Setting, and Participants

The Asymptomatic Myocardial Ischemia in Stroke and Atherosclerotic Disease study is a single-center prospective study in which 405 patients with acute ischemic stroke within 10 days of onset were consecutively enrolled between June 2005 and December 2008 and followed up for 4 years. After excluding 2 patients because of incomplete investigations, 403 were included in this analysis.

Main Outcomes and Measures

Significant ICAD was defined as having 50% or greater stenosis/occlusion by contrast-enhanced/time-of-flight magnetic resonance angiography, computed tomography angiography, and/or transcranial Doppler ultrasonography. Systemic vascular investigations on atherosclerotic disease were performed with ultrasonography in carotid arteries, aorta and femoral arteries, and by angiography in coronary arteries. Coexistent stroke etiologies were assessed using the atherosclerosis, small-vessel disease, cardiac pathology, other cause, and dissection (ASCOD) grading system. We estimated the 4-year risk of major adverse cardiovascular events (MACE), including vascular death, nonfatal cardiac events, nonfatal stroke, and major peripheral arterial events.

Results

Of 403 participants, 298 (74%) were men and the mean (SD) age was 62.6 (13.1) years. Significant ICAD was found in 146 (36.2%). Patients with significant ICAD more often had aortic arch (70 [60.9%] vs 99 [49.0%]; P = .04) and coronary artery (103 [76.9%] vs 153 [63.2%]; P = .007) atherosclerosis than those without. Among patients with ICAD, concurrent stenosis in the extracranial carotid artery (24 [23.4%] vs 3 [9.0%]; P = .08; adjusted hazard ratio[aHR] = 2.12) and the coronary artery (19 [29.9%] vs 8 [12.8%]; P = .01; aHR = 1.90) increased the MACE risk. Furthermore, patients with ICAD who also had any cardiac pathology (ASCOD grade C1-3) were at a higher MACE risk than others (grade C0) (20 [28.2%] vs 7 [11.4%]; P = .01; aHR = 2.24). By contrast, patients with ICAD with any form of small vessel disease (grade S1-3) had a lower MACE risk than those without (grade S0) (20 [17.3%] vs 6 [34.6%]; P = .05; aHR = 0.23).

Conclusions and Relevance

Patients with ICAD often have coexisting systemic atherosclerosis and multiple potential stroke mechanisms that affect their prognosis, suggesting that extensive evaluations of overlapping diseases may allow better risk stratification.

Perfusion and plaque evaluation to predict recurrent stroke in symptomatic middle cerebral artery stenosis

Background and purpose

We investigated the baseline demographics of patients with severe unilateral atherosclerotic stenosis of the middle cerebral artery (MCA) using multimodal MRI and evaluated the haemodynamic impairments and plaque characteristics of patients who had a recurrent stroke.

Materials and methods

We retrospectively recruited consecutive patients with severe unilateral atherosclerotic MCA stenosis who underwent arterial spin labelling (ASL) with postlabelling delay (PLD) of 1.5 and 2.5 s, and vessel wall MRI. For each PLD, cerebral blood flow (CBF) maps were generated. Hypoperfusion volume ratio (HVR) from 2 PLD CBF was calculated. An HVR value ≥50% was considered as severe HVR. Plaque areas, plaque burden, plaque length and remodelling index were measured. Plaque enhancement at maximal lumen narrowing site were graded. Baseline clinical and imaging characteristics were compared between patients with (event+) and without (event−) 1 year ischaemic events.

Results

Forty-three patients (47.23±12.15 years; 28 men) were enrolled in this study. Seven patients had an HVR ≥50%. During the 1-year follow-up, 7 patients had experienced a recurrent stroke. HVR were significantly higher in the event+ than event− (53.17%±29.82% vs 16.9%±15.57%, p=0.0002), whereas no significant difference was detected in plaque areas, plaque burden, remodelling index, plaque length and plaque enhancement grade. The multivariable analysis revealed that a severe HVR was significantly associated with a recurrent stroke (Odds ratio=12.93, 95% confidence interval 1.57 to 106.24, p=0.017) after adjusted by hypertension and smoking.

Conclusion

HVR obtained from two PLD ASL may be a useful imaging predictor of recurrent stroke.

The Barcelona-Asymptomatic Intracranial Atherosclerosis study: Subclinical intracranial atherosclerosis as predictor of long-term vascular events

BACKGROUND AND AIMS

Symptomatic intracranial atherosclerosis (ICAS) is associated with a high risk of stroke recurrence and occurrence of other vascular events. However, ICAS has been poorly studied from its asymptomatic stage. The objective of our study was to determine if subclinical intracranial atherosclerosis is associated with long-term incident vascular events in Caucasians.

METHODS

The Barcelona-Asymptomatic Intracranial Atherosclerosis (AsIA) Study is a population-based study that enrolled 933 subjects with a moderate-high vascular risk and without history of stroke or coronary disease, and determined the prevalence of asymptomatic ICAS and associated risk factors. At baseline visit, carotid atherosclerosis and ICAS were screened by color-coded duplex ultrasound, and moderate-severe stenosis was confirmed by magnetic resonance angiography. At baseline, 8.9% of subjects had asymptomatic ICAS, of whom 3.3% were moderate-severe. In the longitudinal phase, subjects were prospectively followed-up to assess the incidence of a combined primary endpoint of vascular events (stroke, acute coronary syndrome and/or vascular death).

RESULTS

After 7.17 years of follow-up, there were 51 incident cerebrovascular events (16 transient ischemic attacks, 27 ischemic, 8 hemorrhagic strokes), 63 incident coronary events and 23 vascular deaths. After multivariate Cox regression analyses adjusted by age, sex, vascular risk and presence of carotid plaques, ICAS was an independent predictor for overall vascular events (HR 1.83 [1.10-3.03], p = 0.020), and moderate-severe intracranial stenosis was also an independent predictor for cerebrovascular events (HR 2.66 [1.02-6.94], p = 0.046).

CONCLUSIONS

Asymptomatic ICAS is independently associated with the incidence of future vascular events in our population. These findings might have implications for the development of primary prevention strategies.

Remote ischemic conditioning for stroke: clinical data, challenges, and future directions

Despite great improvement during the past several decades, the management of stroke is still far from satisfactory, which warrants alternative or adjunctive strategies. Remote ischemic conditioning (RIC), an easy‐to‐use and noninvasive therapy, can be performed in various clinical scenarios (e.g., prehospital transportation, intrahospital, and at home), and it has been widely investigated for stroke management. RIC has been demonstrated to be well tolerated in patients with acute ischemic stroke and aneurysm subarachnoid hemorrhage, and it may benefit these patients by improving clinical outcomes; in patients with intracranial atherosclerosis, long‐term repeated RIC could be safely performed and benefit patients by reducing recurrent ischemic stroke and transient ischemic attack, as well as improving cerebral perfusion status; long‐term repeated RIC may also benefit patients with cerebral small vessel disease by slowing cognitive decline and reducing volume of white matter hyperintensities on brain MRI; in patients with severe carotid atherosclerotic stenosis undergoing stenting, preprocedural RIC could reduce the odds of new brain lesions on postprocedural MRI. Previous clinical studies suggest broad future prospects of RIC in the field of cerebrovascular diseases. However, the optimal RIC protocol and the mechanisms that RIC protects the brain is not fully clear, and there is lack of sensitive and specific biomarkers of RIC, all these dilemmas prevent RIC from entering clinical practice. This review focuses on recent advances in clinical studies of RIC in stroke management, its challenges, and the potential directions of future studies.

Drug-coated balloons for the treatment of symptomatic intracranial atherosclerosis: initial experience and follow-up outcome

BACKGROUND

The optimal treatment for patients with symptomatic severe intracranial atherosclerotic disease is not well established. Angioplasty and stenting have been attempted, with controversial results, mainly attributed to perioperative complications and a high incidence of restenosis or in-stent restenosis. Drug-coated balloons (DCBs) have shown encouraging results for coronary and peripheral artery disease, without convincing data for intracranial vasculature.

OBJECTIVES

To assess the feasibility, clinical and angiographic outcomes of DCBs for patients with intracranial de novo atherosclerotic disease.

METHODS

Between September 2016 and September 2017, details of 30 patients with 31 arteries treated with DCBs for symptomatic severe intracranial atherosclerotic disease (≥70% stenosis or chronic total occlusion) were retrospectively collected in our centre. All lesions were predilated with conventional balloons. Periprocedural complications and clinical and vascular imaging follow-up outcomes were analysed.

RESULTS

All arteries were successfully dilated with DCBs and 29 (93.5%) arteries achieved good antegrade perfusion, with remedial stenting for two arteries. Two patients presented with new ischemic stroke after the procedure. Over a mean follow-up of 9.8±2.6 months, no patient had recurrent ischemic symptoms. Repeat vascular imaging was performed at 7.0±1.1 months, with cerebral angiography in 24 patients (25 arteries) and MR angiography in six patients (six arteries). Only one (3.2%) artery presented with angiographic asymptomatic restenosis.

CONCLUSIONS

This study suggests that DCB dilatation may be a safe and effective alternative for intracranial de novo atherosclerotic disease.

Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke

Intracranial stenosis is a common cause of ischaemic strokes, in particular, in the Asian, African and Hispanic populations. The randomised multicentre study Stenting and Aggressive Medical Management for the Prevention of Recurrent stroke in Intracranial Stenosis (SAMMPRIS) showed 14.7% risk of stroke or death in the stenting group versus 5.8% in the medical group at 30 days, and 23% in the stenting group versus 15% in the medical group at a median follow-up of 32.4 months. The results demonstrated superiority of medical management over stenting and have almost put the intracranial stenting to rest in recent years. Of note, 16 patients (7.1%) in the stenting group had disabling or fatal stroke within 30 days mostly due to periprocedural complications as compared with 4 patients (1.8%) in the medical group. In contrast, 5 patients (2.2%) in the stenting group and 14 patients (6.2%) in the medical group had a disabling or fatal stroke beyond 30 days, indicating significant benefit of stenting if periprocedural complications can be reduced. Recently, the results of the Chinese Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial and the Wingspan Stent System Post Market Surveillance Study (WEAVE trial) showed 2%-2.7% periprocedural complications. It is time to evaluate the role of intracranial stenting for the prevention of disabling or fatal stroke.

Cost-effectiveness of milk powder fortified with potassium to decrease blood pressure and prevent cardiovascular events among the adult population in China: a Markov model

OBJECTIVE

To model the long-term cost-effectiveness of consuming milk powder fortified with potassium to decrease systolic blood pressure (SBP) and prevent cardiovascular events.

DESIGN

A best case scenario analysis using a Markov model was conducted.

PARTICIPANTS

8.67% of 50-79 year olds who regularly consume milk in China, including individuals with and without a prior diagnosis of hypertension.

INTERVENTION

The model simulated the potential impact of a daily intake of two servings of milk powder fortified with potassium (+700 mg/day) vs the consumption of a milk powder without potassium fortification, assuming a market price equal to 0.99 international dollars (intl$; the consumption of a milk powder without potassium fortification, assuming a market price equal to intl$0.99 for the latter and to intl$1.12 for the first (+13.13%). Both deterministic and probabilistic sensitivity analyses were conducted to test the robustness of the results.

MAIN OUTCOME MEASURES

Estimates of the incidence of cardiovascular events and subsequent mortality in China were derived from the literature as well as the effect of increasing potassium intake on blood pressure. The incremental cost-effectiveness ratio (ICER) was used to determine the cost-effectiveness of a milk powder fortified with potassium taking into consideration the direct medical costs associated with the cardiovascular events, loss of working days and health utilities impact.

RESULTS

With an ICER equal to int$4711.56 per QALY (quality-adjusted life year) in the best case scenario and assuming 100% compliance, the daily consumption of a milk powder fortified with potassium shown to be a cost-effective approach to decrease SBP and reduce cardiovascular events in China. Healthcare savings due to prevention would amount to intl$8.41 billion. Sensitivity analyses showed the robustness of the results.

CONCLUSION

Together with other preventive interventions, the consumption of a milk powder fortified with potassium could represent a cost-effective strategy to attenuate the rapid rise in cardiovascular burden among the 50-79 year olds who regularly consume milk in China.

Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion

Objective

The aim of this study was to evaluate the feasibility and safety of multimodal therapy for patients with non-superacute vertebral basilar artery occlusion.

Method

We performed a retrospective analysis of multimodal therapy for patients with vertebral basilar artery occlusion. All patients who were beyond the time window to receive intravenous thrombolysis and who had deterioration of symptoms after drug treatment received small-balloon dilatation of the occlusive artery to estimate vascular occlusion aetiology. Thrombectomy with a Solitaire AB system was applied to the thrombus, and angioplasty with intracranial stents was used to treat stenosis. During the 3-month follow-up, National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores were recorded regularly.

Results

We included 12 patients with a mean age of 60.4 (SD: 12.9) years. The average score on the NIHSS was 16.6 (SD: 11.6), and the average time from onset to admission was 95 h (SD: 121). The arteries were recanalized for all patients, but the degree of residual stenosis in the parent artery was 17.5% (SD: 20.1). During the follow-up period, one patient died of pulmonary haemorrhage and infection, and another patient died from haemorrhage related to high perfusion. After 3 months of follow-up, the 10 surviving patients showed an average NIHSS score of 7.9 (SD: 8.7) and an average mRS score below 2 (1.3 ± 1.4).

Conclusion

For patients with posterior circulation stroke due to basilar artery or vertebral artery occlusion who present to the hospital 6 h after symptom onset and who exhibit deterioration of symptoms after drug treatment, multimodal recanalization of the occluded artery may be a feasible and safe therapy.

Current Status and Future Perspective of Stenting for Symptomatic Intracranial Atherosclerotic Disease: A Meta-Analysis

The aim of this study was to evaluate the safety and effectiveness of percutaneous transluminal angioplasty and stenting (PTAS) for intracranial atherosclerotic disease (ICAD) by conducting a meta-analysis. Two independent observers searched PubMed, EMBASE, and Cochrane Library for relevant studies up to 31 December 2016. A meta-analysis was conducted using Review Manager 5.3. Three studies involving 581 cases were included. The meta-analysis indicated that any stroke (RR = 3.13; 95% CI: 1.80-5.42), ischemic stroke (RR = 2.15; 95% CI: 1.19-3.89), and intracranial hemorrhage (RR = 14.71; 95% CI: 1.96-110.48) within 30 days in medical therapy alone were lower compared with PTAS plus medical therapy, but there were no significant differences in any stroke and ischemic stroke beyond 30 days between the two groups. There were also no significant differences in any death and myocardial infarction between the two groups. This meta-analysis demonstrated that, compared with medical therapy alone, PTAS for ICAD had a high risk of complication, but most complications in PTAS group occurred within 30 days after the operation, and beyond 30 days the PTAS was not inferior compared with medical therapy alone. Further studies are needed to reduce the periprocedural complications and reappraise the PTAS.

Dr. Norman Chater and Chater's Point

Dr. Norman Chater, a University of California San Francisco-trained microvascular neurosurgeon, dedicated his career to the development of surgical bypass techniques. His work contributed to advancements in microvascular anatomy and the development of cerebral revascularization techniques. He identified Chater's point, an extracranial landmark that marks the posterior extent of the Sylvian fissure, which on craniectomy reliably exposes vessels of the angular gyrus, the vasculature found to be most appropriate for bypass procedures owing to its accessibility and vascular diameter. This surgical landmark continues to be essential for the successful execution of bypass surgeries to this day.

Successful Treatment of Symptomatic Intracranial Carotid Artery Stenosis Using a 24-mm Long Bare Metal Coronary Stent

BACKGROUND

Intracranial arterial atherosclerosis represents a common cause of stroke. Despite aggressive and optimal medical management, many patients will unfortunately suffer additional cerebrovascular events. The role of endovascular intervention for intracranial atherosclerotic disease continues to be uncertain, particularly in regard to extensive, symptomatic stenosis.

CASE DESCRIPTION

We present a case of a 42-year-old man with a complex medical history who presented with recurrent ischemic stroke in the ipsilateral hemisphere despite optimal medical management. Given the length of stenosis and the luminal size of the intracranial cavernous and petrous segments of the internal carotid artery, we used a bare metal coronary stent (4.0 mm × 24 mm). This represents one of the longest stents deployed for intracranial disease reported in the literature.

CONCLUSIONS

This case illustrates that a long coronary stent might be successfully used to manage extensive intracranial lesions. We also review the efficacy of using 1 very long stent versus multiple overlapping stents, with reference to the coronary angiography literature.

A High-Resolution MRI Study of Relationship between Remodeling Patterns and Ischemic Stroke in Patients with Atherosclerotic Middle Cerebral Artery Stenosis

Purpose: Recently, high-resolution magnetic resonance imaging (HR-MRI) has been used to depict the wall characteristics of the intracranial arteries. The aim of this study was to explain the relationship between the remodeling patterns and acute ischemic stroke in patients with atherosclerotic middle cerebral artery (MCA) stenosis using HR-MRI. Materials and Methods: From August 2015 to May 2016, we prospectively screened 33 consecutive patients with unilateral MCA stenosis using time-to-flight MR angiography, including 15 patients with symptomatic MCA stenosis and 18 patients with asymptomatic MCA stenosis. Among them, 14 patients were diagnosed as positive remodeling (PR) and 19 as negative remodeling or non-remodeling. The cross-sectional images of the stenotic MCA wall on HR-MRI including T1WI, T2WI, and PDWI were compared between the symptomatic group and the asymptomatic group as well as the PR group and the non-PR group, based on the vessel area, lumen area, wall area, plaque area, degree of stenosis, remodeling index, and NIHSS score. Results: The symptomatic group had larger wall area (P = 0.040), plaque area (P<0.001), degree of stenosis (P = 0.038), remodeling index (P < 0.001), and NIHSS score (P = 0.003) as well as smaller lumen area (P = 0.001) than the asymptomatic group. In addition, more PR patients were observed in symptomatic group. The PR group had larger plaque area (P = 0.014) and NIHSS score (P = 0.037) than the non-PR group. Demographic and clinical characteristics between the symptomatic group and the asymptomatic group, the PR group and the non-PR group showed no statistical difference. Conclusion: The current study suggests that the HR-MRI has emerged as a promising tool to detect the characteristics of intracranial arteries wall and reveal the relationship between remodeling patterns and ischemic stroke. The PR is an unsafe remodeling way and is prone to cause acute ischemic stroke.

Association between High-density-lipoprotein-cholesterol Levels and the Prevalence of Asymptomatic Intracranial Arterial Stenosis

Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke, and a low level of high-density lipoprotein cholesterol (HDL-C) is also considered to be a predictor for stroke. However, the association between the HDL-C level and asymptomatic ICAS is uncertain. From 2010 to 2011, a random sample of 5,351 participants were enrolled in the Asymptomatic Polyvascular Abnormalities Community (APAC) study. The recruited participants were then separated into 5 roughly uniform-sized factions with varying HDL-C levels. Multivariate logistic regression was implemented to assess the connection of the HDL-C levels and the prevalence of asymptomatic ICAS. The prevalence of asymptomatic ICAS showed no gradual decrease with the increase of HDL-C levels. After adjustment for conventional risk factors, HDL-C levels still showed no significant association with asymptomatic ICAS. The odds ratios (OR) of the prevalence of asymptomatic ICAS between the first group and the other 4 groups were 0.98, 1.00, 0.92, and 0.87 with 95% confidence intervals (CI) being 0.76–1.27, 0.78–1.29, 0.71–1.19, and 0.66–1.13, respectively. The study showed little correlation between HDL-C levels and asymptomatic ICAS. Normal levels of HDL-C are not an independent risk factor for asymptomatic ICAS.

Sex Differences Do Not Exist in Outcomes among Stroke Patients with Intracranial Atherosclerosis in China: Subgroup Analysis from the Chinese Intracranial Atherosclerosis Study

BACKGROUND

To date, sex difference in outcomes among patients with intracranial atherosclerosis (ICAS) has rarely been discussed in China as well as in the world. This study aimed to estimate the sex difference in outcomes among patients with ICAS in Chinese cerebral ischemia patients.

METHODS

We analyzed 1,335 men and women with ICAS who were enrolled in the Chinese Intracranial Atherosclerosis study. They were followed-up for ischemic stroke recurrence, any cause of death, cerebral vascular events (including transient ischemic attack, ischemic and hemorrhagic stroke), combined end points (including cerebral vascular events, angina or myocardial infarction, pulmonary embolism, peripheral vascular events), and unfavorable outcome (modified Rankin scale score of 3-6) at 1 year.

RESULTS

During the follow-up period, 59 (13.44%) combined end points were documented in women and 107 (11.94%) in men. Of the combined end points, 47 were recurrent ischemic stroke events (14 in women and 33 in men), and 51 other causes of deaths (24 in women and 27 in men). There were 349 unfavorable end points (117 in women and 232 in men). The cumulative probability of death was higher in women, but after adjusting for age, diabetes mellitus, hypertension, family history of stroke, current smoker, heavy drinking, hyperhomocysteinemia, and heart disease, there was no significant difference. There was also a lack of difference in 1-year ischemic stroke recurrence, cerebral vascular events, combined end points, and unfavorable outcome between women and men at 1 year.

CONCLUSIONS

These results suggest no sex difference in outcome among patients with ICAS in Chinese cerebral ischemia patients.