Natural history of intracranial atherosclerotic disease

Advances in the Endovascular Management of Cerebrovascular Disease

The field of endovascular neurosurgery has experienced remarkable progress over the last few decades. Endovascular treatments have continued to gain traction as the advancement of technology, technique, and procedural safety has allowed for the expansion of treatment indications of various cerebrovascular pathologies. Interventions such as the coiling of intracranial aneurysms, carotid artery stenting, mechanical thrombectomy in the setting of ischemic stroke, and endovascular embolization of arteriovenous malformations have all seen transformations in their safety and efficacy, expanding the scope of endovascularly treatable conditions and offering new hope to patients who may have otherwise not been candidates for surgical intervention. Despite this notable progress, challenges persist, including complications associated with device deployment and questions regarding long-term outcomes. This article explores the advancements in endovascular neurosurgical techniques, highlighting the impact on patient care, outcomes, and the evolution of traditional surgical methods.

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.

High Prevalence of Asymptomatic Intracranial Atherosclerosis in Elder Women With Tubal Ligation: Result From a Community-Based Study in Shandong, China

Background

In addition to traditional cardiovascular risk factors, gender-specific factors may also contribute to intracranial atherosclerosis. This study aimed to comprehensively investigate the association between asymptomatic intracranial atherosclerosis (aICAS) and menstrual or reproductive history (MRH), namely, menstruation, pregnancy, childbirth, menopause, and contraception.

Methods

Participants in this study were selected from the Kongcun town aICAS study. MRH was collected through structured case report forms, in which menarche age, menstrual regularity, dysmenorrhea, number of pregnancies, number of childbirths, age of first pregnancy, breastfeeding, menopause, menopause age, and contraceptive methods were all involved. All characteristics were compared by chi-squared and nonparametric tests as applicable. Logistic regression model and sensitivity analysis were used to analyze the association between aICAS and MRH.

Results

A total of 1,052 female participants were involved in this study, of which 5.7% had moderate to severe aICAS. Tubal ligation was significantly associated with aICAS in univariate analysis [crude odds ratio (OR), 2.85; 95% CI, 1.22–6.62; P = 0.015]. This association was still significant among female participants over 60 years old after multivariate adjustment (adjusted OR, 4.36; 95% CI, 1.55–12.24; P = 0.005). Sensitivity analysis showed a similar result (adjusted OR, 3.76; 95% CI, 1.24–11.41; P = 0.020). Menopause lost significant association with aICAS after multivariate adjustment (adjusted OR, 1.68; 95% CI, 0.66–4.24; P = 0.275). No other MRH factors were found to be associated with aICAS.

Conclusion

Tubal ligation may be associated with a higher prevalence of aICAS in Chinese elderly women. This provides a new perspective to study the epidemiological characteristics of ICAS.

Current Advances in Endovascular Treatment of Intracranial Atherosclerotic Disease and Future Prospective

OBJECTIVES/BACKGROUND

Medical therapy is the first line of treatment for intracranial atherosclerotic disease (ICAD). Percutaneous transluminal angioplasty and stenting (PTAS) are mainly considered for those patients with severe stenosis and recurrent events despite aggressive medical therapy. In this review, we discuss the application of PTAS as a treatment option for ICAD and its future prospect.

MATERIALS AND METHODS

We did the literature review of the key articles and guidelines to elaborate on the role of PTAS in the management of ICAD based on the current data and expert opinion. We searched PubMed, Google Scholar, and Scopus up to August 2020, and included articles published only in the English language.

RESULTS

Since the publication of the results from SAMMPRIS and VISSIT trials, stenting is no longer recommended for secondary stroke prevention in patients with symptomatic ICAD. However, recent clinical studies on intracranial stenting for a subgroup of ICAD patients have shown promising results, likely due to better patient selection and continued advancement of endovascular techniques.

CONCLUSION

There exists a lack of consensus regarding the best endovascular treatment approach (e.g., angioplasty alone or balloon mounted stent vs. self-expanding stent with or without prior angioplasty) or management of in-stent restenosis. Another area of clinical controversy relates to the ideal use and duration of antiplatelet therapy.

Thrombectomy for Posterior Circulation Stroke: Predictors of Outcomes in a Brazilian Registry

BACKGROUND

Acute basilar artery occlusion is a devastating life-threatening condition. Early recanalization is the therapeutic goal in patients with acute ischemic stroke. Despite the high rates of recanalization achieved with modern devices for basilar occlusions, many patients have had poor clinical outcomes. This study aimed to assess the predictors of good and poor outcomes among patients with basilar artery occlusion treated with thrombectomy.

METHODS

A consecutive registry of 80 patients was included in this retrospective study. The primary end point was to access variables associated with neurologic outcomes defined by a modified Rankin Scale (mRS) score of 0-2, symptomatic intracranial hemorrhage (sICH), and mortality at 3 months follow-up.

RESULTS

Recanalization was achieved in 86.2%, and the sICH rate was 8.7%. A good neurologic outcome (mRS score 0-2) was observed in 26.2% and a moderate outcome (mRS score 0-3) in 32.5% of patients. The mortality was 38.7% at 3 months follow-up.

CONCLUSIONS

After thrombectomy for posterior circulation strokes, young patients, V4-proximal basilar occlusion, (high) baseline posterior circulation Alberta Stroke Program Early CT Score, and complete recanalization were independent predictors of good neurologic outcomes. Failure to recanalize was strongly related to sICH and mortality. In addition, diabetes, atrial fibrillation, and baseline National Institutes of Health Stroke Scale scores ≥10 had an independent association with mortality. This study contributes to the knowledge required to optimize recanalization treatments for posterior circulation strokes and may help to improve future clinical studies.

Comprehensive investigation of RNF213 nonsynonymous variants associated with intracranial artery stenosis

Intracranial artery stenosis (ICAS) is the most common cause of ischemic stroke worldwide. RNF213 single nucleotide variant c.14429G > A (p.Arg4810Lys, rs112735431) was recently reported to be associated with ICAS in East Asians. However, the disease susceptibility of other RNF213 variants has not been clarified. This study comprehensively investigated ICAS-associated RNF213 variants in a pool of 168 Japanese ICAS patients and 1,194 control subjects. We found 138 nonsynonymous germline variants by target resequencing of all coding exons in RNF213. Association study between ICAS patients and control subjects revealed that only p.Arg4810Lys had significant association with ICAS (P = 1.5 × 10^-28, odds ratio = 29.3, 95% confidence interval 15.31-56.2 [dominant model]). Fourteen of 138 variants were rare variants detected in ICAS patients not harboring p.Arg4810Lys variant. Two of these rare variants (p.Cys118Arg and p.Leu2356Phe) consistent with variants previously reported in moyamoya disease patients characterized by stenosis of intracranial artery and association with RNF213, and three rare variants (p.Ser193Gly, p.Val1817Leu, and p.Asp3329Tyr) were found neither in control subjects and Single Nucleotide Polymorphism Database. The present findings may improve our understanding of the genetic background of intracranial artery stenosis.

The hepatitis B core antibody positive/hepatitis B surface antigen negative pattern is associated with the increased risk of intracranial atherosclerotic stenosis

The high prevalence of hepatitis B virus (HBV) infection and intracranial atherosclerotic stenosis (ICAS) in Asia raises the question as to whether HBV infection is associated with ICAS. To answer this question, we tested the association between HBV infection and ICAS. Totally, 3072 in-hospital subjects were retrospectively enrolled. All subjects underwent computed tomography angiography (CTA) and serological testing for HBV infection. Based on the results of CTA, all subjects were categorized into 4 groups including ICAS, extracranial atherosclerotic stenosis (ECAS), ICAS/ECAS (both ICAS and ECAS), and normal. HBV infection was divided into 4 patterns including hepatitis B core antibody (anti-HBc) positive/hepatitis B surface antigen (HBsAg) positive, anti-HBc-positive/HBsAg-negative, anti-HBc-negative/HBsAg-positive, and anti-HBc-negative/HBsAg-negative. Risk factors for atherosclerosis were collected based on medical records. Multiple logistic regression models were used to determine the association between infection patterns and ICAS. We found that the anti-HBc-positive / HBsAg-negative pattern was associated with the increased risk of ICAS (OR = 1.462) and not associated with ECAS or ICAS / ECAS. The HBc-positive/HBsAg-positive pattern was not associated with ICAS, ECAS or ICAS/ECAS. In conclusions, the anti-HBc-positive/HBsAg-negative pattern was associated with the increased risk of ICAS. Anti-HBc should be employed to investigate the association between HBV infection and cerebrovascular diseases.

Risk factors for intracranial atherosclerosis: A systematic review and meta-analysis

BACKGROUND AND AIMS

Intracranial atherosclerosis (ICAS) is a predictable and preventable condition, but existing evidence concerning its risk factors has not been quantitatively assessed. The aim of this meta-analysis is to identify the non-modifiable and modifiable risk factors for ICAS.

METHODS

PubMed and EMBASE were searched (1995-May 15, 2018) for cross-sectional and longitudinal studies exploring risk factors for ICAS. The risk estimates and 95% confidence intervals (CIs) in multivariate analysis were aggregated using random-effect models.

RESULTS

Thirty-four studies comprising 59,736 subjects met the inclusion criteria for the systematic review involving thirty-one risk or protective factors. Seven factors were associated with ICAS, as suggested by the meta-analysis, including advanced age (odds ratio (OR) 1.05, 95% CI 1.03-1.08), metabolic syndrome (OR 2.13, 95% CI 1.35-3.37), diabetes mellitus (OR 1.98, 95% CI 1.69-2.31), hypertension (OR 1.97, 95% CI 1.69-2.31), dyslipidemia (OR 1.29, 95% CI 1.04-1.59), high levels of low-density lipoprotein cholesterol (OR 1.06, 95% CI 1.00-1.12) and high levels of apolipoprotein A1 (OR 0.34, 95% CI 0.15-0.75). The subgroup analysis for study populations indicated advanced age, metabolic syndrome, diabetes mellitus and hypertension as an elevated risk of ICAS among community subjects and stroke patients; according to the subgroup analysis for ethnicity, similar associations remained in Asians, but only metabolic syndrome and diabetes mellitus were correlated with ICAS in Caucasians.

CONCLUSIONS

Individuals with advanced age, metabolic syndrome, diabetes mellitus, hypertension and dyslipidemia might have a higher risk of ICAS, whereas high levels of apolipoprotein A1 might protect against ICAS.

Importance of Collateralization in Patients With Large Artery Intracranial Occlusive Disease: Long-Term Longitudinal Assessment of Cerebral Hemodynamic Function

Patients with large artery intracranial occlusive disease (LAICOD) are at risk for both acute ischemia and chronic hypoperfusion. Collateral circulation plays an important role in prognosis, and imaging plays an essential role in diagnosis, treatment planning, and prognosis of patients with LAICOD. In addition to standard structural imaging, assessment of cerebral hemodynamic function is important to determine the adequacy of collateral supply. Among the currently available methods of assessment of cerebral hemodynamic function, measurement of cerebrovascular reactivity (CVR) using blood oxygen level-dependent (BOLD) MRI and precisely controlled CO₂ has shown to be a safe, reliable, reproducible, and clinically useful method for long-term assessment of patients. Here, we report a case of long-term follow-up in a 28-year-old Caucasian female presented to the neurology clinic with a history of TIAs and LAICOD of the right middle cerebral artery (MCA). Initial structural MRI showed a right MCA stenosis and a small right coronal radiate lacunar infarct. Her CVR study showed a large area of impaired CVR with a paradoxical decrease in BOLD signal with hypercapnia involving the right MCA territory indicating intracerebral steal. The patient was managed medically with anticoagulant and antiplatelet therapy and was followed-up for over 9 years with both structural and functional imaging. Cortical thickness (CT) measures were longitudinally assessed from a region of interest that was applied to subsequent time points in the cortical region exhibiting steal physiology and in the same region of the contralateral healthy hemisphere. In the long-term follow-up, the patient exhibited improvement in her CVR as demonstrated by the development of collaterals with negligible changes to CT. Management of patients with LAICOD remains challenging since no revascularization strategies have shown efficacy except in patients with moyamoya disease. Management is well defined for acute ischemia where the presence and the adequacy of the collateralization dictate the need for intervention. Long-term assessment in neurovascular uncoupling (i.e., chronic ischemia) may reveal improvements in CVR as the durability of compensatory collaterals improve, even in cases with no intervention. Thus, assessment of cerebrovascular hemodynamics using CVR measurements coupled with time-of-flight MR angiography can be useful in the clinical management of patients with LAICOD.

Distribution of atherosclerotic stenosis determining early neurologic deterioration in acute ischemic stroke

Background and purpose

Early neurologic deterioration (END) during the acute stage of stroke is clinically important because of its association with poor outcomes. The purpose of this study was (1) to investigate variables associated with END, (2) to determine the distribution of atherosclerotic stenosis associated with END, and (3) to clarify the relationship between END and clinical outcomes.

Methods

516 patients with acute ischemic stroke were included. The median follow-up period was 31.7 months. END was defined as a ≥2 point increase in the National Institutes of Health Stroke Scale (NIHSS), ≥1 point increase in level of consciousness or motor item of the NIHSS, or the development of any new neurological deficits during the first 72 hours of hospitalization. A signal loss on 1.5-T magnetic resonance angiography exceeding 50% was considered to be significant for the categorization of stenosis pattern.

Results

The prevalence of END was 19.0%. END was associated with intracranial atherosclerotic stenosis (IAS) together with large artery atherosclerosis (LAA) subtype. In particular, stenosis of basilar artery or posterior cerebral artery was independently associated with END. Lesion growth or hypoperfusion was more accountable for END in patients with IAS, whereas intracerebral hemorrhage or edema/herniation was more frequently observed in END patients without IAS. Patients with END had a higher rate of mortality, but a similar rate of further vascular events compared to patients without END.

Conclusion

Pre-stroke IAS and LAA subtype could determine the development of END during the acute stage of ischemic stroke.

Intracranial Atherosclerosis: From Microscopy to High-Resolution Magnetic Resonance Imaging

Intracranial atherosclerosis is one of the leading causes of ischemic stroke and occurs more commonly in patients of Asian, African or Hispanic origin than in Caucasians. Although the histopathology of intracranial atherosclerotic disease resembles extracranial atherosclerosis, there are some notable differences in the onset and severity of atherosclerosis. Current understanding of intracranial atherosclerotic disease has been advanced by the high-resolution magnetic resonance imaging (HRMRI), a novel emerging imaging technique that can directly visualize the vessel wall pathology. However, the pathological validation of HRMRI signal characteristics remains a key step to depict the plaque components and vulnerability in intracranial atherosclerotic lesions. The purpose of this review is to describe the histological features of intracranial atherosclerosis and to state current evidences regarding the validation of MR vessel wall imaging with histopathology.

Cerebral and Coronary Vasculature in Disease Associations and Dissociations in the South Indian Population

INTRODUCTION

Cerebrovascular accidents constitute the most common cause of disability all over the world. In India prevalence rate is 545 per 100000 and mortality rate is around 7.5 per thousand. Therefore the authors undertook a study on patients who underwent coronary artery bypass surgery (CABG). They were investigated for clinical and/or radiological evidence of cerebrovascular disease (CVD) with the aim to decide on early neurological intervention.

PATIENTS AND METHODS

210 patients who had undergone CABG were evaluated with neck vessel Doppler using high resolution duplex scanner system and computed tomography (CT) scan as well as MR angiogram (MRA) in addition to assessment of co morbid risk factors.

RESULTS

91% of patients who had undergone CABG had radiological evidence of CVD. The most common risk associated with CAD and CVD was Hypertension (HT), DM, dyslipidemia and combined HT and DM in that order. Neck vessels were normal in 59%. Significant disease was found in only 7.2%. Internal carotids were abnormal in 82%. Infarcts were seen in 82.1%.

DISCUSSION

This study reveals patients with CAD have a high degree of asymptomatic CVD. It is mostly due to small vessel disease including internal carotids but not so much with large vessels. Therefore, patients with CAD carry a high risk of vascular cognitive dysfunction. This can be reduced by effective management of the systemic risk factors. Screening for large vessel disease which is commonly done is likely to give a false sense of security.

CONCLUSION

As against western population Indians seem to have small and medium sized vessels disease in the setting of CAD.

Neuropathology of supercentenarians - four autopsy case studies

Supercentenarians (aged 110 years old or more) are extremely rare in the world population (the number of living supercentenarians is estimated as 47 in the world), and details about their neuropathological information are limited. Based on previous studies, centenarians (aged 100–109 years old) exhibit several types of neuropathological changes, such as Alzheimer’s disease and Lewy body disease pathology, primary age-related tauopathy, TDP-43 pathology, and hippocampal sclerosis. In the present study, we provide results from neuropathological analyses of four supercentenarian autopsy cases using conventional and immunohistochemical analysis for neurodegenerative disorders. In particular, we focused on the pathology of Alzheimer’s disease and Lewy body disease, as well as the status of hippocampal sclerosis, TDP-43 pathology, aging-related tau astrogliopathy, and cerebrovascular diseases. Three cases were characterized as an “intermediate” level of Alzheimer’s disease changes (NIA-AA guideline) and one was characterized as primary age-related tauopathy. TDP-43 deposits were present in the hippocampus in two cases. Neither Lewy body pathology nor hippocampal sclerosis was observed. Aging-related tau astrogliopathy was consistently observed, particularly in the basal forebrain. Small vessel diseases were also present, but they were relatively mild for cerebral amyloid-beta angiopathy and arteriolosclerosis. Although our study involved a small number of cases, the results provide a better understanding about human longevity. Neuropathological alterations associated with aging were mild to moderate in the supercentenarian brain, suggesting that these individuals might have some neuroprotective factors against aging. Future prospective studies and extensive molecular analyses are needed to determine the mechanisms of human longevity.

Correlation of intracranial atherosclerosis with carotid stenosis in ischemic stroke patients

Introduction:

Carotid stenosis is a major risk factor for ischemic stroke. However, the effect of carotid stenosis on the site of stroke is still under investigation.

Aims:

This study aimed to elucidate how the presence of carotid stenosis influenced the pattern of stroke and also how it interacted with other risk factors for stroke.

Materials and Methods:

Thirty-eight patients with ischemic stroke were included in this study and were investigated with carotid artery Doppler and magnetic resonance angiography for carotid stenosis and intracranial stenosis in the circle of Willis, respectively. Other known risk factors of stroke were also studied in and compared between the subgroups with and without carotid stenosis.

Results:

In patients without carotid stenosis, anterior cerebral artery was the commonest site of stenosis. In patients with carotid stenosis, middle cerebral artery was the commonest site of stenosis. Overall, middle cerebral artery was the commonest territory of stroke. Patients with hypertension, diabetes and history of smoking had preferential stenosis of the anterior cerebral artery.