The diagnosis of intracranial artery stenosis in patients with stroke by transcranial Doppler ultrasound: A meta-analysis

BACKGROUND

Strokes are the most common cause of death and the leading cause of acquired disability in adults worldwide.

OBJECTIVE

The present study aimed to investigate the value of transcranial Doppler ultrasound (TCD) in the diagnosis of intracranial vascular stenosis in patients with a history of stroke.

METHODS

This is a meta-analysis study of diagnostic tests. PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP databases were systematically searched. Diagnostic tests using TCD or transcranial colour Doppler ultrasound (TCCD) for detecting intracranial arterial stenosis in patients with a history of stroke were included, with reference standards of intracranial angiography, computed tomography angiography (CTA), or magnetic resonance angiography. The risk bias map was drawn by Revman v5.3, the sensitivity and specificity forest plot was drawn by Stata v16.0, the receiver operating characteristic curve was drawn, and the area under the curve (AUC) was calculated.

RESULTS

A total of 812 patients with stroke in 12 studies were included in the meta-analysis. The estimated sensitivity of TCD or TCCD for the detection of intracranial vascular stenosis was 0.77-1.00, and the combined sensitivity was 0.96 (95% confidence interval [CI]: 0.88-0.99); the estimated specificity was 0.32-1.00, and the combined specificity was 0.94 (95% CI: 0.82-0.98); the positive likelihood ratio was 15.8 (95% CI: 5.1-48.6); and the negative likelihood ratio was 0.04 (95% CI: 0.01-0.14). The AUC was 0.99 (95% CI: 0.97-0.99).

CONCLUSION

Doppler ultrasound has good consistency with conventional methods for the diagnosis of intracranial artery stenosis in patients with a history of stroke. Different reference standards may affect sensitivity and specificity; when CTA was used as the reference standard, the consistency of the TCD in the diagnosis of intracranial artery stenosis in stroke patients was relatively good.

Ticagrelor Versus Clopidogrel in Minor Stroke or Transient Ischemic Attack With Intracranial Artery Stenosis: A Post Hoc Analysis of CHANCE-2

Background This study aimed to investigate the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in Chinese patients by the presence and clinical presentation of intracranial artery stenosis (ICAS) using randomized trial data from the CHANCE-2 (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II) trial. Methods and Results A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were randomized to either the ticagrelor-aspirin or clopidogrel-aspirin group. Patients without imaging of the intracranial artery were excluded from the nonprespecified subgroup analysis of CHANCE-2. All patients included were classified into the following groups: without ICAS, symptomatic ICAS, or asymptomatic ICAS. The primary efficacy outcome was new strokes within 90 days. There were 5893 patients (median age, 64.8 years; 33.9% women) included, and 172 (4.9%), 171 (10.5%), and 57 (7.7%) cases of new strokes occurred within 90 days in the without ICAS, with symptomatic ICAS, and with asymptomatic ICAS groups, respectively. Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without ICAS (62 [3.5%] versus 110 [6.3%]; hazard ratio [HR], 0.57 [95% CI, 0.41-0.78]) but not in those with symptomatic ICAS (HR, 0.77 [95% CI, 0.56-1.05]) or in those with asymptomatic ICAS (HR, 0.77 [95% CI, 0.43-1.38]) compared with clopidogrel-aspirin (P for interaction=0.14). There were no significant differences in the proportion of severe or moderate bleeding events among different ICAS groups. Conclusions Patients without ICAS received a significantly greater benefit from ticagrelor-aspirin than clopidogrel-aspirin after minor ischemic stroke or transient ischemic attack, and there was no statistically significant difference between treatments in patients with symptomatic ICAS or asymptomatic ICAS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04078737.

Reduced Likelihood of Infarction in Crescendo Transient Ischemic Attack Caused by Vasculitic Middle Cerebral Artery Stenosis

A 53-year-old woman was admitted to our hospital because of increasingly frequent transient speech disturbance and left upper limb weakness. Brain magnetic resonance imaging and angiography revealed multiple intracranial stenoses, including the proximal right middle cerebral artery (MCA), without evidence of infarction. The diagnosis of primary angiitis of the central nervous system was established based on circumferential vascular wall thickening with contrast enhancement observed in the right MCA. Following the administration of dual antiplatelet therapy and intravenous methylprednisolone pulse therapy, the patient experienced complete cessation of symptoms, and the stenosis gradually improved without infarction. The risk of infarct development in crescendo transient ischemic attacks may differ between inflammatory vascular stenosis and atherosclerosis.

Major intracranial arterial stenosis influence association between baseline blood pressure and clinical outcomes after thrombolysis in ischemic stroke patients

BACKGROUND

This study aimed to investigate the relationship between baseline blood pressure (BP) and clinical outcomes after thrombolysis for acute ischemic stroke (AIS) in different intracranial arterial stenosis subgroups.

METHODS

AIS patients from multicenter with intravenous thrombolysis were retrospectively enrolled from January 2013 to December 2021. We categorized participants into severe (≥ 70%) and nonsevere (< 70%) stenosis of major intracranial arteries subgroups. The primary outcome was unfavorable functional outcome defined as 3-month modified Rankin Scale (mRS) ≥2. The association coefficients between baseline BP and functional outcomes were estimated in general linear regression model. The interactive effect was tested to determine the influence of intracranial arterial stenosis on the association between BP and clinical outcomes.

RESULTS

A total of 329 patients were included. Severe subgroup was detected in 151 patients with average age of 70.5. Association between baseline diastolic BP (DBP) and unfavorable functional outcome in intracranial artery stenosis subgroups was significantly different (p for interaction < .05). In nonsevere subgroup, higher baseline DBP was associated with higher risk of unfavorable outcome (OR 1.11, 95% CI 1.03 to 1.20, p = .009) compared with severe subgroup (OR 1.02, 95% CI 0.97 to 1.08, p = .341). Besides, intracranial artery stenosis also modified association between baseline systolic BP (SBP) and 3-month death (p for interaction < .05). In severe subgroup, higher baseline SBP was associated with decreased 3-month death risk (OR 0.88, 95% CI 0.78 to 1, p = .044) compared with nonsevere subgroup (OR 1, 95% CI 0.93 to 1.07, p = .908).

CONCLUSIONS

The major intracranial artery state modulates association between baseline BP and 3-month clinical outcomes after intravenous thrombolysis.

Accuracy of Dose-Saving Artificial-Intelligence-Based 3D Angiography (3DA) for Grading of Intracranial Artery Stenoses: Preliminary Findings

BACKGROUND AND PURPOSE

Based on artificial intelligence (AI), 3D angiography (3DA) is a novel postprocessing algorithm for "DSA-like" 3D imaging of cerebral vasculature. Because 3DA requires neither mask runs nor digital subtraction as the current standard 3D-DSA does, it has the potential to cut the patient dose by 50%. The object was to evaluate 3DA's diagnostic value for visualization of intracranial artery stenoses (IAS) compared to 3D-DSA.

MATERIALS AND METHODS

3D-DSA datasets of IAS (n_IAS = 10) were postprocessed using conventional and prototype software (Siemens Healthineers AG, Erlangen, Germany). Matching reconstructions were assessed by two experienced neuroradiologists in consensus reading, considering image quality (IQ), vessel diameters (VD_1/2), vessel-geometry index (VGI = VD₁/VD₂), and specific qualitative/quantitative parameters of IAS (e.g., location, visual IAS grading [low-/medium-/high-grade] and intra-/poststenotic diameters [d_{intra-/poststenotic} in mm]). Using the NASCET criteria, the percentual degree of luminal restriction was calculated.

RESULTS

In total, 20 angiographic 3D volumes (n_3DA = 10; n_3D-DSA = 10) were successfully reconstructed with equivalent IQ. Assessment of the vessel geometry in 3DA datasets did not differ significantly from 3D-DSA (VD₁: r = 0.994, p = 0.0001; VD₂:r = 0.994, p = 0.0001; VGI: r = 0.899, p = 0.0001). Qualitative analysis of IAS location (3DA/3D-DSA:n_ICA/C4 = 1, n_ICA/C7 = 1, n_MCA/M1 = 4, n_VA/V4 = 2, n_BA = 2) and the visual IAS grading (3DA/3D-DSA:n_low-grade = 3, n_medium-grade = 5, n_high-grade = 2) revealed identical results for 3DA and 3D-DSA, respectively. Quantitative IAS assessment showed a strong correlation regarding intra-/poststenotic diameters (r_{dintrastenotic} = 0.995, p_{dintrastenotic} = 0.0001; r_{dpoststenotic} = 0.995, p_{dpoststenotic} = 0.0001) and the percentual degree of luminal restriction (r_{NASCET 3DA} = 0.981; p_{NASCET 3DA} = 0.0001).

CONCLUSIONS

The AI-based 3DA is a resilient algorithm for the visualization of IAS and shows comparable results to 3D-DSA. Hence, 3DA is a promising new method that allows a considerable patient-dose reduction, and its clinical implementation would be highly desirable.

Association between proprotein convertase subtilisin/kexin type 9 and subclinical cerebrovascular disease in the community

BACKGROUND AND PURPOSE

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a new target for reducing low-density lipoprotein cholesterol and incident cardiovascular disease, including stroke. However, the clinical relevance of circulating PCSK9 levels has been poorly elucidated in the general population, particularly in association with subclinical cerebrovascular disease including cerebral small vessel disease (CSVD) and intracranial artery stenosis (ICAS).

METHODS

In community-dwelling Japanese men (n = 526) aged 46-82 years without a history of cardiovascular disease, the associations of serum PCSK9 levels with the prevalence of CSVD and ICAS were assessed using magnetic resonance imaging. CSVD included lacunar infarction, deep and subcortical white matter hyperintensity, periventricular hyperintensity and cerebral microbleeds.

RESULTS

The median (interquartile range) age at baseline and serum PCSK9 levels were 69 (63-74) years and 240 (205-291) ng/ml, respectively. After adjusting for traditional cardiovascular risk factors including low-density lipoprotein cholesterol, multivariable Poisson regression with robust error variance revealed a significant association between PCSK9 levels (per 1 SD) and ICAS (relative risks 1.18, 95% confidence interval 1.02-1.37). Multivariable ordinal logistic regression for ICAS, with stenosis graded as mild (<50%) or moderate-severe (≥50%), revealed a similar association (common odds ratio 1.31, 95% confidence interval 1.04-1.64). However, no significant association was observed between serum PCSK9 levels and CSVD.

CONCLUSIONS

Higher circulating PCSK9 levels were independently associated with an ICAS prevalence but not with CSVD prevalence. The quantification of circulating PCSK9 levels may help to identify individuals at high risk for cerebrovascular disease in the general population.

Peri-therapeutic multi-modal hemodynamic assessment and detection of predictors for symptomatic in-stent restenosis after percutaneous transluminal angioplasty and stenting

Backgrounds

This study performed multi-modal hemodynamic analysis including quantitative color-coded digital subtraction angiography (QDSA) and computational fluid dynamics (CFD) to delineate peri-therapeutic hemodynamic changes and explore the risk factors for in-stent restenosis (ISR) and symptomatic ISR (sISR).

Methods

Forty patients were retrospectively reviewed. Time to peak (TTP), full width at half maximum (FWHM), cerebral circulation time (CCT), angiographic mean transit time (aMTT), arterial stenosis index (ASI), wash-in gradient (WI), wash-out gradient (WO) and stasis index were calculated with QDSA and translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified from CFD analysis. These hemodynamic parameters were compared between before and after stent deployment and multivariate logistic regression model was established to detect predictors for ISR and sISR at follow-up.

Results

It was found that stenting generally reduced TTP, stasis index, CCT, aMTT and translesional WSSR while significantly increased translesional PR. ASI decreased after stenting, and during the mean follow-up time of 6.48 ± 2.86 months, lower ASI (<0.636) as well as larger stasis index were corroborated to be independently associated with sISR. aMTT showed a linear correlation with CCT before and after stenting.

Conclusion

PTAS not only improved cerebral circulation and blood flow perfusion but also changed local hemodynamics significantly. ASI and stasis index derived from QDSA were proved to play a prominent role in risk stratification for sISR. Multi-modal hemodynamic analysis could facilitate intraoperative real-time hemodynamic monitoring and help the determination of the end point of intervention.

Research progress on risk factors related to intracranial artery, carotid artery, and coronary artery stenosis

In recent decades, with the rapid development of economy, the acceleration of social aging and urbanization, and the prevalence of unhealthy lifestyles, the number of patients with cardiovascular and cerebrovascular diseases has shown an increasing trend year by year. It has also become one of the important causes of disability and death in all ages and groups. Atherosclerosis is the main pathological change of ischemic cardiovascular and cerebrovascular diseases, which mainly invades the large and medium arteries of the body circulation. In particular, cerebral artery and coronary artery lesions have the most significant impact on life. There is the same pathogenic mechanism between intracranial and extracranial arteries and coronary atherosclerosis, so there is a certain relationship between the degree of atherosclerosis. In this paper, the risk factors related to intracranial and extracranial arteries and coronary artery stenosis were reviewed. It provides a theoretical basis for early detection, early diagnosis and early treatment of intracranial and extracranial artery and coronary artery stenosis to reduce the occurrence and development of cardiovascular and cerebrovascular diseases.

Symptomatic Intracranial Artery Stenosis Due to an Unknown Embolus Following Cardiac Surgery: A Case Report

Intracranial artery occlusion due to a foreign body is a complication associated with cardiac surgery that is treated by various techniques. However, little is known about appropriate strategies for symptomatic intracranial artery stenosis due to an unknown embolic source. We reported a case of middle cerebral artery (MCA) stenosis after mitral valve repair (MVR) for infective endocarditis (IE). An 80-year-old man presented with right hemiplegia. MR angiography findings were normal, and diffusion-weighted imaging revealed subtle ischemic change in the left MCA territory. The patient was diagnosed with cardioembolic stroke owing to IE and performed MVR. Four days later, he suddenly presented with consciousness disorder and left hemiplegia. Computed tomography (CT) confirmed a very low-density area within the right MCA. MR angiography revealed right MCA stenosis, which corresponded to the low-density area on CT images. Diffusion-weighted imaging revealed new ischemic change in the right MCA territory. Angiography confirmed an irregular stenosis at the right M2 with antegrade blood flow, and the hemiplegia resolved during angiography. Conservative therapy was performed; however, the resting 123 I-IMP-single photon emission CT revealed moderate perfusion defect in the right MCA territory, and transient left hemiplegia appeared every few days. Therefore, 19 days after the initial transient ischemic attack, the patient was performed superficial temporal artery–MCA anastomosis, and the patient responded with a good clinical course without recurrence of the ischemic symptoms. This strategy may be a safe and effective treatment for symptomatic intracranial artery stenosis due to an unknown embolic source.

Glucose Fluctuation and Severe Internal Carotid Artery Siphon Stenosis in Type 2 Diabetes Patients

The impact of glucose fluctuation on intracranial artery stenosis remains to be elucidated. This study aimed to investigate the association between glucose fluctuation and intracranial artery stenosis. This was a cross-sectional study of type 2 diabetes mellitus (T2DM) patients equipped with the FreeStyle Libre Pro continuous glucose monitoring system (Abbott Laboratories) between February 2019 and June 2020. Glucose fluctuation was evaluated according to the standard deviation (SD) of blood glucose, coefficient of variation (%CV), and mean amplitude of glycemic excursions (MAGE). Magnetic resonance angiography was used to evaluate the degree of intracranial artery stenosis. Of the 103 patients, 8 patients developed severe internal carotid artery (ICA) siphon stenosis (≥70%). SD, %CV, and MAGE were significantly higher in the severe stenosis group than in the non-severe stenosis group (<70%), whereas there was no significant intergroup difference in the mean blood glucose and HbA1c. Multivariable logistic regression analysis adjusted for sex showed that SD, %CV, and MAGE were independent factors associated with severe ICA siphon stenosis. In conclusion, glucose fluctuation is significantly associated with severe ICA siphon stenosis in T2DM patients. Thus, glucose fluctuation can be a target of preventive therapies for intracranial artery stenosis and ischemic stroke.

The short- and long-term efficacy of intravascular stenting in the treatment of intracranial artery stenosis

OBJECTIVE

To investigate the short- and long-term efficacy of intravascular stenting in the treatment of intracranial artery stenosis.

METHODS

This prospective study was conducted in 132 patients who underwent intravascular stenting for intracranial artery stenosis. In the perioperative period, complications were recorded. During a 2-year follow-up, postoperative stenosis rate, collateral circulation, changes in peak blood flow velocity, National Institute of Health stroke scale score, modified Rankin scale score, and restenosis were recorded. Factors influencing postoperative restenosis were analyzed using univariate analysis and multivariate logistic regression analysis.

RESULTS

In the perioperative period, 4 patients had complications, while 1 patient died. Compared with before operation, peak stenosis rate, blood flow velocity, National Institute of Health stroke scale score, and modified Rankin scale score at 1 year and 2 years after operation were significantly decreased, while the classification of collateral circulation was increased (all P<0.05). However, there were no statistical differences in the above indicators between 1-year and 2-year postoperative patients (all P>0.05). Two years after surgery, a total of 8 patients suffered from restenosis. There were statistical differences concerning age (≥70 years), the history of hypertension, diabetes, and coronary heart disease between the restenosis group and the non-restenosis group (all P<0.05). The results of multivariate analysis showed that the history of coronary heart disease and advanced age (≥70 years) were independent risk factors that affect the occurrence of postoperative restenosis.

CONCLUSION

The short- and long-term efficacy of intravascular stenting in the treatment of intracranial artery stenosis is significant. What's more, a history of coronary heart disease and advanced age (≥70 years) are independent risk factors contributing to postoperative restenosis.

A Retrospective Study Comparison Between Stenting and Standardized Medical Treatment for Intracranial Vertebrobasilar Stenosis in a Real-World Chinese Cohort

Background: To date, there has been no consensus regarding the benefits of percutaneous transluminal angioplasty and stenting (PTAS) vs. those of standardized medical treatment (SMT) for patients with symptomatic intracranial vertebrobasilar stenosis (IVBS). The purpose of this retrospective study was to compare the effects of PTAS or SMT on symptomatic IVBS in a real-world Chinese population.

Methods: We included 238 patients with ischemic stroke caused by IVBS stenosis who were admitted to Shandong Provincial Hospital Affiliated to Shandong University between September 2012 and May 2018; 62 of these patients were treated with SMT and 176 underwent PTAS. Ischemic stroke in the territory of the responsible artery, hemorrhage, and death within 1 year were recorded as primary endpoints. Secondary endpoints included assessment of stroke severity and the incidence of re-stenosis. The primary endpoint rates were compared between the PTAS and SMT groups at 7 days, 1, 6 months, and 1 year.

Results: In the PTAS group, the success rate of stent placement was 98.9%. During the entire trial, except for 7 days, the SMT group had a higher frequency of primary endpoint events than did the PTAS group. The primary endpoint was 17.7% (11/62) vs. 8.6% (15/174) at 1 month (p = 0.049), 29% (18/62) vs. 14.4% (25/174) at 6 months (p = 0.01), and 32.2% (20/62) vs. 17.2% (30/174) at 1 year (p = 0.013). The restenosis rate of the target lesion was 13.8%; 60% were symptomatic restenosis and 40% were asymptomatic restenosis. The rate of severe stroke at 1 year after PTAS was 0%, while that in the SMT group was 9.7%.

Conclusions: In a real-world Chinese cohort, PTAS for patients might be superior to SMT, and provide better long-term neurological function recovery and lower disability rate.

A Comparison of Safety and Effectiveness Between Wingspan and Neuroform Stents in Patients With Middle Cerebral Artery Stenosis

Background: Percutaneous transluminal angioplasty and stenting with the Wingspan stent has proven safe and effective in patients with middle cerebral artery stenosis (MCAS), but the off-label use of the Neuroform stent might be an alternative treatment. This study aimed to compare the safety and effectiveness of the above two intracranial stents in patients with MCAS. Methods: We retrospectively analyzed consecutive patients with symptomatic MCAS who had been treated with the Neuroform EZ or the Wingspan stent. A propensity score was generated to control for differences in baseline characteristics. The endpoints were the rate of peri-procedural complications within 30 days after stenting, the in-stent restenosis rate, and any target-vessel-related stroke or deaths during follow-up. Results: After matching for propensity score, the peri-procedural complication rate in the Wingspan group was 7.4% compared with 5.6% in the Neuroform group (p = 1.00), while the follow-up in-stent restenosis rates were 23.3 vs. 14.3%, respectively (p = 0.41). In the restenosis group, the patients tended to be younger (p < 0.01) and the degree of artery stenosis before stenting was higher (p < 0.01). Conclusion: This study indicated that in patients with symptomatic MCAS, Neuroform EZ stents are an alternative to Wingspan. Moreover, younger age and higher degree of artery stenosis before stenting might be a risk factor of in-stent restenosis.

Accuracy of Transcranial Doppler Ultrasound Compared with Magnetic Resonance Angiography in the Diagnosis of Intracranial Artery Stenosis

Background  One of the most common causes of acute cerebral infarction (ACI) is intracranial artery stenosis (ICAS). The goal of our study was to evaluate the accuracy of transcranial Doppler (TCD) compared with magnetic resonance angiography (MRA) for diagnosing ICAS in patients with ACI. Materials and Methods  Consecutive patients presenting with ACI to the neurology department underwent both MRA and TCD examination within 6 hours of difference. To calculate the agreement between the results of MRA and TCD, kappa coefficient test was used. Sensitivity, specificity, and positive and negative TCD predictive values have been calculated in comparison with MRA. Results  A total of 115 patients was included. There were 77 males (66.95%) and 38 females (33.04%). The mean age of patients was 68.32 ± 10.66 years (range 29-80). The agreement between TCD and MRA in detecting stenosis was 0.56 for anterior circulation artery (ACA), and 0.40 for posterior circulation artery. For the detection of ICAS, sensitivity, specificity, positive predictive value, and negative predictive values were 85.9, 90.0, 98.2, and 50.0% for anterior cerebral artery and 73.5, 86.7, 96.2, and 40.0% for posterior cerebral artery, respectively. Conclusions  Moderate agreement of anterior circulation stenosis and fair agreement for posterior circulation stenosis was found between TCD and MRA in the evaluation of ICAS. In anterior circulation, the diagnostic accuracy of TCD is higher compared with the posterior circulation.

Study of the Inflammatory Mechanisms in Hyperhomocysteinemia on Large-Artery Atherosclerosis Based on Hypersensitive C-Reactive Protein-A Study from Southern China

OBJECTIVE

To study the inflammatory mechanism of hyperhomocysteinemia on large-artery atherosclerosis based on hypersensitive C-reactive protein in patients.

METHODS

In all, 153 inpatients and 1357 physical examinees were selected. The levels of homocysteine were compared between the carotid/intracranial artery stenosis group and the nonstenosis group, between the carotid artery unstable plaque group and the nonplaque group, and between the intima-media thickness (IMT) greater than or equal to 1 group and the normal IMT group. The hypersensitive C-reactive protein levels were compared between the lacunar infarction (LI) group and the nonstroke control group and between the unstable plaque group and the nonplaque group.

RESULTS

Homocysteine level was significantly higher in the carotid/intracranial artery stenosis group than in the nonstenosis group, in the LI group than in the inpatient nonstroke group, and in the IMT greater than or equal to 1 group than in the normal IMT group. The hypersensitive C-reactive protein level was significantly higher in the LI group than in the nonstroke group and in the unstable plaque group than in the nonplaque group.

CONCLUSIONS

Hyperhomocysteinemia may aggravate the development of IMT, carotid atherosclerotic plaque instability, and carotid/intracranial artery stenosis by increasing inflammation, ultimately leading to the occurrence of LI. Hyperhomocysteinemia-induced inflammation mechanism warrants further study.

Endovascular treatment for symptomatic intracranial artery stenosis: protocol for a systematic review and network meta-analysis

INTRODUCTION

Atherosclerotic intracranial artery stenosis (ICAS) is one of most common causes of stroke, which is the second-leading cause of death worldwide. Medical, surgical and endovascular therapy are three major treatments for ICAS. Currently, medical therapy is considered as the standard of care for most patients with ICAS, while extracranial to intracranial bypass is only used in rare situations. Balloon angioplasty alone, balloon-mounted stent and self-expanding stent, collectively called endovascular treatment, have shown promising potentials in treating specific subgroups of patients with symptomatic ICAS; however, their comparative safety and efficacy is still unclear. Therefore, a systematic review with network meta-analysis is needed to establish a hierarchy of these endovascular treatments.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols was followed to establish this protocol. The search will be limited to studies published from 1 January 2000 to the formal search date. Major databases including Cochrane Library, MEDLINE, EMBASE, Chinese Biomedical Literature Database, conference proceedings and grey literature database will be searched for clinical studies comparing at least two interventions for patients with symptomatic ICAS. Primary outcomes include short-term and long-term mortality or stroke rate. Random effects pairwise and network meta-analyses of included studies will be performed on STATA (V.14, StataCorp, 2015). The surface under the cumulative ranking curve and mean rank will be calculated in order to establish a hierarchy of the endovascular treatments. Evaluation of the risk of bias, heterogeneity, consistency, transitivity and quality of evidence will follow the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions.

ETHICS AND DISSEMINATION

Ethics approval is not needed as systematic review is based on published studies. Study findings will be presented at international conferences and published on a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018084055; Pre-results.

Imaging characteristics and pathogenesis of intracranial artery stenosis in patients with acute cerebral infarction

The current study aimed to investigate the imaging characteristics and pathogenesis of intracranial artery stenosis in patients with acute cerebral infarction. In total, 84 patients diagnosed with acute cerebral infarction were recruited. Magnetic resonance angiography was performed to detect the existence of intracranial artery stenosis or occlusion. In addition, magnetic resonance imaging and diffusion weighted imaging were employed to analyze the infarction types and characteristics. In the majority of patients, the infarction resulted from internal carotid stenosis (77 cases; 91.7%), while it was caused by vertebral artery stenosis in a small number of cases (7 cases; 8.3%). Multiple infarction was identified the most common type of infarction among all cases (69.0%). The most common types of infarctions in the internal carotid system were multiple infarction implicating both the cortex and centrum ovale (23.4%), and internal watershed infarction (22.1%). Although the number of cases was relatively small, multiple infarction was observed to have a high incidence in the vertebral artery system. Bedside electrocardiogram was also recorded to determine the sinus rhythm and examine the abnormal hemodynamics. The sinus bradycardia rate of patients with multiple infarction was markedly greater in comparison with that in single infarction patients (χ²=0.01, P<0.05). Transcranial Doppler plus microembolus monitoring was utilized to explore the possible pathogenesis of all types of infarctions, such as arterial embolization. As compared with the single infarction patients, the embolus rate in patients with multiple infarction was notably increased by ~3.7-fold (χ²=8.65, P<0.05). In conclusion, the cerebral infarction was common in the internal carotid system, with multiple infarction observed in the majority of cases. The pathogenesis of cerebral infarction included arterial embolization and inadequate hemoperfusion.

Relationship of thyroid function with intracranial arterial stenosis and carotid atheromatous plaques in ischemic stroke patients with euthyroidism

This study aimed to help clarify the possible relationships of thyroid function with intracranial arterial stenosis or carotid atheromatous plaques in ischemic stroke patients with euthyroidism. We retrospectively reviewed the medical records of a consecutive series of ischemic stroke patients prospectively entered into the Chengdu Stroke Registry between February 2010 and March2012. We performed univariate and multivariate analysis to assess possible relationships of thyroid function with intracranial artery stenosis or carotid atheromatous plaques. Of the 172 patients analyzed (42 women; 61.7 ± 14.0 years old), 62 (32.0%) had carotid atheromatous plaques, and 81 (47.1%) had intracranial artery stenosis. Free thyroxine levels were lower in patients with carotid atheromatous plaques than in patients without plaques (15.80±2.09 vs. 16.92±2.69, P = 0.005). After adjusting for age, gender, hyperlipidemia, and previous smoking, free thyroxine levels were independently associated with carotid atheromatous plaques (OR 0.73, 95% CI 0.54-0.99, P = 0.04). In contrast, thyroid function indicators showed no associations with intracranial arterial stenosis. In conclusion, low free thyroxine levels were independently associated with carotid atheromatous plaques in ischemic stroke patients with euthyroidism, but thyroid function indicators were not associated with intracranial artery stenosis.

Role of sLOX-1 in intracranial artery stenosis and in predicting long-term prognosis of acute ischemic stroke

OBJECTIVE

The role of sLOX-1 in acute ischemic stroke still remains unclear. This study aims to demonstrate the value of sLOX-1 in evaluating degrees of intracranial artery stenosis and to predict prognosis in stroke.

METHODS

Two hundred and seventy-two patients were included in this study and basic data were collected within 72 hr on admission. We assessed the association between sLOX-1 levels and stroke conditions in one-year duration. After adjusting for potential confounders, regression analyses were performed.

RESULTS

We found that sLOX-1 levels were increased significantly in severe patients compared to the mild stroke group (p = .011). After adjusting confounders, sLOX-1 was associated with a poor functional outcome in patients with an adjusted OR of 2. 946 (95% CI, 1.788-4.856, p < .001). There was also positive correlation between sLOX-1 levels and the degrees of intracranial artery stenosis in the different groups (p = .029).

CONCLUSIONS

Our study demonstrated that sLOX-1 levels could be used to evaluate the severity of stroke and the degrees of intracranial artery stenosis. Furthermore, sLOX-1 could be exploited to predict the long-term functional outcome of stroke.

Smaller outer diameter of atherosclerotic middle cerebral artery associated with RNF213 c.14576G>A Variant (rs112735431)

Background:

Intracranial atherosclerosis (ICAS) involves diverse histologies and several remodeling patterns. Ring finger protein 213 (RNF213) c.14576G>A variant (rs112735431), recently reported to be associated with ICAS, may be linked with negative remodeling (outer diameter – reducing morphological alteration) of intracranial arteries. This study investigated the outer diameter of atherosclerotic middle cerebral artery (MCA).

Methods:

Patients with unilateral atherosclerotic MCA stenosis/occlusion were enrolled in this single-hospital-based case-control study at The University of Tokyo Hospital. The patients were divided into two groups by the presence of RNF213 c.14576G>A (variant group and wild-type group) and the outer diameter of the MCA was measured with high-resolution magnetic resonance imaging.

Results:

Twenty-eight patients with the wild type and 19 patients with the variant type were included. The outer diameter of the stenotic side MCA was smaller in the variant group than in the wild-type group (P = 8.3 × 10^-6). The outer diameter of the normal side MCA was also smaller in the variant group than in the wild-type group (P = 5.2 × 10^-3). The ratio of stenotic side to normal side was also smaller in the variant group than in the wild-type group (P = 1.5 × 10^-5).

Conclusions:

This study indicates that RNF213 c.14576G>A is associated with negative remodeling of ICAS.

Clinical usefulness of ankle brachial index and brachial-ankle pulse wave velocity in patients with ischemic stroke

Ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are widely used noninvasive modalities to evaluate atherosclerosis. Recently, evidence has increased supporting the use of ABI and baPWV as markers of cerebrovascular disease. This study sought to examine the relationship between ABI and baPWV with ischemic stroke. This study also aimed to determine which pathogenic mechanism, large artery disease (LAD) or small vessel disease (SVD), is related to ABI or baPWV. Retrospectively, 121 patients with ischemic stroke and 38 subjects with no obvious ischemic stroke history were recruited. First, ABI and baPWV were compared between the groups. Then, within the stroke group, the relevance of ABI and baPWV with regard to SVD and LAD, which were classified by brain magnetic resonance image (MRI) and magnetic resonance angiography (MRA) or computed tomography angiography (CTA) findings, was assessed. The baPWV was higher in the stroke group than non-stroke group (1,944.18±416.6 cm/s vs. 1,749.76±669.6 cm/s, P<0.01). Regarding LAD, we found that mean ABI value was lower in the group with extracranial large artery stenosis (P<0.01), and there was an inverse linear correlation between ABI and the grade of extracranial large artery stenosis (P<0.01). For SVD, there was a significant correlation between SVD and baPWV (2,057.6±456.57 cm/s in the SVD (+) group vs. 1,491±271.62 cm/s in the SVD (-) group; P<0.01). However, the grade of abnormalities detected in SVD did not correlate linearly with baPWV. These findings show that baPWV is a reliable surrogate marker of ischemic stroke. Furthermore, baPWV and ABI can be used to indicate the presence of small vessel disease and large arterial disease, respectively.

A Case of Recurrent Ischemic Stroke Involving Subacute, Progressive Intracranial Cerebral Arterial Sclerosis Prior to Diagnosis with JAK2-mutated Polycythemia Vera

CASE REPORT

A 58-year-old man presenting with no vascular risk factors visited our hospital with right hemiparesis and total aphasia. Diffusion-weighted magnetic resonance imaging of the brain showed multiple hyperintensities in watershed distributions in the left hemisphere. Magnetic resonance angiography (MRA) revealed stenosis of the middle cerebral artery, despite normal MRA findings 2 months prior. One year after the first stroke, the patient experienced a recurrent ischemic stroke involving the left anterior choroidal artery, pulmonary embolism, and deep venous thrombosis. After the recurrent stroke event, hemoglobin levels increased gradually. Two years after the first stroke, a JAK2V-617F mutation was detected.

CONCLUSION

Our report suggests that progressive intracranial arterial sclerosis and venous thrombosis of undetermined etiologies could be several initial symptoms of polycythemia vera.

Effects of cilostazol on the progression and regression of symptomatic intracranial artery stenosis: it reduces the risk of ischemic stroke

OBJECTIVE:

To assess the efficacy and safety of cilostazol on the progression and regression of symptomatic intracranial artery stenosis.

DATA RETRIVAL:

We searched the main databases for eligible trials including Medline (from 1966 to June 2014), Embase (from 1980 to June 2014), Cochrane Library (Issue 6, 2014), Chinese National Knowledge Infrastructure (from 1995 to June 2014), Current Controlled Trials (http://controlled-trials.com), Clinical Trials.gov (http://clinicaltrials.gov), and Chinese Clinical Trial Registry (http://www.chictr.org). All studies regarding prevention and treatment of symptomatic intracranial arterial stenosis by cilostazol were collected. The Mesh or text keywords were the English words: “cilostazol, phosphodiesterase 3 inhibitor, atherosclerosis, and ischemic stroke.” No restrictions were put on publications or publication language.

SELECTION CRITERIA:

Grade A or B randomized controlled trials were selected according to the quality of evaluation criteria from the Cochrane Collaboration, in which cilostazol and aspirin were used to evaluate the effects of cilostazol in the treatment of patients with symptomatic intracranial artery stenosis. The quality of study methodology was evaluated based on criteria described in Cochrane Reviewer's Handbook 5.0.1. RevMan 5.2 software was used for data analysis.

MAIN OUTCOME MEASURES:

Clinical efficacy and safety of cilostazol in stopping progression and promoting regression of symptomatic intracranial artery stenosis were measured by magnetic resonance angiography and transcranial Doppler.

RESULTS:

Two randomized controlled trials with a total of 203 patients were included in this study. The results showed that while cilostazol was associated with a significantly reduced progression of intracranial artery stenosis (OR = 0.21, 95%CI: 0.09–0.47, P < 0.01), it had no beneficial effect on symptom regression (OR = 1.42, 95%CI: 0.80–2.51, P = 0.24). During the follow-up period, although some adverse effects developed, including headache, gastrointestinal disturbance, and dizziness, incidences of bleeding were lower than in aspirin-treated patients.

CONCLUSION:

Cilostazol may prevent the progression of symptomatic intracranial artery stenosis, which could reduce the incidence of ischemic stroke.

Matrix metalloproteinase 9 level as an indicator for restenosis following cervical and intracranial angioplasty and stenting

Cervical and intracranial angioplasty and stenting is an effective and safe method of reducing the risk of ischemic stroke, but it may be affected by in-stent restenosis. The present study investigated serum level of matrix metalloproteinase 9 as a predictor of restenosis after 40 patients underwent cervical and/or intracranial angioplasty and stenting. Results showed that restenosis occurred in 30% (3/10) of patients when the serum level of matrix metalloproteinase 9 at 3 days after surgery was 2.5 times higher than preoperative level. No restenosis occurred when the serum level of matrix metalloproteinase 9 at 3 days after surgery was not 2.5 times higher than preoperative level. Restenosis occurred in 12% (2/17) of patients when the serum level of matrix metalloproteinase 9 was higher than preoperative level for more than 30 days after surgery, but only occurred in 4% (1/23) of patients when the serum level of matrix metalloproteinase 9 was higher than preoperative level for less than 30 days after surgery. However, the differences observed were not statistically significant (P > 0.05). Experimental findings indicate that when the serum level of matrix metalloproteinase 9 is 2.5 times higher than preoperative level at 3 days after cervical and intracranial angioplasty and stenting, it may serve as a predictor of in-stent restenosis.

Ischemic stroke in Takayasu's arteritis: lesion patterns and possible mechanisms

Background and Purpose

The purpose of the present study was to use brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) to identify the mechanism of stroke in patients with Takayasu's arteritis (TA).

Methods

Among a retrospective cohort of 190 TA patients, 21 (3 males and 18 females) with a mean age of 39.9 years (range 15-68 years) who had acute cerebral infarctions were included in lesion pattern analyses. The patients' characteristics were reviewed, and infarction patterns and the degree of cerebral artery stenosis were evaluated. Ischemic lesions were categorized into five subgroups: cortical border-zone, internal border-zone, large lobar, large deep, and small subcortical infarctions.

Results

In total, 21 ischemic stroke events with relevant ischemic lesions on MRI were observed. The frequencies of the lesion types were as follows: large lobar (n=7, 33.3%), cortical border zone (n=6, 28.6%), internal border zone (n=1, 4.8%), small cortical (n=0, 0%), and large deep (n=7, 33.3%). MRA revealed that 11 patients had intracranial artery stenosis.

Conclusions

Hemodynamic compromise in large-artery stenosis and thromboembolic mechanisms play significant roles in ischemic stroke associated with TA.

Cilostazol improves symptomatic intracranial artery stenosis - Evaluation of cerebral blood flow with single photon emission computed tomography

Background:

To evaluate the effectiveness of cilostazol in patients with intracranial arterial stenosis, we used magnetic resonance angiography (MRA). The drug's effect on the cerebral blood flow (CBF) was examined by single photon emission computed tomography (SPECT).

Methods:

In this retrospective study, we evaluated the clinical outcomes of 20 patients with stenosis in the M1 segment of the middle cerebral artery (MCA) who had suffered ischemic stroke within 12 weeks or manifested asymptomatic stenosis exceeding 50%. All patients received cilostazol (100 mg twice daily). MRA and SPECT (at rest and after acetazolamide challenge) studies were performed before and 6 and 12 months after the start of cilostazol treatment.

Results:

In 5 patients the stenotic lesion showed improvement on MRA. Mean stenosis before cilostazol therapy was 71.7 ± 4.9%, which improved to 39.0 ± 3.2% at 6 months and to 27.2 ± 2.8% at 12 months. SPECT study showed that CBF was improved in 3 patients; in one there was improvement at rest and the other 2 manifested improvement upon acetazolamide challenge.

Conclusions:

Cilostazol had a remodeling effect on stenotic lesions due to arteriosclerotic changes and improved CBF in some patients.