Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial

Predictors for recurrent ischemic stroke in patients with watershed infarct induced by intracranial artery stenosis

BACKGROUND AND PURPOSE

Symptomatic intracranial artery stenosis (sICAS) is strongly associated with an elevated risk of recurrent ischemic stroke, yet the underlying risk factors remain elusive. In this present study, we aimed to investigate the risk factors and predictive value of imaging features for recurrent ischemic stroke in patients with watershed infarction caused by ICAS.

METHODS

We prospectively collected clinical information and imaging data from patients with watershed infarction caused by ICAS. The primary outcome was recurrent ischemic cerebrovascular events in the same territory within 1 year. The original magnetic resonance images (MRI) were post-processed by the Fast-processing of ischemic stroke (F-Stroke) software to compute the perfusion parameters. The assessment of white matter hyperintensity (WMH) was performed in accordance with the Fazekas scale. Binary logistic regression analysis was performed to explore the association of imaging characteristics and recurrent ischemic stroke. Subsequently, we performed ROC curve analyses to determine their discriminatory capacity for ischemic stroke recurrence.

RESULTS

A total of 139 patients were successfully enrolled in the present study. The recurrence rate in the total population was 18.71 %. Compared with patients without recurrent ischemic stroke, those who experienced recurrence had a higher proportion of prior ischemic stroke history (25.66 % vs. 53.85 %) and severe WMH (30.77 % vs. 7.97 %), as well as higher baseline NIHSS scores and volume of Tmax > 4 s. Logistic regression analysis revealed that both the volume of Tmax > 4 s and severe WMH significantly influenced the risk of recurrent ischemic stroke occurrence. Furthermore, ROC curve analyses demonstrated that the discriminatory capacity of the volume of Tmax > 4 s (AUC = 0.64, 95 %CI = 0.51-0.77, P = 0.029) was marginally superior to WMH scores (AUC = 0.62, 95 %CI = 0.49-0.75, P = 0.066). Whereas, the combination of the volume of Tmax > 4 s and the WMH scores showed better discriminatory capacity (AUC = 0.73, 95 %CI = 0.61-0.85, P < 0.001).

CONCLUSION

MR-guiding cerebral hypoperfusion and severe WMH is susceptible to recurrence of ischemic stroke, thereby serving as valuable predictors for recurrence in patients with watershed infarction caused by ICAS.

Is invasive fractional flow measurement accurate in intracranial stenosis? A computational simulation study

BACKGROUND

In intracranial atherosclerotic stenosis (ICAS), low fractional flow (FF) may indicate hemodynamic significance.

OBJECTIVE

To investigate, using simulation models, whether invasive measurement could accurately reflect 'true' FF, when the catheter/pressure wire might disturb focal flow during measurement.

METHODS

We recruited 5 patients with high-grade, symptomatic M1 middle cerebral artery stenosis in three-dimensional rotational angiography (3DRA). In each case, the stenotic severity was manually manipulated to 50%, 60%, 70%, and 80%. At each stenotic severity, we simulated four situations: no catheter/pressure wire insertion ('in vivo' status); only catheter inserted proximally to the ICAS; catheter inserted and pressure sensor placed at 1 cm and 2 cm distally to the ICAS lesion. The blood flow was simulated with computational fluid dynamics modeling, and FF measured as post-stenotic and pre-stenotic pressure ratio. We calculated relative differences of FFs simulated at other situations compared with in vivo status.

RESULTS

Compared with in vivo status, catheter insertion had no significant influence on simulated FFs. With pressure wire passing through the ICAS, simulated FFs slightly decreased (mostly <10%) at 50% and 60% stenoses, which significantly decreased (up to 50% and 88%) at 70% and 80% stenoses. The effects of pressure wire on FFs were similar when the pressure sensor was placed at 1 cm and 2 cm distally to the ICAS.

CONCLUSIONS

Invasive measurement of FF may overestimate the hemodynamic significance of ICAS with severe stenosis, as the pressure wire may further reduce the flow across the small residual lumen. The findings warrant verification in larger-scale studies, with information on collateral circulation and validation with other imaging modalities.

Establishment and validation of a clinical prediction model for in-stent restenosis after intracranial and extracranial stent implantation

Objective

This study aims to analyze the risk factors for in-stent restenosis in patients who have undergone successful cerebral artery stent implantation and to develop a nomogram-based predictive model.

Methods

We utilized data retrospectively collected from 488 patients at Hebei Provincial People's Hospital between April 2019 and March 2024. After applying the inclusion criteria, 390 patients were further analyzed and divided into a training group (n = 274) and a validation group (n = 116). In the training group, we used univariate and multivariate logistic regression to identify independent risk factors for stroke recurrence and then created a nomogram. The nomogram's discrimination and calibration were assessed by examining various metrics, including the concordance index (C-index), the area under the Receiver Operating Characteristic (ROC) curve (AUC), and calibration plots. Decision curve analysis (DCA) was employed to evaluate the clinical utility of the nomogram by quantifying the net benefit for patients at different probability thresholds.

Results

The nomogram for predicting in-stent restenosis in patients undergoing cerebral artery stenting included seven variables: triglyceride-glucose index (TyG), presence of Diabetes Mellitus, postoperative dual antiplatelet therapy, body mass index (BMI), and preoperative MRS score. The C-index (0.807 for the training cohort and 0.804 for the validation cohort) indicated satisfactory discriminative ability of the nomogram. Furthermore, DCA indicated a clinical net benefit from the nomogram.

Conclusion

The predictive model constructed includes six predictive factors: TyG, presence of Diabetes Mellitus, postoperative dual antiplatelet therapy, BMI, and preoperative MRS score. The model demonstrates good predictive ability and can be utilized to predict ischemic stroke recurrence in patients with symptomatic ICAS after successful stent placement.

Design of the "EAST" strategy in patients with symptomatic intracranial atherosclerotic stenosis

Introduction

There is a high risk of stroke occurrence and recurrence in patients with intracranial atherosclerotic stenosis (ICAS) despite aggressive medical therapy. Evolocumab is a monoclonal antibody which can inhibit proprotein convertase subtilisin-kexin type 9 (PCSK9) and effectively reduce the level of low-density lipoprotein cholesterol. We hypothesize that evolocumab added to statin therapy (EAST) can stabilize intracranial plaques in patients with symptomatic ICAS.

Methods and analysis

This is a prospective, randomized, open-label, blinded end-point study, which will assess the efficacy and safety of evolocumab in patients with symptomatic ICAS. Eighty patients who suffer a stroke/transient ischemic attack (TIA) caused by ICAS recently will be randomly allocated in a 1:1 ratio to the evolocumab plus statin treatment group or the statin treatment group. High resolution vessel wall magnetic resonance imaging (HR-vwMRI) will be performed at recruitment and after 6 months and 12 months. The primary outcome is changes in plaque characteristics assessed by HR-vwMRI at 6th month and 12th month after treatment. Cognitive and neurological function will also be evaluated at recruitment and follow-up. This trial is being conducted at the first affiliated hospital of Nanjing medical university, China.

Ethics and dissemination

All participants will sign written informed consents. Peer-reviewed articles will be published to disseminate study outcomes.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT05741086.

Feasibility of emergent single-step intracranial self-expanding stent deployment using over-the-wire coronary balloons in intracranial atherosclerosis-related large vessel occlusion thrombectomy

BACKGROUND

The currently US Food and Drug Administration approved intracranial stent delivery system involves a multistep deployment process that requires the use of an exchange length microwire (ELW). In this study, we describe a single-step approach to deploy the Neuroform Atlas stent without the need for ELW or lesion re-access, using the MINI TREK II over-the-wire (OTW) semi-compliant coronary balloon.

METHODS

We performed a retrospective review of prospectively maintained mechanical thrombectomy databases from two comprehensive stroke centers. The study included consecutive large vessel occlusion (LVO) stroke patients who underwent single-step angioplasty with the MINI TREK II OTW balloon followed by deployment of the Neuroform Atlas intracranial stent, without the use of an ELW.

RESULTS

A total of 12 patients met the inclusion criteria. Among them, the median age was 67 years (IQR: 58-73) and 50% were female. Most patients had middle cerebral artery (MCA) M1 occlusion (75%). One-third of the patients received intravenous thrombolysis. All patients achieved successful reperfusion (modified Treatment in Cerebral Ischemia (mTICI) 2b/3) with a median of two passes. The median National Institutes of Health Stroke Scale (NIHSS) score decreased from 14 (IQR: 10-19) at baseline to 4 (IQR: 1-9) at discharge, and the median modified Rankin Scale (mRS) score was 1 (IQR: 1-4) at discharge and 3 (IQR: 2-4) at 90 days. None of the patients in this series experienced symptomatic intracranial hemorrhage, though two patients (16.7%) were dead at 90 days but there was no procedural-related mortality.

CONCLUSIONS

This preliminary experience demonstrates the technical feasibility and success of single-step deployment of the Neuroform Atlas stent following angioplasty with the MINI TREK II OTW balloon, without the need for an ELW or lesion re-access. Larger prospective studies with extended clinical follow-up are needed to validate these findings.

Stenting Versus Medical Therapy for Symptomatic Intracranial Artery Stenosis: Long-Term Follow-Up of a Randomized Trial

BACKGROUND

Whether the long-term benefit of stroke prevention when stenting is added to medical therapy (MT) over MT alone for symptomatic severe intracranial artery stenosis offsets the perioperative risks of the stenting has not been directly evaluated in a randomized trial. We aimed to compare the long-term (>3 years) effect of stenting versus MT alone in patients with symptomatic severe intracranial artery stenosis in a randomized trial.

METHODS

We extended the follow-up of 358 subjects enrolled in a multicenter, open-label, randomized trial conducted at 8 centers in China. Patients with transient ischemic attack or stroke attributed to severe intracranial stenosis (70% to 99%) were recruited between March 5, 2014, and November 10, 2016. The primary outcome was a composite of stroke or death within 30 days or stroke in the territory of the qualifying artery beyond 30 days. Other secondary outcomes included stroke in the territory of the qualifying artery, as well as disabling stroke or death after enrollment.

RESULTS

A total of 358 patients (stenting 176 versus MT 182) were recruited from March 5, 2014, and followed up till January 22, 2024. The median duration of follow-up was 7.4 years (interquartile range, 6.0-8.0). The primary outcome was not significantly different (stenting 14.8% versus MT 14.3%; hazard ratio, 1.02 [95% CI, 0.58-1.77]; P=0.97). No significant difference was found between groups for the secondary outcomes: stroke in the territory of qualifying artery (14.8% versus 14.3%; hazard ratio, 1.02 [95% CI, 0.58-1.77]; P=0.97), disabling stroke or death (16.5% versus 14.3%; hazard ratio, 1.12 [95% CI, 0.66-1.91]; P=0.70), and death (9.1% versus 7.1%; hazard ratio, 1.22 [95% CI, 0.58-2.58]; P=0.60).

CONCLUSIONS

This study provides compelling evidence that, even over prolonged observed periods, the addition of stenting to MT does not confer additional benefits to MT alone in patients with symptomatic severe intracranial artery stenosis. These results underscore the importance of MT as the cornerstone of long-term stroke prevention in this patient population.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01763320.

Stenting for Symptomatic Severe Intracranial Arterial Stenosis with Downstream Perfusion Deficit in Anterior Circulation: A Retrospective Propensity-Matched Study

PURPOSE

The purpose of this study is to investigate whether patients with symptomatic severe intracranial atherosclerotic stenosis (ICAS) and downstream perfusion deficit could benefit from adding percutaneous transluminal angioplasty and stenting (PTAS) to medical therapy.

MATERIALS AND METHODS

We retrospectively reviewed patients with symptomatic severe ICAS and an Alberta Stroke Program Early CT score of < 6 on mean transit time map who received either medical plus PTAS therapy (PTAS group) or medical therapy alone (medical group) between January 2016 and December 2019 at a single center. After 1:1 propensity score matching, we analyzed the primary outcome-cumulative event rate (defined as ischemic stroke in the qualifying artery)-along with four secondary outcomes (any intracranial hemorrhage within 30 days; disabling stroke or death; any stroke, transient ischemic attack, or cardiovascular events; and death by the end of follow-up).

RESULTS

A total of 145 patients (79 in the PTAS group, 66 in the medical group) were included. After PSM, during a median follow-up of 43 months, the cumulative event rate was significantly lower in the PTAS group (11.6% [5/43]) than in the medical group (34.9%[15/43]; hazard ratio:0.35; 95%CI:0.15-0.85; P = 0.034). No significant difference was found for the primary outcome of ischemic stroke within 30 days or 1, 2, and 3 years, or for other secondary outcomes.

CONCLUSIONS

PTAS combined with medical therapy was associated with a lower probability of ischemic stroke over three years of follow-up than medical therapy alone. These findings should be interpreted with caution due to the study's retrospective design and single-center setting.

Predictors of ischemic stroke recurrence in patients with symptomatic ICAS and contralateral high-grade stenosis

OBJECTIVE

This study aims to identify predictive factors for the recurrence risk of ischemic stroke in patients with symptomatic ICAS and contralateral high-grade stenosis (sICAS-CHS).

METHODS

We consecutively enrolled patients diagnosed with sICAS-CHS, which characterized by severe symptomatic intracranial artery stenosis (sICAS) alongside severe contralateral asymptomatic internal carotid artery or middle cerebral artery stenosis, confirmed by CT angiography (CTA). Over a one-year period, these patients were followed up to assess the recurrence risk of ischemic stroke. Binary logistic regression analysis was utilized to investigate the independent predictors of ipsilateral ischemic stroke recurrence within the territory of the symptomatic ICAS.

RESULTS

The study included 80 patients with sICAS-CHS, comprising 56 males (70 %) with an average age of 69.44 ± 9.97 years. Over the one-year follow-up period, 16 patients (20 %) experienced recurrent ischemic strokes. Binary logistic regression analysis revealed that presence of watershed infarction (OR=6.002, p = 0.019), hyperhomocysteinemia (OR=4.469, p = 0.039), medication adherence (OR=0.207, p = 0.034), and endovascular therapy (OR=0.084, p = 0.029) were independent predictors of ischemic stroke recurrence in this cohort.

CONCLUSIONS

Patients with severe sICAS-CHS portended a considerable high recurrence risk of ischemic stroke. It is advisable to prioritize these individuals for endovascular therapy, particularly those who have suffered watershed infarctions.

Percutaneous transluminal angioplasty and stenting (PTAS) in patients with symptomatic intracranial vertebrobasilar artery stenosis (IVBS)

BACKGROUND

Approximately 20% of all transient ischaemic attacks (TIAs) and ischaemic strokes occur within the posterior circulation, with vertebrobasilar stenosis identified as the cause in roughly 25% of the cases. Studies have shown that about a quarter of these patients have atherosclerotic stenosis of at least 50% of the vertebrobasilar artery. Stenosis has been shown to be associated with an increased risk of 90-day recurrent vertebrobasilar stroke, particularly in the first few weeks, which is significantly higher when compared with patients with stenosis of the anterior circulation. Therefore, aggressive treatment is important for the patient's prognosis. Stenting is emerging as a promising therapeutic strategy for persistent ischaemia events that do not respond to the best medical treatment, but it is not without complications. We systematically reviewed the literature on percutaneous transluminal angioplasty and stenting (PTAS) for intracranial vertebrobasilar artery stenosis (IVBS).

METHODS

PubMed, Web-of-Science and Scopus were searched upon the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to include prospective/retrospective cohort, randomised/non-randomised clinical trials and case series studies describing PTAS for IVBS. Pooled rates of intervention-related complications and outcomes were analysed with random-effect model meta-analysis using StataMP V.18.0 software.

RESULTS

31 studies were found eligible which included 1928 cases. 1103 basilar artery stenosis cases were reported in 27 studies 0.65 (95% CI 0.53, 0.76), I2: 99.72%. 648 vertebral cases were reported in 18 studies 0.60 (95% CI 0.49, 0.70), I2: 97.49%. In four studies, the rate of vertebrobasilar stenosis cases calculated as a proportion of the total sample size was 0.10 (95% CI 0.05, 0. 15). Mean stenosis in 21 included studies was found to be 0.83 (95% CI 0.79, 0.88), I2: 0.00%, which shows variation of baseline stenosis between studies was minimal. 51 deaths were recorded in 24 studies. Meta-analysis of mortality showed the overall rate of mortality was 0.03 (95% CI 0.02, 0.05), I2: 44.90%. In 14 studies, symptomatic intracranial haemorrhage events were recorded at an overall rate of 0.01 (95% CI 0.00, 0.02), I2: 0.00%. Generally, a follow-up period of at least 3 months was reported in the included studies. Furthermore, procedural stroke/TIA was evaluated in seven studies, four of which reported no events (0.03 (95% CI 0.00, 0.08), I2: 20.38%). Mean time from initial symptoms to recanalisation was 23.98 (95% CI 18.56, 29.40), I2=98.8%, p=0.00 days.

CONCLUSION

In certain individuals with medically unresolved, severe, symptomatic and non-acute IVBS, elective vertebrobasilar PTAS appears to be both safe and effective. Various stent designs and angioplasty-assisted techniques should be taken into consideration based on the specific clinical and radiological traits of the lesions. Future randomised controlled trials are required to verify these results.

DRug-coated Balloon for Endovascular treatment of sYmptOmatic intracraNial stenotic Disease (DR. BEYOND): the protocol of a multicentre randomised trial

BACKGROUND

Although endovascular stenting is considered an effective and safe therapeutic option for symptomatic intracranial atherosclerotic disease (sICAD), an elevated rate of restenosis remains an important issue for the conventional bare-metal stent (BMS). Recent evidence from observational studies suggests that applying drug-coated balloons (DCB) in sICAD may decrease restenosis occurrence. Additional large randomised studies are warranted to provide firmer evidence and to determine which patients would benefit most from DCB.

AIM

To design a randomised trial to examine DCB angioplasty (Taijieweiye intracranial paclitaxel-coated balloon catheter) versus BMS stenting (Wingspan intracranial stent system) in patients with sICAD.

DESIGN

This is a multicentre, prospective, randomised, open-label, blinded end-point study to assess whether DCB angioplasty reduces the risk of restenosis compared with BMS stenting in sICAD patients with high-grade stenosis (≥70%-99%). Our goal is to randomly assign 198 eligible individuals at a 1:1 ratio to undergo DCB angioplasty (intervention group) or BMS stenting (control group).

OUTCOME

The primary efficacy outcome is restenosis at 6 months post treatment, that is, >50% stenosis in or within 5 mm of the treated segment and >20% absolute luminal loss. The primary safety outcome is stroke or death within 30 days post treatment.

DISCUSSION

The DRug-coated Balloon for Endovascular treatment of sYmptOmatic intracraNial stenotic Disease trial aims to produce strong evidence on the efficacy and safety of DCB angioplasty as a promising therapeutic option for sICAD cases with high-grade stenosis.

Correlation of computed fractional flow and in-stent restenosis in patients with intracranial atherosclerotic stenosis

OBJECTIVE

Fractional flow (FF) reserve has been developed as a gold standard for coronary intervention. Intracranial FF is also a valuable hemodynamic index to assess the severity of narrowing in intracranial atherosclerotic stenosis (ICAS). This study aims to investigate the predictive value of FF in assessing restenosis following endovascular treatment in patients with symptomatic ICAS.

METHODS

This retrospective study recruited 67 patients with symptomatic ICAS who received intracranial stenting between March 2019 and January 2024. FF was measured by dedicated software (AccuICAD) before and after stenting. During follow-up, patients were categorized into two groups based on the occurrence of in-stent restenosis (ISR): ISR group and non-ISR group. Multivariate regression analysis and Kaplan-Meier survival analysis were performed to identify the predictive factors for ISR.

RESULTS

Post-FF was significantly different between the ISR and non-ISR groups (0.84±0.09 vs 0.92±0.06, respectively, P<0.01). Univariate and multivariate Cox regression analyses identified post-FF (HR 0.0, 95% CI 0.0 to 0.08, P=0.005) and smoking (HR 3.06, 95% CI 1.02 to 9.19, P=0.047) as the two predictors of ISR. Receiver operating characteristic curve analysis confirmed the predictive value of post-FF for ISR (AUC=0.783, 95% CI 0.645 to 0.920, P=0.003), with a cut-off value of 0.94. Kaplan-Meier survival analysis further demonstrated that patients with a post-FF value >0.94 had a significantly lower incidence of ISR (P=0.001).

CONCLUSION

In this study, post-FF effectively predicted ISR, providing an intraoperative evaluation value for stenting in ICAS.

Advances in endovascular thrombectomy for the treatment of acute ischemic stroke

INTRODUCTION

Acute ischemic stroke (AIS) is the second leading cause of death and one of the leading causes of long-term disability globally. Endovascular thrombectomy (EVT) has revolutionized treatment for large vessel occlusion (LVO), providing 20% increase in post-stroke functional independence compared to intravenous thrombolysis (IVT) alone. Despite its proven efficacy, EVT is underutilized. While it is suitable for at least 15-20% of AIS patients, its mean adoption ranges from less than 1% to 7% in different areas.

AREAS COVERED

This review highlights key findings from pivotal randomized controlled trials and real-world data, focusing on patient selection criteria, advancements in thrombectomy devices, and procedural innovations. A comprehensive literature search was performed using PubMed, Scopus, EMBASE and the Cochrane Library for relevant randomized controlled trials and observational studies.

EXPERT OPINION

Disparity in access to EVT requires strategic investments in healthcare systems and international multidisciplinary collaboration. Enhancing geographic coverage with thrombectomy-capable centers and optimizing prehospital triage systems are essential. Bridging the gap between treatment capability and real-world implementation is critical to improving global AIS outcomes.

Evaluation of Middle Cerebral Artery Culprit Plaque Inflammation in Ischemic Stroke Using CAIPIRINHA-Dixon-TWIST Dynamic Contrast-Enhanced Magnetic Resonance Imaging

BACKGROUND

Middle cerebral artery (MCA) plaques are a leading cause of ischemic stroke (IS). Plaque inflammation is crucial for plaque stability and urgently needs quantitative detection.

PURPOSE

To explore the utility of Controlled Aliasing in Parallel Imaging Results in Higher Acceleration (CAIPIRINHA)-Dixon-Time-resolved angiography With Interleaved Stochastic Trajectories (TWIST) (CDT) dynamic contrast-enhanced MRI (DCE-MRI) for evaluating MCA culprit plaque inflammation changes over stroke time and with diabetes mellitus (DM).

STUDY TYPE

Prospective.

POPULATION

Ninety-four patients (51.6 ± 12.23 years, 32 females, 23 DM) with acute IS (AIS; N = 43) and non-acute IS (non-AIS; 14 days < stroke time ≤ 3 months; N = 51).

FIELD STRENGTH/SEQUENCE

3-T, CDT DCE-MRI and three-dimensional (3D) Sampling Perfection with Application optimized Contrast using different flip angle Evolution (3D-SPACE) T1-weighted imaging (T1WI).

ASSESSMENT

Stroke time (from initial IS symptoms to MRI) and DM were registered. For 94 MCA culprit plaques, Ktrans from CDT DCE-MRI and enhancement ratio (ER) from 3D-SPACE T1WI were compared between groups with and without AIS and DM.

STATISTICAL TESTS

Shapiro-Wilk test, Bland-Altman analysis, Passing and Bablok test, independent t-test, Mann-Whitney U test, Chi-squared test, Fisher's exact test, receiver operating characteristics (ROC) with the area under the curve (AUC), DeLong's test, and Spearman rank correlation test with the P-value significance level of 0.05.

RESULTS

Ktrans and ER of MCA culprit plaques were significantly higher in AIS than non-AIS patients (Ktrans = 0.098 s-1 vs. 0.037 s-1; ER = 0.86 vs. 0.55). Ktrans showed better AUC for distinguishing AIS from non-AIS patients (0.87 vs. 0.75) and stronger negative correlation with stroke time than ER (r = -0.60 vs. -0.34). DM patients had significantly higher Ktrans and ER than non-DM patients in IS and AIS groups.

DATA CONCLUSION

Imaging by CDT DCE-MRI may allow to quantitatively evaluate MCA culprit plaques over stroke time and DM.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Deep learning network based on high-resolution magnetic resonance vessel wall imaging combined with attention mechanism for predicting stroke recurrence in patients with symptomatic intracranial atherosclerosis

Background

High-resolution magnetic resonance vessel wall imaging (HR-VWI) offers enhanced visualization of vascular structures, thereby facilitating the deep learning (DL) network's acquisition of more extensive and detailed image information. This study aimed to develop a high-precision integrated model leveraging DL with an attention mechanism based on HR-VWI for predicting recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS).

Methods

A retrospective study was conducted involving 363 sICAS patients who underwent HR-VWI, with data divided into a training set (n=254) from Center 1 (The First Affiliated Hospital of Xinxiang Medical University) and a test set (n=109) from Center 2 (The Sixth People's Hospital of Shanghai Jiao Tong University). Two convolutional neural network (CNN) models, ResNet50 and DenseNet169, were employed as feature extractors to capture image information from culprit plaques in HR-VWI. Integrating the Transformer attention mechanism, an advanced ensemble model, Trans-CNN, was constructed to predict stroke recurrence in sICAS patients. Model performance was evaluated using receiver operating characteristic (ROC) curves, with DeLong's test for comparing models. Additionally, decision curve analysis (DCA) and calibration curves were utilized to assess the model's practical and clinical value.

Results

Trans-CNN demonstrated superior predictive performance, outperforming other models in both the training and test sets. Specifically, in the training set, Trans-CNN achieved an area under the curve (AUC) of 0.951 [95% confidence interval (CI): 0.923-0.974], accuracy of 0.880 (95% CI: 0.797-0.937), sensitivity of 0.900 (95% CI: 0.836-1.000), and specificity of 0.882 (95% CI: 0.757-0.948). Similarly, in the test set, it achieved an AUC of 0.912 (95% CI: 0.839-0.969), accuracy of 0.858 (95% CI: 0.743-0.936), sensitivity of 0.880 (95% CI: 0.693-1.000), and specificity of 0.810 (95% CI: 0.690-0.976). The AUC improvement of Trans-CNN over all other models was statistically significant (DeLong's test, P<0.05). Calibration curve analysis revealed good agreement between predicted probabilities and observed outcomes in both sets. DCA further underscored the potential value of Trans-CNN in guiding clinical decision-making.

Conclusions

The integrated model combining DL with an attention mechanism based on HR-VWI exhibits excellent performance in assessing the risk of stroke recurrence in sICAS patients. This advancement holds significant potential in assisting clinicians in diagnosis and developing individualized treatment strategies.

Submaximal Angioplasty for Severe Intracranial Atherosclerotic Stenosis: Benefit of Revascularization at Last

Intracranial atherosclerotic stenosis is a leading cause of stroke with a significant risk of recurrent ischemic events despite aggressive medical management. The longstanding benefits of percutaneous angioplasty and stenting in coronary artery disease, where atherosclerosis is the overarching cause in nearly all cases, provided a compelling rationale for exploring similar interventions in intracranial atherosclerotic stenosis. However, 3 percutaneous angioplasty and stenting randomized trials showed negative or neutral results. The recent BASIS trial (Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis) was the first randomized trial in intracranial atherosclerotic stenosis to demonstrate the benefits of endovascular treatment, suggesting that submaximal balloon angioplasty might be in the sweet spot between mitigating early complications and securing long-term efficacy. These findings represent a significant advancement in the field, reinvigorating the goal of effective revascularization as a viable secondary prevention approach for intracranial atherosclerotic stenosis. However, several uncertainties still need to be addressed before the widespread implementation of angioplasty in clinical practice.

Efficacy and Safety of Initiating Intravenous Glycoprotein IIb/IIIa Inhibitors Before Acute Stent Implantation in Patients with Cerebral Infarction: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the safety and efficacy of initiating glycoprotein IIb/IIIa inhibitor (GPI) infusion prior to acute intracranial artery stent implantation.

METHODS

We performed a meta-analysis using RevMan software to calculate the pooled risk ratio and 95% confidence intervals (CIs) to assess efficacy and safety.

RESULTS

The systematic review and meta-analysis included 7 studies involving 1156 patients who underwent acute stent implantation. 1) Efficacy outcomes: GPI not significantly improved favorable 90-day functional outcome (P = 0.05, I2 = 0%, CI 1.14[1.00-1.30]). GPI significantly reduced perioperative stent thrombosis (P < 0.00001, I2 = 0%, CI 0.21[0.1-0.43]), the results did not indicate a significant advantage of GPI in recanalization (P = 0.53, I2 = 0%, CI 1.01[0.98-1.04]). 2) The findings showed that GPI did not result in a higher incidence of spontaneous intracerebral hemorrhage (P = 0.76, I2 = 0%, CI 0.93[0.59-1.48]), GPI not significantly improved favorable 90-day functional outcome in patients after stenting (P = 0.05, I2 = 0%, CI 1.14[1.00-1.30]). 3) Subgroup analysis: No statistically significant differences in recanalization (Thrombolysis in Cerebral Infarction ≥2b) (P = 0.9, I2 = 0%, CI 1.00[0.95-1.06]) and perioperative spontaneous intracerebral hemorrhage (P = 0.77, I2 = 5%, CI 1.50[1.01-2.22]) between the two groups, GPI was associated with a significant reduction in the incidence of perioperative stent thrombosis (P = 0.0003, I2 = 0%, CI 0.22[0.09-0.50]) and demonstrated an improvement in favorable clinical outcomes at 90 days after acute carotid stenting (P = 0.04, I2 = 1%, P= 0.001, CI 1.23[0.98-1.54]).

CONCLUSIONS

The use of intravenous GPI before acute stent implantation can reduce perioperative intravascular thrombosis but does not improve patient outcomes at 90 days. The use of intravenous GPI before carotid acute stenting may enhance 90-day outcomes and reduce perioperative stent thrombosis.

Lipoprotein(a), remote ischemic conditioning, and stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis

This study is to determine symptomatic intracranial atherosclerotic stenosis (ICAS), a significant stroke cause with high recurrence risks, by examining the relationship between lipoprotein(a) and ischemic stroke recurrence. Analyzing data from the RICA trial (chronic remote ischemic conditioning in patients with symptomatic ICAS) involving 1286 patients aged 40-80 years across 84 Chinese stroke centers, we found that participants with lipoprotein(a) levels above 17.4 ​mg/dL experienced markedly higher stroke recurrence rates (adjusted hazard ratio [HR], 1.38; 95 ​% CI, 1.05-1.80; P ​= ​0.02), with each doubling of lipoprotein(a) increasing recurrent stroke risk by 18 ​% (adjusted HR, 1.18; 95 ​% CI, 1.09-1.29; P ​< ​0.001). Notably, among high lipoprotein(a) participants, the remote ischemic conditioning group demonstrated a lower stroke incidence (16.7 ​%) compared to the control group (22.6 ​%), suggesting potential therapeutic benefits (adjusted HR, 0.67; 95 ​% CI, 0.47-0.96; P ​= ​0.03). The study revealed that elevated lipoprotein(a) levels are independently correlated with increased recurrent ischemic stroke risk in patients with symptomatic ICAS, and those with higher lipoprotein(a) levels might derive more clinical advantages from remote ischemic conditioning. Additional research is required to validate these results.

Higher Time to Peak after Stent Implantation in Symptomatic High-Grade Intracranial Atherosclerotic Stenosis is Related to In-Stent Restenosis

Little is known about the association between periprocedural hemodynamics and in-stent restenosis (ISR) following stent implantation in patients with symptomatic intracranial atherosclerotic stenosis (ICAS). This study aims to identify periprocedural hemodynamics that may be associated with ISR. Subjects were selected from the NOVA trial (The First-in-man Trial Evaluating the Safety and Efficacy of the NOVA Intracranial Stent Trial). ISR was defined as greater than 50% stenosis of the luminal diameter within or immediately adjacent to (within 5 mm) the implanted stent. Periprocedural hemodynamics, including cerebral blood flow, cerebral blood volume, mean transit time, and time to peak (TTP), were derived from the time-density curve generated from digital subtraction angiography using the fast Fourier transform algorithm. Of the 263 patients enrolled in the NOVA trial, 176 with symptomatic high-grade ICAS who underwent stent implantation were included in this study. Of these, 35 (19.9%) were diagnosed with ISR at the one-year follow-up. No significant differences in pre-procedure hemodynamics were observed between stent groups and between the ISR groups and the non-ISR group. Higher post-procedure TTP (OR, 1.95; 95% CI, 1.26-3.02), the use of bare-metal stents (OR, 5.40; 95% CI, 2.21-13.19), and higher post-procedure residual stenosis (OR, 1.08; 95% CI, 1.03-1.13) were independent factors associated with ISR. Higher post-procedure TTP, the use of bare-metal stents, and higher post-procedure residual stenosis were independent factors associated with ISR. The combined use of periprocedural hemodynamics and clinical factors may help predict ISR in patients with symptomatic high-grade ICAS.

A bibliometric and visualized analysis of interventional treatment for intracranial atherosclerotic stenosis (from 2004 to 2023)

Intracranial atherosclerotic stenosis is a notable factor leading to ischemic strokes, with a sustained elevated risk of recurrence despite intensive medical management. Recent years have witnessed a surge in research focusing on interventional strategies for addressing this condition. This study seeks to assess the current state and future development paths of interventional therapies for intracranial atherosclerotic stenosis, offering critical insights and recommendations for future research endeavors in this field. A comprehensive bibliometric evaluation was conducted using the bibliometric analysis tools VOSviewer_1.6.20 and CiteSpace 6.3.1, sourcing data from the Web of Science Core Collection database. This analysis encompassed literature related to interventional treatments for intracranial atherosclerotic stenosis from 2004 to 2023, supplemented by graphical illustrations. Following a thorough screening process, we identified 3,384 articles suitable for inclusion in this analysis. An observable increase in publication volume has been noted over the last two decades, with the United States leading in the number of publications. Interestingly, China has shown a significant rise in publication activity in recent years, with Capital Medical University being a prominent contributor. Noteworthy authors in this domain include Derdeyn, C.P. and Levy, E.I., and the Journal of Neurointerventional Surgery has emerged as the primary venue for these articles. The domain of interventional treatments for intracranial atherosclerotic stenosis presents considerable potential for future developments, highlighting the need for a concerted approach towards personalized and precise therapeutic strategies grounded in rigorous multicenter research.

Endovascular therapy versus best medical treatment for symptomatic intracranial atherosclerotic stenosis: A systematic review and meta-analysis

INTRODUCTION

Evidence on endovascular therapy (EVT) for symptomatic intracranial stenosis (sICAS) from randomized-controlled clinical trials (RCTs) is conflicting. While prior RCTs on percutaneous transluminal angioplasty and stenting (PTAS) demonstrated harm or no benefit over best medical treatment (BMT), recent data suggest that submaximal balloon angioplasty with BMT may be superior to BMT alone.

PATIENTS AND METHODS

A systematic review and meta-analysis of RCTs was conducted to evaluate the safety and efficacy of elective EVT plus BMT compared to BMT alone for sICAS.

RESULTS

Six RCTs (5 on PTAS and 1 on balloon-angioplasty) comprising 1606 patients were included. EVT increased the risk of any stroke or death (RR = 2.68; 95% CI: 1.72-4.19; I2 = 0%), ischemic stroke within the territory of the qualifying artery (RR = 2.51; 95% CI: 1.36-4.61; I2 = 0%), any ischemic stroke (RR = 1.99; 95% CI: 1.17-3.38; I2 = 0%), intracranial hemorrhage (RR = 6.23; 95% CI: 1.92-20.2; I2 = 0%), and mortality (RR = 3.52; 95% CI: 1.04-11.88; I2 = 0%) within 30 days. No significant benefit from EVT was detected regarding the risk of any stroke or death (RR = 0.29, 95% CI: 0.06-1.38; I2 = 68%), ischemic stroke in the territory of the qualifying artery (RR = 0.44, 95% CI: 0.14-1.33; I2 = 59%) and mortality (RR = 0.49, 95% CI: 0.16-1.55; I2 = 0%) beyond 30 days through 1 year.

DISCUSSION AND CONCLUSION

EVT is associated with adverse early outcomes, without reducing the risk of long-term stroke recurrence or mortality compared to BMT. Further research is warranted to identify high-risk subgroups who may benefit from EVT for sICAS and refine interventions to minimize periprocedural risks.

Mortality-Related Factors and 1-Year Survival in Patients After Intracranial Stenting for Intracranial Arterial Critical Stenosis and Occlusion

Background: Studies analyzing factors associated with mortality after intracranial stenting are limited. We aimed to investigate potential factors associated with 1-year mortality after urgent or elective intracranial stenting in those patients with intracranial atherosclerotic stenosis. Methods: Patients, who underwent urgent intracranial stenting of the target lesion either due to acute stroke unresponsive to mechanical thrombectomy, or who underwent elective stenting for symptomatic intracranial atherosclerotic stenosis were included in the study. The Modified Rankin Scale (mRS) score was evaluated on admission and grouped accordingly: ≤2 vs. >2. Restenosis and mortality rates in the 1-year follow-up were also analyzed. Results: A total of 60 patients were included in the study; the mean age was 60.2 (±10.8). The ratio of urgent/elective intracranial stenting was 7/53. Complete revascularization was achieved in all patients, but no periprocedural complications occurred. The rate of in-hospital mortality was 1/60, 1-year mortality due to any cause 4/60, and restenosis in a 1-year follow-up was 4/60. The age over 65 years, previous history of stroke, atrial fibrillation (AF), and rheumatic mitral valve disease were associated with mortality (p < 0.001, p = 0.002, p = 0.017, and p = 0.003, respectively). The median mRS score on admission was lower in the surviving patients at 1 year (p = 0.001). Conclusions: Intracranial stenting may provide long-term survival with low adverse event rates in elective and selected emergency cases. Advanced age, poor functional status, previous stroke, AF, and rheumatic mitral valve disease are associated with 1-year mortality.

Comparison of drug-coated balloon with bare-metal stent in patients with symptomatic intracranial atherosclerotic stenosis: the AcoArt sICAS randomized clinical trial

BACKGROUND

Restenosis after stenting with a standard bare-metal stent (BMS) is the main cause of stroke recurrence for symptomatic intracranial atherosclerotic stenosis (sICAS). Whether a drug-coated balloon (DCB) could reduce the risk of restenosis for such patients is unknown. We aimed to investigate the efficacy and safety of DCB in reducing 6 month restenosis in patients with sICAS.

METHODS

A prospective, multicenter, randomized, open-label, blinded endpoint clinical trial was conducted at 13 stroke centers across China. Eligible patients aged 18-80 years with sICAS defined as a recent transient ischemic attack (<180 days) or ischemic stroke (14-180 days) before enrollment attributed to a 70-99% atherosclerotic stenosis of a major intracranial artery were recruited between June 4, 2021 and September 15, 2022 (final follow-up: April 13, 2023). Patients were randomly assigned to receive a DCB (n=90) or BMS at a 1:1 ratio. The primary outcome was the post-procedure incidence of restenosis in the target lesion at 6 months (165-225 days). The safety outcome was post-procedure target vessel-related stroke (hemorrhage or ischemia) or death at 30 days.

RESULTS

Among 201 randomized patients, 180 were confirmed eligible (mean age 58 years) and completed the trial. Compared with BMS, DCB was associated with a lower rate of post-procedure incidence of restenosis in the target lesion at 6 months (6.9% vs 32.9%, OR 0.15, 95% CI 0.05 to 0.42, P=0.0003). Regarding the safety outcome, post-procedure target vessel-related stroke (hemorrhage or ischemia) or death at 30 days did not differ between the two groups (4.4% vs 5.6%, OR 0.79, 95%CI 0.21 to 3.05, P=0.73).

CONCLUSION

DCB was superior to BMS in reducing the incidence of restenosis without increasing the risk of target vessel-related stroke or death within 6 months. Further trials comparing the outcomes of DCB with medical management for sICAS are warranted.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04631055.

Clinical implications of haemodynamics in symptomatic intracranial atherosclerotic stenosis by computational fluid dynamics modelling: a systematic review

BACKGROUND

Recently, computational fluid dynamics (CFD) has been used to simulate blood flow of symptomatic intracranial atherosclerotic stenosis (sICAS) and investigate the clinical implications of its haemodynamic features, which were systematically reviewed in this study.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology statements, we searched PubMed and Embase up to March 2024 and screened for articles reporting clinical implications of haemodynamic parameters in sICAS derived from CFD models.

RESULTS

19 articles met the inclusion criteria, all studies recruiting patients from China. Most studies used CT angiography (CTA) as the source image for vessel segmentation, and generic boundary conditions, rigid vessel wall and Newtonian fluid assumptions for CFD modelling, in patients with 50%-99% sICAS. Pressure and wall shear stress (WSS) were quantified in almost all studies, and the translesional changes in pressure and WSS were usually quantified with a poststenotic to prestenotic pressure ratio (PR) and stenotic-throat to prestenotic WSS ratio (WSSR). Lower PR was associated with more severe stenosis, better leptomeningeal collaterals, prolonged perfusion time and internal borderzone infarcts. Higher WSSR and other WSS measures were associated with positive vessel wall remodelling, regression of luminal stenosis and artery-to-artery embolism. Lower PR and higher WSSR were both associated with the presence and severity of cerebral small vessel disease. Moreover, translesional PR and WSSR were promising predictors for stroke recurrence in medically treated patients with sICAS and outcomes after acute reperfusion therapy, which also provided indicators to assess the effects of stenting treatment on focal haemodynamics.

CONCLUSIONS

CFD is a promising tool in investigating the pathophysiology of ICAS and in risk stratification of patients with sICAS. Future studies are warranted for standardisation of the modelling methods and validation of the simulation results in sICAS, for its wider applications in clinical research and practice.

Comprehensive imaging analysis of intracranial atherosclerosis

Intracranial atherosclerotic disease (ICAD) involves the build-up of atherosclerotic plaques in cerebral arteries, significantly contributing to stroke worldwide. Diagnosing ICAD entails various techniques that measure arterial stenosis severity. Digital subtraction angiography, CT angiography, and magnetic resonance angiography are established methods for assessing stenosis. High-resolution MRI offers additional insights into plaque morphology including plaque burden, hemorrhage, remodeling, and contrast enhancement. These metrics and plaque traits help identify symptomatic plaques. Techniques like transcranial Doppler, CT perfusion, computational fluid dynamics, and quantitative MRA analyze blood flow restrictions due to ICAD. Intravascular ultrasound or optical coherence tomography have a very high spatial resolution and can assess the structure of the arterial wall and the plaque from the lumen of the target vascular territory. Positron emission tomography could further detect inflammation markers. This review aims to provide a comprehensive overview of the spectrum of current modalities for atherosclerotic plaque analysis and risk stratification.

Onyx frontier DES in the setting of intracranial atherosclerotic disease: multicenter retrospective insights from early clinical experience

BACKGROUND

Intracranial atherosclerotic disease (ICAD) is a leading cause of stroke, often refractory to aggressive medical therapy. Recent advancements in drug-eluting stents (DES) show promise for improved efficacy in intracranial applications relative to traditional ICAD treatments.

METHODS

We retrospectively collected all consecutive deployments of the Onyx Frontier [Medtronic, Santa Rosa, CA] stent in the setting of ICAD between August 2022 and August 2024 at six high-volume neuro-interventional centers across the US. Patients were included if their indication for stenting (eg, acute/recurrent stroke) was secondary to ICAD. Primary outcome was periprocedural stroke (<72 hours) and secondary outcomes included degree of pre- and post-stent vessel stenosis and National Institutes of Health Stroke Scale (NIHSS) scores at most recent follow-up. Secondary outcomes were assessed via paired t-tests.

RESULTS

Among 55 patients that met our inclusion criteria, the mean age was 62, mean presentation NIHSS was 10, and 40% were female. A total of 62 devices were used. Most common occlusion locations included the middle cerebral and internal carotid arteries. The periprocedural stroke rate was 10.9%, with a mortality rate of 1.8%. Mean vessel stenosis significantly decreased from 84.90% pre-stent to 2.00% post-stent (P<0.05). Mean NIHSS score improved from 10.37 preoperatively to 3.23 at follow-up (p<0.05). Procedural failure did not occur, however complications occurred in 16.4% of cases.

CONCLUSION

Our findings suggest that stenting in this setting results in a lower periprocedural stroke rate than appreciated in historical trials such as SAMMPRIS and VISSIT. However, recent CASSISS and BASIS trials demonstrate far reduced periprocedural stroke rates in the context of submaximal angioplasty for ICAD. This, in conjunction with complication rate, suggest that the Onyx Frontier, while promising, may not offer a definitive solution to ICAD.

Effects of different endovascular treatments on cerebral perfusion changes and stroke recurrence in patients with intracranial atherosclerosis

BACKGROUND

In patients with refractory intracranial atherosclerotic disease (ICAD), percutaneous transluminal balloon angioplasty (PTBA) is less complex but typically results in higher postprocedural residual stenosis than percutaneous transluminal angioplasty with stenting (PTAS).

METHODS

This study included patients with symptomatic ICAD with 70-99% stenosis treated with either PTBA or PTAS. All patients underwent preprocedural and postprocedural CT perfusion, which was processed by automated RAPID software. The rate of cerebral perfusion change was defined as the ratio of the volume of perfusion change to the preprocedural perfusion volume. Perioperative complications within a 30-day follow-up period were documented. Baseline characteristics, degree of stenosis before and after procedures, perioperative complications, and the rates of cerebral perfusion change were compared between groups. Patients were followed up for stroke recurrence within 1 year postprocedure, with survival analysis used to examine the relationship between procedure type and recurrence.

RESULTS

Between March and December 2021, 107 patients were enrolled: 30 (28.0%) were treated with PTBA and 77 (72.0%) with percutaneous transluminal angioplasty with stenting (PTAS). The PTBA group showed higher postprocedural residual stenosis than the PTAS group (P<0.004). The cerebral perfusion change rates were not significantly different between the groups (P=0.891). Three (3.9%) complications occurred in the PTAS group and none in the PTBA group during the 30-day follow-up. Stroke recurrence did not significantly differ between the procedures (P=0.960).

CONCLUSIONS

Immediate cerebral perfusion changes and the rate of stroke recurrences have no significant difference between the two groups.

Prevalence of intracerebral thrombus detected by optical coherence tomography in patients with posterior circulation stroke or transient ischemic attack

BACKGROUND

The incidence of thrombosis in patients with intracranial atherosclerotic stenosis (ICAS) remains unclear. Optical coherence tomography (OCT) has the potential to explore the vessel wall structure of posterior-circulation ICAS because of its relatively straight anatomical structure compared with that of the anterior cerebral arteries. This study aimed to determine the prevalence and characteristics of thrombosis in the posterior-circulation ICAS using OCT.

METHODS

This prospective study was conducted on 135 patients with posterior-circulation arterial stenosis who underwent OCT. All patients were symptomatic and had a severely stenotic lesion (70-99%) in the vetebrobasilar artery. The enrolled patients were classified according to the presence of in situ thrombus as defined by OCT. Clinical data and OCT characteristics were compared.

RESULTS

Eighty-two patients diagnosed with posterior-circulation ICAS were enrolled. In situ thrombi were identified in 34 patients. Clinically, patients with in situ thrombus were more prone to cerebral infarctions than transient ischemic attacks. The percentage area of stenosis in the non-thrombus group was significantly lower than that in the thrombus group. The thrombus burden, mean flow area, mean thrombus area, maximum lipid arc, and mean lumen area were significantly different among white, red, and mixed thrombi.

CONCLUSIONS

We achieved in vivo vessel wall structural analysis of posterior-circulation ICAS with the largest sample size. We also revealed the true incidence of in situ thrombosis and potential corresponding clinical events of posterior-circulation ICAS for the first time.

Prognostic value of angiographic based quantitative flow ratio and anatomic features in intracranial atherosclerotic stenosis

BACKGROUND

Patients with intracranial atherosclerotic stenosis (ICAS) are prone to stroke recurrence despite aggressive medical treatment. Further assessment of the anatomy and physiology of ICAS is urgently needed to facilitate individualized therapy. We explored the predictive value of angiography based hemodynamic and anatomical features for ICAS patients.

METHODS

In this retrospective study, patients with moderate-to-severe stenosis of the middle cerebral artery (MCA) were enrolled. The hemodynamic assessment was performed using the single view Murray's law based quantitative flow ratio (μQFR) approach. The locations of lesions were categorized as perforator rich segments of the MCA (pMCA) and others. Multivariate Cox models were developed to identify significant predictors. The primary outcomes were defined as stroke and transient ischemic attack.

RESULTS

Among the 333 patients (median (IQR) age, 56 (49-63) years, 70.3% men) over a median follow-up period of 64.5 months, 50 (15.0%) had the primary outcomes, and 80.0% occurred within 5 years. Patients with lower μQFR values (dichotomized at 0.73) had a higher risk of the 5 year primary outcomes (log rank P=0.023), and good collateral circulation may have attenuated the risk. In the multivariate analyses, μQFR (adjusted HR=0.345; 95% CI 0.155 to 0.766; P=0.009), lesion located in pMCA (adjusted HR=0.377; 95% CI 0.190 to 0.749; P=0.005), and diameter ratio of the internal carotid artery (adjusted HR=4.187; 95% CI 1.071 to 16.370; P=0.040) were significantly associated with the 5 year primary outcomes.

CONCLUSIONS

Angiography based μQFR and anatomical features, namely plaque localization and internal carotid artery expansion, could serve as promising prognostic indexes for MCA atherosclerosis.

Stenting versus medical treatment alone for symptomatic intracranial artery stenosis: a preplanned pooled individual patient data analysis

BACKGROUND

Whether the safety and efficacy of percutaneous transluminal angioplasty and stenting (PTAS) is significantly different from that of medical treatment alone for symptomatic intracranial arterial stenosis (ICAS) is debatable. A study was undertaken to determine the safety and efficacy of both treatments for symptomatic ICAS.

METHODS

This preplanned pooled individual patient data analysis included 400 participants treated with PTAS and 409 treated with medical treatment alone in two large multicenter randomized clinical trials (SAMMPRIS and CASSISS). Patients were treated with PTAS using a self-expanding stent or medical treatment alone. The primary outcome was stroke or death within 30 days, or ischemic stroke in the territory of the qualifying artery more than 30 days after enrollment.

RESULTS

Individual data were obtained for 809 patients, 451 from SAMMPRIS and 358 from CASSISS. 400 participants were randomly assigned to the PTAS group and 409 to the medical group. The risk of the primary outcome was not significant between the PTAS and medical groups (17.5% vs 13.2%; HR 1.37 (95% CI 0.96 to 1.95), P=0.08). However, the risk of stroke or death within 30 days was higher in the PTAS group (10.5% vs 4.2%; HR 2.62 (95% CI 1.49 to 4.61), P<0.001). Patients of white ethnicity (HR 1.97, 95% CI 1.17 to 3.31) and those with hyperlipidemia (HR 2.04, 95% CI 1.27 to 3.26) or a transient ischemic attack (TIA) (HR 2.19, 95% CI 1.08 to 4.45) were at higher risk for PTAS.

CONCLUSIONS

PTAS poses an increased risk of short-term stroke/death and therefore is not advised as primary treatment for symptomatic ICAS. A balance exists between stroke risks and revascularization benefits. For patients with asymptomatic ICAS of white ethnicity and those with hyperlipidemia or a history of TIA, a thorough assessment is warranted before considering PTAS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00576693, NCT01763320.

Impact of drug-coated balloon for vascular luminal dilatational remodeling after balloon angioplasty in intracranial atherosclerotic stenosis - a retrospective cohort study

OBJECTIVE

This study aimed to examine the effect of drug-coated balloons (DCBs) on vascular luminal dilatational remodeling (VLDR) following simple balloon angioplasty.

METHODS

A retrospective cohort study was conducted using data from patients diagnosed with intracranial atherosclerotic stenosis (ICAS), who were treated exclusively with balloon angioplasty at Henan Provincial People's Hospital between June 2019 and April 2023. Inverse probability weighting (IPW) was used to create balanced cohorts of patients who underwent drug-coated balloon angioplasty (DCBA) and plain old balloon angioplasty (POBA). The primary endpoint was VLDR occurrence during follow-up, with the effect of DCBA on VLDR assessed by adjusted multivariate regression.

RESULTS

The study included 110 patients who underwent simple percutaneous transluminal angioplasty, with 60 in the DCBA group and 50 in the POBA group. At follow-up, the stenosis rate in the DCBA group was lower than in the POBA group (P<0.001). The decrease in stenosis rate (DSR) was greater in the DCBA group compared with the POBA group (P<0.001). Nineteen patients (31.7%) in the DCBA group experienced VLDR, whereas only four (8%) in the POBA group developed VLDR, a statistically significant difference (P=0.002). After IPW adjustment, differences in stenosis rate (34.17 (20.00, 46.72) vs 46.00 (37.88, 70.00), P<0.001), DSR (-1.66 (-16.71, 11.40) vs -18.00 (-28.00, -3.00), P<0.001) and VLDR incidence (32.2% vs 9.9%, P<0.001) between the DCBA and POBA groups remained significant. Multivariate regression analysis identified DCBA as an independent factor influencing VLDR occurrence.

CONCLUSION

This study demonstrated that, compared with POBA, DCBA increases VLDR occurrence in ICAS patients during follow-up.

Hemodynamic evaluation of symptomatic and asymptomatic intracranial atherosclerotic stenosis using cerebral angiographic images: an exploratory study

BACKGROUND

Previous studies suggest that it may be inappropriate to determine treatment strategies solely based on the degree of stenosis for patients with intracranial atherosclerotic stenosis (ICAS). In order to better risk stratify patients with ICAS, we developed a novel non-invasive fractional flow (FF) calculation technique based on intracranial angiography (Angio-FF) to assess the hemodynamics for patients with ICAS. This study aims to investigate the difference in FF between symptomatic and asymptomatic patients with ICAS and its potential optimal threshold.

METHODS

A total of 124 patients with ICAS with severe intracranial stenosis who had undergone cerebral angiography were recruited. According to the time of onset, the patients were divided into a symptomatic ICAS group (n=78) and an asymptomatic ICAS group (n=46). The Angio-FF of each group was collected and compared. Receiver-operating characteristic curve (ROC) analysis was performed to assess the discriminative ability of Angio-FF to predict hemodynamics for ICAS.

RESULTS

Compared with the asymptomatic ICAS group, the symptomatic ICAS group had a significantly lower Angio-FF (0.75 (0.66-0.85) vs 0.85 (0.77-0.89), P<0.001). The optimal cut-off value of Angio-FF for distinguishing symptomatic ICAS from asymptomatic ICAS was 0.785 (sensitivity 71.74%, specificity 57.69%).

CONCLUSIONS

Patients with Angio-FF <0.7853 may be more prone to intracranial ischemic events. Angio-FF of 0.7853 can serve as a boundary for whether patients with ICAS exhibit clinical symptoms.

The Impact of Modified Body Mass Index on Clinical Prognosis in the Elderly With Acute Ischemic Stroke

OBJECTIVES

The modified body mass index (mBMI) combines the body mass index and serum albumin, accurately reflecting the nutritional status. It remains uncertain whether modified body mass index influences neurological function and clinical prognosis in elderly patients with acute ischemic stroke.

METHODS

We divided the cohort into quartiles of mBMI (1 to 4). The primary outcome was analyzed using the percentage of patients with a 90-day modified Rankin scale (mRS) score of 0 to 1. There were 7 secondary outcomes, including the disability level at 90 days and the National Institute of Health Stroke Scale (NIHSS) score at 14 and 90 days.

RESULTS

mBMI was negatively associated with clinical prognosis at 90-day mRS score in the primary outcome (β=-0.167; 95% CI -0.311 to 0.023, P =0.023). Moreover, mBMI1 (<896.72) and primary outcomes (β=0.438; 95% CI: -0.018 to 0.894) were positively correlated with higher mBMI. Moreover, the number and percentage of patients completing all the duties and activities are also higher. Age-adjusted Charlson comorbidity index (aCCI) and posterior circulation lesion were positively associated with the clinical prognosis 90-day mRS score in the primary outcome (β=2.218; 95% CI: 1.144-4.300, β=2.771; 95% CI: 1.700-4.516). However, BMI and serum albumin were not associated the with clinical prognosis primary outcome. BMI negatively correlates with secondary outcomes (NIHSS at discharge, β=-0.023; 95% CI: -0.102 to 0.057).

CONCLUSIONS

Our study revealed that mBMI and not BMI could be a better primary outcome predictor in the elderly with acute ischemic stroke, and lower mBMI showed a worse prognosis.

Demographic Characteristics and Treatment Outcomes of Intracranial Atherosclerosis Stenting: A Retrospective Case-Series of 216 Consecutive Patients

Background/Objectives: Intracranial atherosclerosis (ICAS) is a major cause of ischemic stroke, disproportionately affecting populations with significant vascular risk factors. Although ICAS imposes a considerable health burden, research on this condition in Central Asia remains scarce, especially among the Kazakh population. This study analyzes demographic characteristics, treatment outcomes, and procedural challenges associated with ICAS in 216 patients treated at a single institution. Methods: This retrospective study included patients with ≥70% intracranial artery stenosis confirmed by imaging and presenting with ischemic symptoms. All patients underwent angioplasty and stenting with dual antiplatelet therapy (DAPT). Data collected included demographics, comorbidities, stenosis characteristics, procedural details, and outcomes assessed by the modified Rankin Scale (mRS). Results: The median age was 63.5 years (IQR: 57-68.6), and 73.7% were male. Hypertension was the most common comorbidity (98%), followed by ischemic heart disease (58%) and diabetes mellitus (40.9%). Multi-location ICAS was significantly associated with patients over 75 years of age (p = 0.025). Additionally, obesity and stenosis severity greater than 70% showed trends toward significance, with p-values of 0.064 and 0.079, respectively. Stenosis predominantly affected the internal carotid artery (54.5%) and vertebrobasilar system (31.6%). The average hospital stay was longer for posterior circulation stenosis (7.1 days) compared to anterior circulation (4.7 days). The periprocedural complication rate was 0.7%, with two deaths attributed to ischemic complications. At follow-up, four patients experienced worsening mRS scores (>2), particularly those with severe stenosis in the basilar artery and M1 segment. Conclusions: ICAS in the Kazakh population is strongly associated with hypertension and aging, with posterior circulation stenosis contributing disproportionately to worse outcomes. The low complication rates highlight the safety of modern endovascular techniques. However, further research is needed to optimize treatment strategies for severe and multi-location ICAS, particularly in Central Asian populations.

Panvascular concept in the evaluation and treatment of intracranial atherosclerotic stenosis

Cerebrovascular disease is the leading causes of death and disability worldwide. Intracranial atherosclerotic stenosis (ICAS) is one of the major causes of ischemic stroke, especially in the Asian population. It is urgent to explore effective screening methods for early diagnosis to improve prognosis of patients with ICAS. Recently, the concept of panvascular medicine has provided a direction for the exploration of evaluation of ICAS. Based on the concept of "panvascular medicine," atherosclerosis is the common pathological feature of panvascular disease, such as ICAS and coronary artery disease (CAD). In-depth research on the formation and development of plaques, the development and application of more precise preoperative assessment and detection methods, and the utilization of new interventional equipment have greatly enhanced the precision of diagnosis and treatment of CAD. Studies attempt to apply similar evaluation and treatment in ICAS. The deeper understanding, the more accurate diagnosis and treatment, contributing to improve the prognosis of patients with ICAS. This review focuses on these evaluations and treatment of CAD applied in the field of ICAS.

Drug-eluting stents versus bare-metal stents for intracranial atherosclerotic stenosis: a systematic review and meta-analysis

BACKGROUND

In-stent restenosis (ISR) is the primary cause of stroke recurrence after intracranial stenting. Drug-eluting stents (DES) have recently shown great potential for reducing restenosis. This systematic review aimed to evaluate the efficacy and safety of DES compared with bare-metal stents (BMS) for intracranial atherosclerotic stenosis (ICAS).

METHODS

We systematically searched the MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, Embase (Ovid) and Web of Science databases for studies published from inception through 10 October 2023, comparing DES with BMS for the treatment of symptomatic severe ICAS. We included randomised controlled trials and cohort studies that compared DES and BMS in adult patients with ICAS. The primary outcomes were stroke or death within 30 days and ISR within 1 year. Secondary outcomes included procedure-related adverse events, technical success, functional evaluation findings, restenosis degree and other safety endpoints within 1 year. Subgroup analyses were conducted across different study types.

RESULTS

A total of 510 participants fulfilling all eligibility criteria were enrolled in four studies. DES had a similar rate of any stroke or death within 1 month (3 studies, 476 participants: risk ratio (RR): 1.00; 95% CI: 0.46 to 1.11; p=1.00; I2=31%) to that of the BMS group and had a significantly lower rate of ISR within 1 year (4 studies, 429 participants: RR: 0.23; 95% CI: 0.13 to 0.41; p<0.001; I2=0%). Moreover, a lower rate of stroke recurrence within 1 year was reported (3 studies, 436 participants: RR: 0.46; 95% CI: 0.24 to 0.88; p=0.02; I2=52%) in the DES group.

CONCLUSION

This review demonstrates that the application of DES for intracranial stenting is safe and can significantly reduce the rates of ISR and recurrent ischaemic events. Further research is required to validate these results.

PROSPERO REGISTRATION NUMBER

CRD42022338178.

Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND AND OBJECTIVES

Drug-coated balloons (DCBs) have exhibited promising results in coronary and peripheral artery diseases, but conclusive evidence is lacking in intracranial vasculature. We assessed the safety and efficacy of DCBs vs stent angioplasty for symptomatic intracranial atherosclerotic stenosis (sICAS) and initially identified patients who might have benefited most from DCB treatment.

METHODS

A single-center, retrospective cohort study was conducted from June 2021 to May 2022 with 154 patients with sICAS divided into 2 treatment groups: a DCB group (with or without remedial stenting, n = 47) and a stent group (n = 107). The treatment outcomes were compared using 1:2 propensity score matching. The primary safety end point was perioperative stroke or mortality, and the primary efficacy end point was the rate of target vessel restenosis at 12 months. The degree of luminal change was analyzed as a subgroup, defined as the difference between the degree of stenosis at follow-up and immediately after intervention.

RESULTS

One hundred eighteen patients were enrolled using propensity score matching, with 43 patients in the DCB group and 75 in the stent group. The incidence of perioperative adverse events was 2.3% in the DCB group and 8.0% in the stent group ( P = .420). At a median follow-up of 12 months, the incidence of restenosis (11.9% [5/43] vs 28.0% [21/75], P = .045) and the median degree of stenosis (30% [20%, 44%] vs 30% [30%, 70%], P = .009, CI [0-0.01, 0.2]) were significantly lower in the DCB group than in the stent group. DCB angioplasty effectively prevented adverse events in the target vessel area and significantly reduced the degree of luminal change in the M1 segment of the middle cerebral artery (0 [0, 15%] vs 10% [0, 50%], P = .016).

CONCLUSION

DCB angioplasty might be a safe and effective alternative to stent angioplasty to treat sICAS, particularly among patients with M1 segment of the middle cerebral artery stenosis.

Neuroprotection on ischemic brain injury by Mg2+/H2 released from endovascular Mg implant

Most acute ischemic stroke patients with large vessel occlusion require stent implantation for complete recanalization. Yet, due to ischemia-reperfusion injury, over half of these patients still experience poor prognoses. Thus, neuroprotective treatment is imperative to alleviate the ischemic brain injury, and a proof-of-concept study was conducted on "biodegradable neuroprotective stent". This concept is premised on the hypothesis that locally released Mg2+/H2 from Mg metal within the bloodstream could offer synergistic neuroprotection against reperfusion injury in distant cerebral ischemic tissues. Initially, the study evaluated pure Mg's neuroactive potential using oxygen-glucose deprivation/reoxygenation (OGD/R) injured neuron cells. Subsequently, a pure Mg wire was implanted into the common carotid artery of the transient middle cerebral artery occlusion (MCAO) rat model to simulate human brain ischemia/reperfusion injury. In vitro analyses revealed that pure Mg extract aided mouse hippocampal neuronal cell (HT-22) in defending against OGD/R injury. Additionally, the protective effects of the Mg wire on behavioral abnormalities, neural injury, blood-brain barrier disruption, and cerebral blood flow reduction in MCAO rats were verified. Conclusively, Mg-based biodegradable neuroprotective implants could serve as an effective local Mg2+/H2 delivery system for treating distant cerebral ischemic diseases.

Evaluation of safety and efficacy of intracranial self-expanding drug-eluting stents for symptomatic intracranial atherosclerotic stenosis: a prospective, multicentre, randomised controlled, superiority clinical trial protocol

BACKGROUND

In-stent restenosis (ISR) is a crucial factor that affects the long-term efficacy of intracranial bare metal stent (BMS) implantation for intracranial atherosclerotic stenosis (ICAS). Patients with intracranial ISR are at a high risk of recurrent ischaemic events. The NOVA intracranial drug-eluting stent (DES) trial demonstrates that a DES can reduce ISR and stroke recurrence after intracranial bare stent implantation. However, the application of balloon-expanded DES necessitates specific vascular conditions. The objective of this study is to assess the safety and efficacy of self-expanding DES for treating symptomatic ICAS (sICAS).

METHODS

This is a prospective, multicentre, randomised, controlled, superiority clinical trial that is conducted in 16 clinical trial centres in China. This study aims to recruit 208 patients with sICAS. Eligible subjects are randomly assigned to two groups at a ratio of 1:1. The experimental group is treated with DES (Xinwei intracranial DES system). The control group is treated with BMS (Wingspan intracranial stent system). All subjects are followed up within 7 days after surgery or before discharge; 30 days after surgery; and 6, 12 and 24 months after surgery. The primary outcome of the trial is the incidence of ISR at 6 months after surgery to verify the safety and efficacy of intracranial DESs. After 6 months of follow-up, the clinical summary report is issued for product registration application, and the follow-up of 12 months and 24 months after operation is conducted to evaluate the medium and long-term efficacy.

ETHICS AND DISSEMINATION

The study involving human participants is reviewed and approved by the Ethics Committee of Drugs (devices) Clinical Experiment in Henan Provincial People's Hospital (reference number: AF/SC-08/05.0) and other research centres participating in the clinical trial (supplemental file 2). The results yield from this study will be presented at international conferences and sent to a peer-reviewed journal to be considered for publication.

TRIAL REGISTRATION NUMBER

Registered on 2 November 2023 with Chinese clinical trial registry. Registration number is ChiCTR2300077271.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and Validation of a Flow-Dependent Endothelialized 3D Model of Intracranial Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is a major cause of stroke globally, with mechanisms presumed to be shared with atherosclerosis in other vascular regions. Due to the scarcity of relevant animal models, testing biological hypotheses specific to ICAD is challenging. We developed a workflow to create patient-specific models of the middle cerebral artery (MCA) from neuroimaging studies, such as CT angiography. These models, which can be endothelialized with human endothelial cells and subjected to flow forces, provide a reproducible ICAD model. Using imaging from the SAMMPRIS clinical trial, we validated this novel model. Computational fluid dynamics flow velocities correlated strongly with particle-derived flow, regardless of stenosis degree. Post-stenotic flow disruption varied with stenosis severity. Single-cell RNA-seq identified flow-dependent endothelial gene expression and specific endothelial subclusters in diseased MCA segments, including upregulated genes linked to atherosclerosis. Confocal microscopy revealed flow-dependent changes in endothelial cell proliferation and morphology in vessel segments related to stenosis. This platform, rooted in the specific anatomy of cerebral circulation, enables detailed modeling of ICAD lesions and pathways. Given the high stroke risk associated with ICAD and the lack of effective treatments, these experimental models are crucial for developing new ICAD-related stroke therapies.

Prevalence, diagnosis and management of intracranial atherosclerosis in White populations: a narrative review

BACKGROUND

Intracranial atherosclerotic disease (ICAD) represents a leading cause of ischemic stroke worldwide, conferring increased risk of recurrent stroke and poor clinical outcomes among stroke survivors. Emerging evidence indicates a paradigm shift, pointing towards increasing detection rates of ICAD among White populations and an evolving epidemiological profile across racial and ethnic groups. The present review aims to provide a comprehensive overview of ICAD, focusing on its pathophysiology, diagnostic approach, and evolving epidemiological trends, including underlying mechanisms, advanced neuroimaging techniques for diagnostic evaluation, racial disparities in prevalence, and current and emerging management strategies.

MAIN BODY

Atherosclerotic plaque accumulation and progressive arterial stenosis of major intracranial arteries comprise the pathophysiological hallmark of ICAD. In clinical practice, the diagnosis of intracranial artery stenosis (ICAS) or high-grade ICAS is reached when luminal narrowing exceeds 50% and 70%, respectively. Advanced neuroimaging, including high-resolution vessel wall MRI (HRVW-MRI), has recently enabled ICAD detection before luminal stenosis occurs. While earlier studies disclosed significant racial disparities in ICAS prevalence, with higher rates among Asians, Hispanics, and Blacks, recent evidence reveals rising detection rates of ICAD among White populations. Genetic, environmental and epigenetic factors have been suggested to confer an increased susceptibility of certain ethnicities and races to ICAD. Nevertheless, with improved accessibility to advanced neuroimaging, ICAD is increasingly recognized as an underlying stroke etiology among White patients presenting with acute ischemic stroke and stroke of undetermined etiology. While conventional management of ICAS entails risk factor modification, pharmacotherapy, and endovascular treatment in selected high-risk patients, substantial progress remains to be made in the management of ICAD at its early, pre-stenotic stages.

CONCLUSION

ICAD remains a critical yet underappreciated risk factor for ischemic stroke across all populations, highlighting the need for increased awareness and improved diagnostic strategies. The emerging epidemiological profile of ICAD across racial groups necessitates a reassessment of risk factors, screening protocols and preventive strategies. Future research should focus on refining the diagnostic criteria and expanding the therapeutic options to cover the full spectrum of ICAD, with the aim of improving patient outcomes and reducing the global burden of intracranial atherosclerosis and stroke.

Predictors and Outcomes of Periprocedural Intracranial Hemorrhage after Stenting for Symptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND AND PURPOSE

Periprocedural intracranial hemorrhage is one of common complications after stent placement for symptomatic intracranial atherosclerotic stenosis. This study was conducted to demonstrate predictors and long-term outcomes of periprocedural intracranial hemorrhage after stent placement for symptomatic intracranial atherosclerotic stenosis.

MATERIALS AND METHODS

We retrospectively analyzed patients with symptomatic intracranial atherosclerotic stenosis stent placement in a prospective cohort at a high-volume stroke center. Clinical, radiologic, and periprocedural characteristics and long-term outcomes were reviewed. Periprocedural intracranial hemorrhage was classified as procedure-related hemorrhage (PRH) and non-procedure-related hemorrhage (NPRH). The long-term outcomes were compared between patients with PRH and NPRH, and the predictors of NPRH were explored.

RESULTS

Among 1849 patients, 24 (1.3%) had periprocedural intracranial hemorrhage, including PRH (4) and NPRH (20). The postprocedural 30-day mRS was 0-2 in 9 (37.5%) cases, 3-5 in 5 (20.8%) cases, and 6 in 10 (41.7%) cases. For the 14 survivors, the long-term (median of 78 months) mRS were 0-2 in 10 (76.9%) cases and 3-5 in 3 (23.1%) cases. The proportion of poor long-term outcomes (mRS ≥3) in patients with NPRH was significantly higher than those with PRH (68.4% versus 0%, P = .024). Anterior circulation (P = .002), high preprocedural stenosis rate (P < .001), and cerebral infarction within 30 days (P = .006) were independent predictors of NPRH after stent placement.

CONCLUSIONS

Patients with NPRH had worse outcomes than those with PRH after stent placement for symptomatic ICAS. Anterior circulation, severe preprocedural stenosis, and recent infarction are independent predictors of NPRH.

Discontinuation of antiplatelet therapy after stent-assisted coil embolisation of cerebral aneurysm: a nationwide cohort study

INTRODUCTION

Stent-assisted coil embolisation (SACE) for the treatment of unruptured cerebral aneurysms has been increasingly used. Long-term advantages of antiplatelet therapy (APT) post-SACE treatment are still not well understood. We investigated the long-term effects of APT on clinical prognosis after SACE.

PATIENTS AND METHODS

We conducted a retrospective study using nationwide health insurance claims data from South Korea, including patients with cerebral aneurysm treated with SACE from January 2009 to December 2020. The study outcomes consisted of the occurrence of cerebral infarction and major haemorrhage. To evaluate the impact of APT, we employed a multivariable time-dependent Cox proportional hazards regression model for each of the three distinct periods: 1-12 months, 12-24 months and >24 months after SACE.

RESULTS

This study included 17 692 unruptured cerebral aneurysm patients treated with SACE. During the mean follow-up of 4.2 years, there were 379 (2.1%) patients with cerebral infarction and 190 (1.1%) patients with major haemorrhage. The percentage of patients receiving APT was 79.5% at 1 year, which gradually decreased to 58.3% at 2 years after SACE. APT was beneficial in preventing cerebral infarction within 12 months after SACE (adjusted HR (aHR) 0.56; 95% CI, 0.35 to 0.89; p=0.014). After 12 months, this association was not evident. APT increased the risk of haemorrhage after 24 months (aHR 1.76; 95% CI 1.11 to 2.87; p=0.016).

DISCUSSION AND CONCLUSION

Our findings suggest that in patients with unruptured cerebral aneurysm treated with SACE, the reasonable duration of APT for preventing cerebral infarction might be 1 year after SACE.

Edge-Type Hyperintense Intracranial Artery Plaque: A Potential MRI Biomarker of Stroke Recurrence

BACKGROUND

Identifying patients at high risk of stroke recurrence is important for stroke prevention and treatment.

PURPOSE

To explore the characteristics of T1 hyperintense plaques (HIP) and their relationship with stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis (sICAS).

STUDY TYPE

Retrospective.

POPULATION

One hundred fifty-seven patients with moderate-to-severe (≥50%) nonocclusive sICAS and MRI studies (42 females and 115 males, mean age 58.69 ± 10.68 years).

FIELD STRENGTH/SEQUENCE

3D higher-resolution black-blood T1-weighted fast-spin-echo sequence at 3.0 T.

ASSESSMENT

HIP (signal intensity [SI] of plaque-to-adjacent gray matter >1.0 on non-contrast T1-weighted images) and non-HIP plaques were identified. HIP plaques were categorized as edge type (high SI adjacent to lumen) and non-edge type (high SI within plaque). Clinical and imaging features of different plaque types were compared. Stroke recurrence was assessed through telephone or medical records at 3 and 6 months, and then once a year post-MRI. The relationship between edge type and non-edge types HIP with stroke recurrence was analyzed.

STATISTICAL TESTS

Student's t test, Mann-Whitney U-test, chi square test and Fisher's exact test to compare features between plaque types. Kaplan-Meier curves (with log-rank tests) and Cox proportional hazards regression to assess relationship between stroke recurrence and different plaque types. A two-tailed P-value of <0.05 was considered statistically significant.

RESULTS

Of 157 culprit lesions, 87 (55%) were HIPs (43 edge type, 44 non-edge type) and 70 (45%) were non-HIPs. Plaque thickness, area, and volume were significantly higher for HIPs than for non-HIPs. Among patients with HIPs, edge type was significantly more likely in the posterior circulation (53.5% vs. 27.3%), and had significantly higher plaque thickness, length, area, volume, plaque burden, and remodeling index than non-edge type. Edge-type HIP was significantly more common than non-edge HIP in patients with diabetes mellitus (51.2% vs. 29.5%) and dyslipidemia (79.1% vs. 54.5%). During median follow-up of 27 months, 33 patients experienced stroke recurrence. Recurrence was associated with edge-type HIP (adjusted hazard ratio = 2.83; 95% confidence interval: 1.40-5.69), both in the overall cohort (34.9% vs. 15.8%) and in patients with HIP (34.9% vs. 9.0%). Age ≥60 years and edge-type HIP had a significant interaction.

DATA CONCLUSIONS

Hyperintense plaque may be categorized as edge type or non-edge type. Edge-type HIP may be a potential MRI biomarker of stroke recurrence.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

PTP1B Modulates Carotid Plaque Vulnerability in Atherosclerosis Through Rab5-PDGFRβ-Mediated Endocytosis Disruption and Apoptosis

BACKGROUND

Protein tyrosine phosphatase 1B (PTP1B) is a protein tyrosine phosphatase and modulates platelet-derived growth factor (PDGF)/platelet-derived growth factor receptor (PDGFR) signaling in vascular smooth muscle cells (VSMCs) via endocytosis. However, the related molecular pathways that participated in the interaction of endo-lysosome and the trafficking of PDGFR are largely unknown. This study aims to determine the subcellular regulating mechanism of PTP1B to the endo-lysosome degradation of PDGFR in atherosclerotic carotid plaques, thereby offering a potential therapeutic target for the stabilization of carotid plaques.

METHODS

The immunohistochemical staining technique was employed to assess the expression levels of both PDGFR-β and Caspase 3 in stable and vulnerable carotid plaques. Tunnel staining was utilized to quantify the apoptosis of carotid plaques. Live-cell imaging was employed to observe endocytic motility, while cell apoptosis was evaluated through Propidium Iodide staining. In an in vivo experiment, ApoE-/- mice were administered a PTP1B inhibitor to investigate the impact of PTP1B on atherosclerosis.

RESULTS

The heightened expression of PDGFR-β correlates with apoptosis in patients with vulnerable carotid plaques. At the subcellular level of VSMCs, PDGFR-β plays a pivotal role in sustaining a balanced endocytosis system motility, regulated by the expression of Rab5, a key regulator of endocytic motility. And PTP1B modulates PDGFR-β signaling via Rab5-mediated endocytosis. Additionally, disrupted endocytic motility influences the interplay between endosomes and lysosomes, which is crucial for controlling PDGFR-β trafficking. Elevated PTP1B expression induces cellular apoptosis and impedes migration and proliferation of carotid VSMCs. Ultimately, mice with PTP1B deficiency exhibit a reduction in atherosclerosis.

CONCLUSION

Our results illustrate that PTP1B induces disruption in endocytosis and apoptosis of VSMCs through the Rab5-PDGFRβ pathway, suggesting a potential association with the heightened vulnerability of carotid plaques.

Single-Center Experience With Endovascular Therapy in Acute Occlusion of ICAS: Preferred Stent Thrombectomy Versus Preferred Angioplasty

OBJECTIVES

The preferred endovascular therapy (EVT) for large-vessel occlusion in intracranial atherosclerosis (ICAS) is unknown. We compared the efficacy of preferred stent thrombectomy and preferred angioplasty in patients with acute large-vessel occlusion in ICAS.

METHODS

Data from consecutive EVT patients (May 2020 to September 2023) with acute middle cerebral artery occlusion in ICAS were retrospectively analyzed. Preferred angioplasty was performed if there was a preoperative "microcatheter first-pass effect;" otherwise, preferred stent thrombectomy was performed. Analyses were grouped according to the two EVT treatments. Clinical data of all patients, including the time from puncture to recanalization, rate of successful reperfusion, early neurological improvement, intracranial hemorrhage, and modified Rankin Scale score at 90 days, were recorded and analyzed.

RESULTS

Six-two patients were enrolled in this study (mean age was 60.66±13.21 y, 22.6% female). The preferred angioplasty group had a higher first-pass recanalization rate than the preferred stent thrombectomy group (61.3% vs. 21.9%, P <0.001) and a higher proportion of patients who were functionally independent (defined as a modified Rankin Scale score of 0 to 3) at 90 days [odds ratio,3.681; 95% confidence interval (CI):1.009 to 13.428; P =0.048]. There was no significant difference between the groups in the time from puncture to recanalization, the frequency of successful reperfusion, and early neurological improvement, or intracranial hemorrhage ( P >0.05).

CONCLUSIONS

This study suggests that for acute middle cerebral artery occlusion in ICAS, preferred angioplasty may be a safe and effective procedure.