Intracranial artery stenosis or occlusion predicts ischemic recurrence after transient ischemic attack

Effects of endovascular recanalization on symptomatic non-acute occlusion of intracranial arteries

To investigate the effect and safety of recanalization surgery for non-acute occlusion of large intracranial arteries and factors affecting clincial outcomes. Patients with non-acute occlusion of internal carotid artery (ICA), middle cerebral artery (MCA), and vertebrobasilar artery (VBA) treated with recanalization were retrospectively enrolled. The clinical and angiographic data were analyzed. 177 patients were enrolled, including 67 patients with intracranial ICA occlusion, 52 with MCA occlusion, and 58 with VBA occlusion. Successful recanalization was achieved in 152 (85.9%) patients. Complications occurred in 15 patients (8.5%). Followed up for 3-7 months, the 90 day mRS was significantly improved compared with that before the procedure. Among 152 patients with successful recanalization, eight patients experienced reocclusion (5.3%), and 11 patients experienced restenosis (7.2%). Successful recanalization was significantly (P < 0.05) associated with occlusion duration, calcification or angulation of the occluded segment. Complications were significantly (P < 0.05) associated with location of occlusion, hyperlipidemia, and patients' height. Restentosis or reocclusion at follow-up was significantly (P < 0.05) associated with complications and mRS at 90 days. The significant (P < 0.05) independent risk factors were angulation and calcification for successful recanalization, hyperlipidemia for complications, and mRS at 90 days for restenosis or reocclusion at follow-up. Recanalization surgery may be a safe and effective approach for patients with non-acute symptomatic occlusion of large intracranial arteries, and factors significantly independently associated with successful recanalization, periprocedural complications and restenosis or reocclusion after surgery have been identified for future reference to improve clinical outcomes.

Association of occlusion time with successful endovascular recanalization in patients with symptomatic chronic intracranial total occlusion

OBJECTIVE

Endovascular treatment is one of the choices for symptomatic chronic intracranial total occlusion (CITO); however, its safety and efficacy remain unclear. The present study was performed to evaluate the safety and long-term outcome of endovascular treatment for CITO at a high-volume stroke center.

METHODS

Data about patients with symptomatic CITO who received endovascular treatment were retrospectively collected. Technique success was regarded as ≤ 30% residual stenosis. Periprocedural complications within 30 days were used to evaluate safety. Baseline characteristics and lesion features were compared between patients with successful recanalization and those with recanalization failure. Stroke recurrence and in-stent restenosis (ISR) of the culprit arteries during follow-up were used to evaluate long-term efficacy.

RESULTS

From June 2012 to September 2019, 117 patients (mean ± SD age 55.8 ± 9.6 years) were included. The successful recanalization rate was 82.9% (97/117 patients). The combined rate of periprocedural stroke, myocardial infarction, and death was 8.5% (10/117). Compared with patients with successful recanalization, patients with recanalization failure had longer occlusion time and longer lesion length (27.0 mm vs 15.4 mm, p = 0.001). In the median 23.0-month clinical follow-up period, recurrent stroke occurred in 12.6% (11/87) of patients with successful recanalization. In the median 5-month imaging follow-up period, ISR was detected in 26.6% (21/79) of patients.

CONCLUSIONS

Endovascular treatment was relatively safe for patients with symptomatic CITO. Shorter occlusion time and shorter lesion length may be associated with higher recanalization rate. The rates of stroke recurrence and symptomatic ISR were acceptable but need to be confirmed in future studies.

Elevated hs-CRP and Symptomatic Intracranial/Extracranial Artery Stenosis Predict Stroke Recurrence after Acute Ischemic Stroke or TIA

AIM

This study aimed to investigate the relationship between symptomatic or asymptomatic intracranial/extracranial artery stenosis and high-sensitivity C-reactive protein (hs-CRP) levels in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA).

METHODS

This study included 10404 patients from the Third China National Stroke Registry. Patients were divided into four or six groups according to patterns of intracranial or extracranial artery stenosis and hs-CRP levels. The outcomes were recurrence of ischemic stroke, stroke, and combined vascular events (CVE) at 1 year. The associations between different combinations of hsCRP levels and patterns of artery stenosis and recurrent events were analyzed by multivariable Cox regression models.

RESULTS

Patients in Group III (hs-CRP ＜3＋symptomatic intracranial or extracranial artery stenosis) had higher risk of recurrent ischemic stroke (adjusted hazard ratio (HR) 1.73, 95% confidence interval (CI) 1.20-2.48,p=0.003). Those in Group VI (hs-CRP ≥ 3＋symptomatic intracranial or extracranial artery stenosis) had the highest risk of recurrent ischemic stroke (HR 2.04, 95% CI 1.42-2.92, p=0.0001) within 1 year compared with Group I (hs-CRP ＜3＋no artery stenosis). Asymptomatic intracranial or extracranial artery stenosis did not increase the risk of ischemic events compared with no artery stenosis regardless of hs-CRP levels.

CONCLUSION

Symptomatic intracranial or extracranial artery stenosis was associated with increased risk of recurrent ischemic stroke, stroke, and CVE at 1 year in patients with AIS or TIA, especially in patients with elevated hs-CRP levels. Asymptomatic intracranial or extracranial artery stenosis did not increase the risk of ischemic events compared with no artery stenosis regardless of hs-CRP levels.

Coexistent cerebral small vessel disease and multiple infarctions predict recurrent stroke

Background and purpose

To investigate the association of different status of cerebral small vessel disease (CSVD) and infarction number with recurrence after acute minor stroke and transient ischaemic attack (TIA).

Methods

This study was a post hoc analysis of the Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial, and includes 886 patients with acute minor stroke and TIA. The status of CSVD and infarction number was recorded for each individual. Infarction number were classified as multiple acute infarctions (MAIs≥2), single acute infarction (SAI =1), and non-acute infarction (NAI =0). The CSVD burden were grouped into non-CSVD (0 score) and CSVD (1–4 score). The primary outcome was a recurrent stroke at the 1-year follow-up. The secondary outcomes were recurrent ischaemic stroke, composite vascular event (CVE), and TIA. We analyzed the relationships between different status of CSVD burden and infarction pattern with the risk of outcomes using multivariable Cox regression models.

Results

Among all 886 patients included in present analysis, recurrent stroke was occurred in 93 (10.5%) patients during 1-year follow-up. After adjusted for all potential covariates, compared with patients with non-CSVD and NAI, patients with CSVD and MAIs were associated with approximately 9.5-fold increased risk of recurrent stroke at 1 year (HR 9.560, 95% CI 1.273–71.787, p=0.028). Similar results observed in ischaemic stroke and CVE.

Conclusion

The status of CSVD and infarction number predicted recurrent stroke in patients with acute minor stroke and TIA, especially for those with coexistent CSVD and MAIs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-022-06027-6.

Circulating MicroRNAs as Potential Biomarkers for Ischemic Stroke in Patients with Asymptomatic Intracranial Artery Stenosis

Circulating microRNAs have been shown to be biomarkers of various diseases. We aimed to investigate whether circulating microRNA can serve as a biomarker to predict ischemic stroke risk in asymptomatic intracranial artery stenosis. A total of 716 participants from the Asymptomatic Polyvascular Abnormalities Community study who had asymptomatic intracranial artery stenosis at baseline were enrolled (2010-11). Patients who suffered incident ischemic stroke were classified into the case group, and age- and sex-matched individuals without stroke were used as controls. MicroRNA microarrays were used to distinguish baseline circulating serum microRNA levels between the case and the control groups (GEO accession number GSE201860). The differentially expressed microRNAs were validated by real-time PCR. MicroRNA microarrays were performed in baseline serum samples from12 subjects who developed ischemic stroke and 12 age- and sex-matched subjects without stroke during the 2014-15 follow-up period. Twenty microRNAs were differentially expressed between the two groups (fold change > 1.3 and p < 0.05 for all). Hsa-miR-486-5p, hsa-miR-92a-3p, hsa-miR-6089 from them were selected and validated in the baseline serum samples of ten subjects with incident ischemic stroke and another ten age- and sex-matched subjects without stroke during the 2016-17 follow-up period. Hsa-miR-1225-5p, with a large fold change value and a reported relationship with cardiovascular or cerebrovascular diseases, was also validated. Ultimately, only hsa-miR-6089 was differentially downregulated among patients with intracranial artery stenosis who developed ischemic stroke (p < 0.05). In patients with asymptomatic intracranial artery stenosis, downregulated serum hsa-miR-6089 may be associated with the risk of ischemic stroke.

A nomogram for predicting the in-hospital risk of recurrence among patients with minor non-cardiac stroke

BACKGROUND

Patients with minor stroke suffer a substantial risk of further recurrences, especially in the first two weeks. We aimed to develop and validate a prognostic nomogram to predict in-hospital stroke recurrence among patients with acute minor stroke.

METHODS

A total of 1326 patients with minor non-cardiac stroke (NIHSS) ≤5) from three centers were divided into development cohort (1016 patients from two centers) and validation cohort (310 patients from another center). Recurrent stroke was defined as a new ischemic stroke. A logistic regression model was employed to develop the nomogram to predict in-hospital stroke recurrence in patients with minor stroke using demographic, medical and imaging information. We then validated the nomogram externally. The predictive discrimination and calibration of the nomogram were assessed in the development and validation cohorts by area under the curve (AUC) and calibration plots.

RESULTS

During a median length of stay of 12 days, stroke recurrence occurred in 34 patients (3.3%). Predictors of in-hospital recurrence included prior history of transient ischemic attack, baseline NIHSS score, multiple infarctions, and carotid stenosis. The clinical and imaging-based nomogram B demonstrated adequate calibration and discrimination (AUC = 0.777), which was validated among 273 patients in a separate validation cohort (AUC = 0.753). Our clinical-imaging based nomogram was determined to be superior to the clinical-based nomogram and the RRE90 score in terms of discrimination.

CONCLUSION

A prognostic nomogram that integrates clinical and imaging information to predict the in-hospital risk of stroke recurrence among patients after acute minor stroke was constructed and validated externally. The nomogram demonstrated adequate calibration and discrimination in both the development and validation cohort.

Prevalence of Intracranial Atherosclerotic Disease in Patients with Low-Risk Transient or Persistent Neurologic Events

BACKGROUND AND PURPOSE

There are limited data on the prevalence and outcome of intracranial atherosclerotic disease in patients with low-risk transient or persistent minor neurologic events. We sought to determine the prevalence and risk factors associated with intracranial atherosclerotic disease in patients with low-risk transient or persistent neurologic events.

MATERIALS AND METHODS

Participants with available intracranial vascular imaging from the Diagnosis of Uncertain-Origin Benign Transient Neurologic Symptoms (DOUBT) study, a large prospective multicenter cohort study, were included in this post hoc analysis. The prevalence of intracranial atherosclerotic disease of ≥50% was determined, and the association with baseline characteristics and DWI lesions was evaluated using logistic regression.

RESULTS

We included 661 patients with a median age of 62 years (interquartile range, 53-70 years), of whom 53% were women. Intracranial atherosclerotic disease was found in 81 (12.3%) patients; asymptomatic intracranial atherosclerotic disease alone, in 65 (9.8%); and symptomatic intracranial atherosclerotic disease, in 16 (2.4%). The most frequent location was in the posterior cerebral artery (29%). Age was the only factor associated with any intracranial atherosclerotic disease (adjusted OR, 1.9 for 10 years increase; 95% CI, 1.6-2.5). Multivariable logistic regression showed a strong association between intracranial atherosclerotic disease and the presence of acute infarct on MR imaging (adjusted OR, 3.47; 95% CI, 1.91-6.25).

CONCLUSIONS

Intracranial atherosclerotic disease is not rare in patients with transient or persistent minor neurologic events and is independently associated with the presence of MR imaging-proved ischemia in this context. Evaluation of the intracranial arteries could be valuable in establishing the etiology of such low-risk events.

Predictive Value of the ABCD3-I for Short- and Long-Term Stroke after TIA with or without sICAS

Aims: We aimed to validate the predictive value of the ABCD3-I score for short-term and long-term stroke risk after transient ischemic attack (TIA) and to evaluate the influence of symptomatic intracranial artery stenosis (sICAS) on the performance of ABCD3-I.

Methods: We recruited TIA patients from the Third China National Stroke Registry study. Outcome parameters were stroke events during the 14-day, 3-month, 6-month, and 12-month points. The area under the curve (AUC) was calculated as a measure of predictive ability. A multivariable-adjusted Cox proportional hazards model was used to assess the hazard ratio of risk factors for stroke.

Results: Among 986 patients, 3.9%, 5.1%, 6.5 %, and 8.2% of participants experienced a stroke event during the 14-day, 3-month, 6-month, and 12-month points post TIA, respectively. The AUCs of ABCD3-I score for the prediction of stroke were 0.786, 0.732, 0.715, and 0.699 at the 14-day, 3-month, 6-month, and 12-month points, respectively. The AUCs were 0.774, 0.690, 0.617, and 0.611 in patients with sICAS, 0.789, 0.748, and 0.758 and 0.734 in those without sICAS. P values of the interaction between ABCD3-I categories and sICAS were 0.0618 for 14-day, 0.0098 for 3-month, 0.0318 for 6-month, and 0.0294 for 12-month.

Conclusions: ABCD3-I score performed well in predicting short-term risk of a stroke after an index TIA in patients with or without sICAS. However, the predictive power decayed with the prolonged period, and the decayed extent was more pronounced among those with sICAS. The assessment of sICAS is a non-ignorable item when using the ABCD3-I score for long-term stroke risk prediction in patients with TIA.

Cerebral large artery stenosis and occlusion in POEMS syndrome

BACKGROUND

This study aimed to investigate the frequency and risk factors for cerebral artery stenosis and occlusion in patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome.

METHODS

We reviewed results of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in 61 patients with POEMS syndrome seen between 2010 and 2017. Stenosis or occlusion was assessed in the initial MRA/CTA. Multivariate analysis was used to identify risk factors for artery stenosis/occlusion. In an autopsy case, pathologic examination was conducted of the occluded middle cerebral arteries.

RESULTS

Stenosis (> 50 %) or occlusion of the major cerebral arteries was found in 29 (47.5 %) patients on the initial MRA/CTA. The internal carotid artery was involved most frequently (32.8 %), followed by the anterior (21.3 %) and middle (16.4 %) cerebral arteries. The basilar (1.3 %) and vertebral (3.6 %) arteries were rarely affected. Cerebral infarction developed in eight (13.1 %) patients. The serum vascular endothelial growth factor (VEGF) level was an independent predictor for stenosis/occlusion (odds ratio, 1.228; 95 % confidence interval, 1.042-1.447; P = 0.014). An autopsy study showed occluded middle cerebral arteries by fibrous and myxomatous thickening of intima with splitting of the internal elastic lamina. Follow-up MRA in 23 patients showed improved, worsened, and unchanged stenosis in 20.7 %, 8.7 %, and 69.6 %, respectively.

CONCLUSIONS

Cerebral large-vessel stenosis or occlusion is frequently seen in approximately half of patients with POEMS syndrome. Vasculopathy was related to serum VEGF levels and thereby disease activity. Assessment of cerebral vessels is recommended in these patients to improve management.

Balloon-mounted stenting for ICAS in a multicenter registry study in China: a comparison with the WEAVE/WOVEN trial

Background

The outcome of deploying balloon-mounted stents for symptomatic intracranial atherosclerotic stenosis (ICAS) has not been fully investigated. In this study we evaluate the safety and long-term outcome of using balloon-mounted stents to treat symptomatic ICAS in comparison with the WEAVE/WOVEN study.

Methods

In a multicenter registry study of stenting for symptomatic intracranial artery stenosis in China, 159 patients treated with an intracranial balloon-mounted stent approved by the China Food and Drug Administration were evaluated. The morphological features of the lesions were categorized by Mori classification. The endpoints, including periprocedural and long-term clinical and radiological outcomes, were the same as those in the WEAVE/WOVEN study.

Results

In the present study the mean percent stenosis before and after stenting was 84.0% and 6.1%, respectively. The proportions of Mori A, Mori B, and Mori C lesions were 33.3%, 52.2%, and 14.5%, respectively. The 72-hour rates of stroke and mortality after the procedure were 0%. The 1-year rates of any stroke, ischemic stroke, hemorrhagic stroke, and death were 6.3% (10/159), 5.7% (9/159), 0.6% (1/159), and 0.6% (1/159), respectively. The 1-year rate of in-stent restenosis (ISR) was 23.4% (15/64). The rate of ISR in Mori C lesions (53.8%, 7/13) was significantly higher than that in Mori A (15.8%, 3/19) or Mori B lesions (15.6%, 5/32) (p=0.024).

Conclusions

The short-term and long-term outcomes of using a balloon-mounted stent for symptomatic ICAS with focal and non-angular lesions (Mori A and B type) and smooth arterial access were comparable to the results of the WEAVE/WOVEN trial.

Outcome of endovascular recanalization for intracranial in-stent restenosis

BACKGROUND AND PURPOSE

In-stent restenosis (ISR) is one of the long-term adverse outcomes of endovascular angioplasty and stenting for symptomatic intracranial arterial stenosis. In this study, we try to evaluate the safety and efficacy of endovascular treatment for intracranial ISR.

METHODS

We retrospectively collected patients with intracranial ISR who underwent endovascular treatment from June 2012 to August 2019 at a high-volume stroke center. Successful recanalization was defined as ≤30% residual stenosis. Stroke, myocardial infarction, and death after stenting within 30 days were used to evaluate periprocedural safety. Recurrent stroke in the territory of the culprit vessel and re-ISR in patients with clinical and vascular imaging follow-up data were used to evaluate the long-term outcome.

RESULTS

32 patients (59.6±7.2 years old) with ISR were recruited, including 22 patients (68.8%) treated with balloon dilatation, 8 patients (25%) with stenting, and 2 patients (6.3%) with failed procedures. Successful recanalization was achieved in 71.9% (23/32) of patients. There was no stroke, myocardial infarction or death within 30 days after the procedure. Recurrent stroke was found in 10.7% (3/28) of the patients, and re-ISR was found in 42.1% (8/19) of the patients. The re-ISR rate was lower in patients with stenting than in those with balloon dilatation (0% vs 57.1%, p=0.090), and in patients with successful recanalization than in those with unsuccessful recanalization (33.3% vs 75.0%, p=0.352), but with no statistically significant difference.

CONCLUSIONS

The periprocedural safety of endovascular treatment for intracranial ISR may be acceptable, but the long-term rates of recurrent stroke and re-ISR remain at high levels.

Elevated Neutrophil and Presence of Intracranial Artery Stenosis Increase the Risk of Recurrent Stroke

Background and Purpose- The association of neutrophil and intracranial artery stenosis (ICAS) with the prognosis of stroke is uncertain. This study evaluated the relationship between neutrophil levels with and without ICAS and the prognosis of patients with minor stroke or transient ischemic attack. Methods- Data from the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events) was reviewed. Patients were divided into 4 groups according to the dichotomy of neutrophil counts and status of ICAS. The primary outcome was a new stroke (ischemic or hemorrhagic), and secondary outcomes included a new composite vascular event (stroke, myocardial infarction, or cardiovascular death) and ischemic stroke. Safety outcome was any hemorrhage at 90 days. The association between neutrophil counts with and without ICAS and risk of any outcome was analyzed by Cox regression models. Results- Of 1034 patients included in this subgroup analysis, 91 had recurrent strokes. Compared with the lower neutrophil levels without ICAS, higher neutrophil levels with ICAS significantly increased the risk of stroke recurrence (adjusted hazard ratio, 2.26; 95% CI, 1.19-4.31; P=0.01) and composite outcome (adjusted hazard ratio, 1.98; 95% CI, 1.06-3.67; P=0.03). However, there was no safety issue. Conclusions- Concomitant presence of higher neutrophil levels and ICAS was associated with the increased risk of stroke recurrence, and combined adverse outcome events in patients already had minor ischemic stroke or high-risk transient ischemic attack. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00979589.

Assessment of cerebral infarction after transient cerebral ischemic attack by ABCD2 score combined with the position of intracranial vascular stenosis

This study aims to investigate the value of the ABCD score combined with the position of the offending vessel stenosis in predicting the risk of transient ischemic attack (TIA) to develop into cerebral infarction.The ABCD score and head magnetic resonance imaging + magnetic resonance angiography (MRA) results of 192 patients with TIA were retrospectively analyzed. With the 7th day as the endpoint time, these patients were divided into 3 groups, according to ABCD scores: low-risk group (n = 105), moderate-risk group (n = 60), and high-risk group (n = 27). Blood vessels were screened using head MRA results, and patients were accordingly divided into 2 groups: proximal vascular stenosis group (n = 71) and nonproximal vascular stenosis group (n = 171). Then, the association of the position of the intracranial vascular stenosis and ABCD score with short-term prognosis was analyzed.Based on the ABCD score, the incidence of cerebral infarction after 1 week was significantly higher in the high-risk group (85.7%) than in the moderate-risk group (16.7%) and low-risk group (1.9%), and the differences were statistically significant (P < .05). When the ABCD score was ≥4 points, the incidence of cerebral infarction after 1 week was significantly higher in the proximal vascular stenosis group (59.1%) than in the nonproximal vascular stenosis group (30.8%), and the difference was statistically significant (P < .05). When the ABCD score was <4 points, the incidence of cerebral infarction after 1 week in the proximal stenosis group (2%) was not significantly different from that in the nonproximal stenosis group (1.9%, P > .05).The ABCD score combined with proximal offending vessel stenosis can improve the short-term prediction of cerebral infarction in patients with TIA.

CHA2 DS2 -VASc scores for outcome prediction in acute ischaemic stroke

BACKGROUND

The CHADS₂ and CHA₂ DS₂ -VASc scores are clinical risk stratification instruments that are used clinically to assess the risk of stroke in patients with atrial fibrillation (AF). The aim of this study was to evaluate whether the prestroke CHADS₂ and CHA₂ DS₂ -VASc scores could be useful for predicting infarction severity and long-term outcomes in patients with acute ischaemic stroke.

MATERIALS AND METHODS

This prospective study included all 1494 patients who had acute ischaemic stroke without haemorrhagic transformation which was evidenced with magnetic resonance (MR) imaging during hospitalization. Total infarction volume and arterial stenosis score were calculated based on MR imaging. National Institutes of Health Stroke Scale scores (NIHSSs) were obtained at admission and discharge by board-certified neurologists. The clinical outcomes were defined as composite endpoints of restroke and mortality and were recorded with the mean follow-up period of 37.5 months.

RESULTS

There were 195 (13.1%) patients with AF. The patients with AF had significantly higher median CHADS₂ and CHA₂ DS₂ -VASc scores than the patients without AF (P < .001). Patients with higher CHADS₂ and CHA₂ DS₂ -VASc scores had significantly higher total infarction volume, arterial stenosis score and NIHSS scores at discharge and poorer clinical outcomes. After adjusting for age, gender and AF, only CHA₂ DS₂ -VASc scores could predict both restroke and composite endpoints.

CONCLUSIONS

Prestroke CHA₂ DS₂ -VASc scores appear to have better clinical value for predicting the severity of infarction and long-term clinical outcomes in acute ischaemic stroke patients with and without AF.

Predictors of Stroke Events in Patients with Transient Ischemic Attack Attributable to Intracranial Stenotic Lesions

Objective The purpose of this study was to identify the predictors of subsequent ischemic stroke events in patients with transient ischemic attack (TIA) attributable to intracranial arterial occlusive lesions. Methods The study population included 82 patients (55 men; mean age, 69.3±12.1 years) with TIA caused by intracranial arterial occlusive lesions who were admitted to our stroke care unit within 48 h of the onset of a TIA between April 2008 and November 2015. TIA was diagnosed if focal neurological symptoms ascribable to a vascular etiology lasted less than 24 h, irrespective of the presence of ischemic insults on imaging. The primary endpoint was an ischemic stroke event within 90 days of the onset of a TIA. Results The 90-day risk of ischemic stroke after the onset of a TIA was 14.6% [95% confidence interval (CI): 8.6-23.9%]. Cox proportional hazards multivariate analyses revealed that diffusion-weighted imaging (DWI) positivity [hazard ratio (HR), 8.73; 95%CI, 2.20-41.59; p=0.002], prior ischemic stroke (HR, 4.03; 95%CI, 1.07-15.99; p=0.040), and a high serum level of alkaline phosphatase (ALP) on admission (HR, 1.15; 95%CI, 1.05-1.26; p=0.002, for every +10 U/L) were significant independent predictors of ischemic stroke within 90 days after the onset of a TIA. Conclusion Our results suggested that patients with a TIA attributable to intracranial artery disease who showed DWI lesions, prior ischemic stroke, or high serum levels of ALP on admission were at high risk of subsequent ischemic stroke events.

High-sensitive C-reactive protein and dual antiplatelet in intracranial arterial stenosis

Objective

To determine the relationship of high-sensitive C-reactive protein (hsCRP) and the efficacy and safety of dual antiplatelet therapy in patients with and without intracranial arterial stenosis (ICAS) in the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial.

Methods

A subgroup of 807 patients with both magnetic resonance angiography images and hsCRP measurement was analyzed. Cox proportional hazards models were used to assess the interaction of hsCRP levels with the effects of dual and single antiplatelet therapy.

Results

A total of 358 (44.4%) patients had ICAS and 449 (55.6%) did not. The proportion of patients with elevated hsCRP levels was higher in the ICAS group than in the non-ICAS group (40.2% vs 30.1%, p = 0.003). There was significant interaction between hsCRP and the 2 antiplatelet therapy groups in their effects on recurrent stroke after adjustment for confounding factors in the patients with ICAS (p = 0.012), but not in those without (p = 0.256). Compared with aspirin alone, clopidogrel plus aspirin significantly reduced the risk of recurrent stroke only in the patients with ICAS and nonelevated hsCRP levels (adjusted hazard ratio 0.27; 95% confidence interval 0.11 to 0.69; p = 0.006). Similar results were observed for composite vascular events. No significant difference in bleeding was found.

Conclusions

Presence of both ICAS and nonelevated hsCRP levels may predict better response to dual antiplatelet therapy in reducing new stroke and composite vascular events in minor stroke or high-risk TIA patients. Further large-scale randomized and controlled clinical trials are needed to confirm this finding.

Angioplasty, Stenting and Other Potential Treatments of Atherosclerotic Stenosis of the Intracranial Arteries: Past, Present and Future

Although there is an intuitive appeal to treat symptomatic stenotic intracranial arteries with endovascular therapies such as angioplasty and stenting, current data from randomized trials show intensive medical therapy is far superior for preventing stroke. This is in large part due to the high risk of peri-procedural stroke from angioplasty and stenting. If angioplasty and stenting is to emerge as a proven treatment for intracranial stenosis, endovascular techniques will need to become much safer, identification of patients with intracranial stenosis who are at particularly high risk of stroke despite intensive medical therapy will need to be targeted, and well-designed randomized trials will be necessary to show endovascular therapy is superior to medical therapy in these high-risk patients.

Fast acceleration of ASL-based time-resolved magnetic resonance angiography by acquisition of control and labeled images in the same shot (fast ACTRESS): An optimization study

PURPOSE

To establish an optimized sequence design for fast acceleration of arterial spin labeling (ASL)-based time-resolved magnetic resonance angiography (MRA) by acquisition of control and labeled images in the same shot (fast ACTRESS) and a scan time of <1min, for the evaluation of intracranial vessels.

MATERIALS AND METHODS

Ten healthy volunteers with no unilateral symptomatic arterial stenosis, who underwent 3-tesla MRI, were investigated. Imaging parameters for the fast ACTRESS sequence were set with an acquisition time of 45s. During post-processing, the first phase in the multi-phase readout, which was defined as the control image, was subtracted from each of the other phases. Thus, four-dimensional (4D)-MRA images of each phase were obtained. The maximum intensity projection was used for the reconstruction of 4D-MRA images and time-to-signal intensity curves (TIC) obtained for each vessel. The area under the curve (AUC), peak time, and maximum signal intensity were obtained from TIC. The different labeling types were broadly divided into six groups: L1, L2, L3, L4, L5, and L6 according to the actual number of labeling pulse.

RESULTS

A total of 5040 regions of interest were evaluated. The peak SI of L3, except for those in the A2 segment of the anterior cerebral artery, was significantly higher than that of L5. However, there were no significant differences between L4 and L5. Although the AUCs of L3 and L4 for anterior circulation were relatively higher than that of the other subgroups, the AUC of L3 was significantly higher than that of L4.

CONCLUSION

The fast ACTRESS was optimized and indicated that the labeling type of L3 was the most appropriate for the well visualization of intracranial arteries. The fast ACTRESS sequence was useful to acquire well-delineated images of intracranial vessels in ˂1min.

Association of multiple infarctions and ICAS with outcomes of minor stroke and TIA

OBJECTIVE

To estimate the association of different patterns of infarction and intracranial arterial stenosis (ICAS) with the prognosis of acute minor ischemic stroke and TIA.

METHODS

We derived data from the Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. A total of 1,089 patients from 45 of 114 participating sites of the trial undergoing baseline MRI/angiography were included in this subgroup analysis. Patterns of infarction and ICAS were recorded for each individual. The primary efficacy outcome was an ischemic stroke at the 90-day follow-up. We assessed the associations between imaging patterns and prognosis of patients using multivariable Cox regression models.

RESULTS

Among the 1,089 patients included in this subgroup analysis, 93 (8.5%) patients had a recurrent ischemic stroke at 90 days. Compared with those without infarction or ICAS, patients with single infarction with ICAS (11.9% vs 1.3%, hazard ratio [HR] 6.25, 95% confidence intervals [CIs] 1.40-27.86, p = 0.02) and single infarction without ICAS (6.8% vs 1.3%, HR 4.65, 95% CI 1.05-20.64, p = 0.04) were all associated with an increased risk of ischemic stroke at 90 days. Patients with both multiple infarctions and ICAS were associated with approximately 13-fold risk of ischemic stroke at 90 days (18.0% vs 1.3%, HR 13.14, 95% CI 2.96-58.36, p < 0.001).

CONCLUSIONS

The presence of multiple infarctions and ICAS were both associated with an increased risk of 90-day ischemic stroke in patients with minor stroke or TIA, while the presence of both imaging features had a combined effect.

CLINICALTRIALSGOV IDENTIFIER

NCT00979589.

Clinical, Laboratory, and Imaging Characteristics of Transient Ischemic Attack Caused by Large Artery Lesions: A Comparison between Carotid and Intracranial Arteries

Background/Aims

The aims of this study were to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions.

Methods

Among 445 patients admitted to our stroke care unit within 48 h of TIA onset between April 2008 and December 2013, 85 patients (63 men, mean age 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 and 90 days after TIA onset.

Results

Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared with those in the extracranial group. Eleven patients in the extracranial group and none in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2 vs. 0%, p = 0.044) and the 90-day risk (17.1 vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group.

Conclusions

Among our patients with TIA caused by large artery disease, patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Thirty-Day Outcome of a Multicenter Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China

Background and Purpose—

Although recent trials have suggested that stenting is worse than medical therapy for patients with severe symptomatic intracranial atherosclerotic stenosis, it is not clear whether this conclusion applies to a subset of patients with hypoperfusion symptoms. To justify for a new trial in China, we performed a multicenter prospective registry study to evaluate the safety and efficacy of endovascular stenting within 30 days for patients with severe symptomatic intracranial atherosclerotic stenosis.

Methods—

Patients with symptomatic intracranial atherosclerotic stenosis caused by 70% to 99% stenosis combined with poor collaterals were enrolled. The patients were treated either with balloon-mounted stent or with balloon predilation plus self-expanding stent as determined by the operators following a guideline. The primary outcome within 30 days is stroke, transient ischemic attack, and death after stenting. The secondary outcome is successful revascularization. The baseline characteristics and outcomes of the 2 treatment groups were compared.

Results—

From September 2013 to January 2015, among 354 consecutive patients, 300 patients (aged 58.3±9.78 years) were recruited, including 159 patients treated with balloon-mounted stent and 141 patients with balloon plus self-expanding stent. The 30-day rate of stroke, transient ischemic attack, and death was 4.3%. Successful revascularization was 97.3%. Patients treated with balloon-mounted stent were older, less likely to have middle cerebral artery lesions, more likely to have vertebral artery lesions, more likely to have Mori A lesions, less likely to have Mori C lesions, and likely to have lower degree of residual stenosis than patients treated with balloon plus self-expanding stent.

Conclusions—

The short-term safety and efficacy of endovascular stenting for patients with severe symptomatic intracranial atherosclerotic stenosis in China is acceptable. Balloon-mounted stent may have lower degree of residual stenosis than self-expanding stent.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01968122.

Evaluation of Cranial and Cervical Arteries and Brain Tissue in Transient Ischemic Attack Patients with Magnetic Resonance Angiography and Diffusion-Weighted Imaging

Background

Magnetic resonance angiography (MRA) and diffusion-weighted imaging (DWI) have been widely used in the prediction of ischemic stroke; however, the differences of the 2 methods in detection the artery lesion differences between transient ischemic attack (TIA) and infarction patients have been long neglected. We performed the present study to investigate the differences between vessel characteristics detected by MRA and DWI in acute stroke and TIA patients.

Material/Methods

We classified 110 subjects into 2 groups and all the patients underwent both MRA and DWI. The degree of stenosis of cranial and cervical arteries, the distribution of the stenosis, the development and changes of the vessels, and the DWI scanning results of the brain tissue were all analyzed.

Results

We detected a significant difference in the number and the degree of stenosis of cranial and cervical arteries among the 3 groups (P=0.006). Compared with health controls, patients with TIA and cerebral infraction had much more severe stenosis and occlusive arteries (P<0.05). However, no significant difference was detected between TIA and cerebral infraction patients (P=0.148). Moreover, a higher rate of unilateral vertebral artery dysplasia was found in the vertebrobasilar TIA patients. Higher lesion signals were also observed by DWI in TIA patients of internal carotid artery system (4/8, 50%).

Conclusions

Vessel characteristics were not significantly different between TIA and infarction patients. Unilateral vertebral artery hypoplasia was a predisposing factor for vertebrobasilar TIA and ischemic focus in DWI detection was always caused by severe artery lesions.

Transient ischemic attacks: predictability of future ischemic stroke or transient ischemic attack events

The short-term risk of an ischemic stroke after a transient ischemic attack (TIA) is estimated to be approximately 3%–10% at 2 days, 5% at 7 days, and 9%–17% at 90 days, depending on active or passive ascertainment of ischemic stroke. Various risk prediction scores are available to identify high-risk patients. We present here a pragmatic review of the literature discussing the main scoring systems. We also provide the sensitivity, specificity, positive predictive value, and negative predictive value for each scoring system. Our review shows that scoring systems including brain imaging and vascular imaging are better at risk prediction than scores that do not include this information.

Perfusion deficits detected by arterial spin-labeling in patients with TIA with negative diffusion and vascular imaging

BACKGROUND AND PURPOSE

A substantial portion of clinically diagnosed TIA cases is imaging-negative. The purpose of the current study is to determine if arterial spin-labeling is helpful in detecting perfusion abnormalities in patients presenting clinically with TIA.

MATERIALS AND METHODS

Pseudocontinuous arterial spin-labeling with 3D background-suppressed gradient and spin-echo was acquired on 49 patients suspected of TIA within 24 hours of symptom onset. All patients were free of stroke history and had no lesion-specific findings on general MR, DWI, and MRA sequences. The calculated arterial spin-labeling CBF maps were scored from 1-3 on the basis of presence and severity of perfusion disturbance by 3 independent observers blinded to patient history. An age-matched cohort of 36 patients diagnosed with no cerebrovascular events was evaluated as a control. Interobserver agreement was assessed by use of the Kendall concordance test.

RESULTS

Scoring of perfusion abnormalities on arterial spin-labeling scans of the TIA cohort was highly concordant among the 3 observers (W = 0.812). The sensitivity and specificity of arterial spin-labeling in the diagnosis of perfusion abnormalities in TIA was 55.8% and 90.7%, respectively. In 93.3% (70/75) of the arterial spin-labeling CBF map readings with positive scores (≥2), the brain regions where perfusion abnormalities were identified by 3 observers matched with the neurologic deficits at TIA onset.

CONCLUSIONS

In this preliminary study, arterial spin-labeling showed promise in the detection of perfusion abnormalities that correlated with clinically diagnosed TIA in patients with otherwise normal neuroimaging results.