scholarly journals Intracranial Atherosclerosis: A Disease of Functional, not Anatomic Stenosis? How Trans-Stenotic Pressure Gradients Can Help Guide Treatment

2019 ◽  
Vol 18 (6) ◽  
pp. 599-605
Author(s):  
Mario Zanaty ◽  
James D Rossen ◽  
Jorge A Roa ◽  
Daichi Nakagawa ◽  
Joseph S Hudson ◽  
...  
Keyword(s):  
Medical Therapy ◽  
Predictive Biomarker ◽  
Arterial Stenosis ◽  
Actual State ◽  
Pressure Gradients ◽  
Flow Limitation ◽  
Anterior Circulation ◽  
Intracranial Atherosclerotic Disease ◽  
Hemodynamic Assessment ◽  
Distal Flow

Abstract Background Most trials have assessed intracranial atherosclerotic disease (ICAD) severity based on angiographic stenosis. However, anatomic stenosis might not accurately identify the actual state of functional post-stenotic flow limitation. Objective To investigate whether angiographic stenosis correlates with physiologic distal flow limitation, measured as trans-stenotic pressure gradients, in ICAD patients. Methods In patients referred for endovascular treatment of anterior circulation symptomatic ICAD who failed maximal medical therapy (MMT) per SAMMPRIS (Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis) criteria, angiographic luminal diameters and percentages of stenosis were correlated with trans-stenotic pressure gradients, calculated as distal/proximal pressure ratios (DPPR) and proximal minus distal pressure gradients (PDPG), by way of Spearman correlation coefficients. Results Nine patients (3 men, 6 women) were evaluated. Atherosclerotic lesions’ locations included internal carotid artery in 5 subjects (2 cavernous, 3 supraclinoid) and proximal middle cerebral artery (M1) in 4 patients. Mean percentage of stenosis was 80 ± 8% (range 75%-94%). Minimal lumen diameter at the most stenotic ICAD site ranged from 0.2 to 0.9 mm (0.59 ± 0.41 mm). DPPR ranged from 0.38 to 0.63 (0.56 ± 0.14). PDPG ranged from 35 to 57 mm Hg (50 ± 8 mm Hg). Spearman coefficients showed no correlation between DPPR or PDPG and angiographic minimal luminal diameters or percentages of stenosis. There were no procedural complications related to trans-stenotic pressure measurements. CONCLUSION Angiographic stenosis does not reflect the physiologic severity of distal flow limitation in patients with ICAD. Hemodynamic assessment using trans-stenotic pressure ratios and gradients may serve as a more reliable predictive biomarker for MMT failure and response to revascularization.

scholarly journals Undersized angioplasty and stenting of symptomatic intracranial tight stenosis with Enterprise: Evaluation of clinical and vascular outcome

2015 ◽  
Vol 22 (2) ◽  
pp. 187-195 ◽  
Author(s):  
Kun-Yu Lee ◽  
David Yen-Ting Chen ◽  
Hui-Ling Hsu ◽  
Chi-Jen Chen ◽  
Ying-Chi Tseng
Keyword(s):  
Medical Therapy ◽  
Arterial Stenosis ◽  
Modified Rankin Scale ◽  
Intracranial Arterial Stenosis ◽  
Stent Deployment ◽  
Technical Success Rate ◽  
Stent Restenosis ◽  
Intracranial Atherosclerotic Disease ◽  
Stenotic Lesions

Background Severe intracranial arterial stenosis results in more than 10% incidence of stroke and transient ischemic attack. Using undersized angioplasty with off-label closed-cell Enterprise stent may be a feasible alternative option for treating patients with intracranial atherosclerotic disease who fail dual-antiplatelet medical therapy. The results of the authors’ study are presented in this paper. Materials and methods Between January 2013 and July 2014, 24 symptomatic patients with a total of 30 intracranial arterial stenotic lesions refractory to medical therapy, who underwent undersized angioplasty and Enterprise stenting, were retrospectively reviewed in the authors’ institution. The results evaluated include technical success rate, clinical outcome measured as modified Rankin Scale at presentation and follow-up, peri-procedural morbidity within 30 days and 1 year, and follow-up vessel patency. Results Stent deployment was successfully achieved in all stenotic lesions (30/30). Mean pre-stent and post-stent diameter residual stenosis was 81% and 18%, respectively. The peri-procedural complication rate during 30 days after stenting was 10% per lesion (3/30), including intracranial hemorrhage, in-stent thrombosis and ischemic stroke. No further thromboembolic event or complication occurred in any patient more than 30 days after stenting. Modified Rankin scale ≤ 2 was observed in 64% and 83% of patients at initial presentation and follow-up (mean 15.8 months), respectively. Imaging follow-up was available in 17 of 24 patients (70.8%) and 20 of 30 treated lesions (66.6%) with a mean follow-up period of 15.4 months. Only one asymptomatic in-stent restenosis occurred in 20 available lesions (5.0%). Conclusion This preliminary study suggests that using undersized angioplasty and Enterprise stenting may effectively treat high-degree symptomatic intracranial arterial stenosis with favorable clinical and angiographic outcome.

Abstract T P102: Recurrent Stroke Risk in Patients With ICAD Treated With Aggressive Medical Management: A Comparison With The Sammpris Trial

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Rajbeer S Sangha ◽  
Carlos Corado ◽  
Richard A Bernstein ◽  
Ilana Ruff ◽  
Yvonne Curran ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Real World ◽  
Medical Management ◽  
Stroke Risk ◽  
Recurrent Stroke ◽  
High Dose ◽  
Stroke Subtype ◽  
Anterior Circulation ◽  
Intracranial Atherosclerotic Disease ◽  
Aggressive Medical Management

Background: Since the SAMMPRIS trial, aggressive medical management (AMM) with the use of dual antiplatelets (aspirin, clopidogrel) and high dose statin therapy has been standard of care for patients with symptomatic intracranial atherosclerotic disease (ICAD). However, there is limited data on the “real-world” application of this regimen. We hypothesized that 30-day recurrent stroke risk among patients treated with AMM would be similar to that in SAMMPRIS medically-treated patients. Methods: Using the prospective Northwestern University Brain Attack Registry, we identified all patients admitted between 8/1/12 and 1/31/14 with 1) confirmed ischemic stroke or transient ischemic attack (TIA); 2) independently adjudicated symptomatic ICAD; and 3) discharged on AMM. At 30 days (28-35 day window) post-stroke, patients or proxies were contacted by telephone to review events and outcomes. We also utilized an electronic surveillance system of hospital records at any of 3 health system hospitals with confirmation by manual review of the medical record in all instances of reported recurrent stroke or TIA. Ischemic stroke in the territory of the symptomatic stenotic artery was the primary outcome. We calculated 30-day rate of stroke in the territory of the stenotic artery and 95% confidence intervals using the Wald method and compared it with that reported in the SAMMPRIS trial. Results: Among 36 patients who met study criteria, 13 (36.1%) were female and mean age was 65.4 (± 9.7) years. Median initial NIHSS score was 4 (interquartile range 0-17). Symptomatic ICAD was localized to the anterior circulation in 21 (58%) patients and posterior circulation in 15 (41.7%). At 30 days, 3 of the 36 patients (8.3%, 95% CI 2.1-22.6%) had recurrent stroke compared to 5.8% in the medical arm of SAMMPRIS (p=0.47). An additional 3 patients (8.3%) experienced TIA within 30 days. Conclusions: In a single-center observational cohort study, we found that AMM in patients with symptomatic ICAD yielded similar rates of recurrent stroke at 30-days as observed in the SAMMPRIS trial. Our study provides “real-world” confirmation of the potential benefits of AMM in this high-risk stroke subtype.

Abstract TP32: Efficacy and Safety of Hyper-acute Stenting for Symptomatic Intracranial Atherosclerotic Disease

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Alexander McQuinn ◽  
Andrew Cheung ◽  
Jason Wenderoth ◽  
Amer Mitchelle ◽  
Christopher Blair ◽  
...  
Keyword(s):  
Symptom Onset ◽  
Ct Perfusion ◽  
Early Postoperative Period ◽  
Atherosclerotic Disease ◽  
Target Vessel ◽  
Efficacy And Safety ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Intracranial Atherosclerotic Disease ◽  
Select Group

Introduction: Recent data suggests stenting of symptomatic intracranial atherosclerotic disease (ICAD) in the hyper-acute period (< 8 days of symptom onset) is associated with a high incidence of early postoperative morbidity and mortality. We assessed the efficacy and safety of this select group of patients at our institutions. Methods: Between December 2017 to May 2019, anterior circulation stroke patients who underwent acute stenting of symptomatic intracranial atherosclerotic disease with the Atlas stent (Stryker) were identified from a prospectively maintained database of stroke patients at two comprehensive stroke centres. Baseline characteristics, imaging, and clinical outcomes are reported. Results: Nine cases were identified (mean age 71years, 44.4% male, median NIHSS 9 (range 5-18)). All patients had baseline mRS of 3 or less. Median time from symptom onset to groin puncture was 10hours (range 4-96hours). All patients received dual-antiplatelet therapy with Aspirin and Prasugrel(DAPT) either immediately before or after the procedure. In patients who did not receive pre-procedure loading with DAPT (55.6%), a single intravenous dose of Abciximab (mean 9mg +/- 4mg) or Tirofiban (1mg) was given intra-operatively. No thromboembolic complications or mortality occurred in the early postoperative period (within 72hours). All patients showed improvement in target vessel perfusion on day-one CT-perfusion. At 90-days, 7 (77.8%) patients were either functionally independent (mRS 0-2) or at their pre-operative baseline. No symptomatic intracranial haemorrhage occurred. No recurrent target vessel strokes were recorded. One patient died of medical complications unrelated to intracranial stenting and one patient was mRS 3 at 90-days. Conclusion: Hyper-acute stenting of symptomatic ICAD may be safe and effective. Antiplatelet treatment strategies and advances in stent devices may be critical in the success of this approach.

Abstract WMP45: Borderzone Infarct Pattern Predicts Recurrent Stroke in Patients With Intracranial Stenosis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Shyam Prabhakaran ◽  
Rajbeer Sangha ◽  
Sameer Ansari ◽  
Jose Romano ◽  
PN Sylaja ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Recurrent Stroke ◽  
Strong Predictor ◽  
Single Center ◽  
Anterior Circulation ◽  
Nihss Score ◽  
Intracranial Atherosclerotic Disease ◽  
Index Stroke ◽  
Ischemic Attack ◽  
Mixed Pattern

Introduction: Despite aggressive medical management, patients with symptomatic intracranial atherosclerotic disease (ICAD) remain at high risk for recurrent stroke. There are no reliable biomarkers to identify those at highest risk and in whom flow restorative procedures may be warranted. We hypothesized that a borderzone infarct pattern would predict 90-day recurrent stroke in the territory of symptomatic ICAD. Methods: Using the prospective registry at a single center, we identified consecutive patients admitted between 2012 and 2017 with confirmed ischemic stroke or transient ischemic attack (TIA) and independently adjudicated symptomatic ICAD with stenosis of >50%. We ascertained clinical events within 3 months of index stroke through telephone interview. Ischemic stroke in the territory of the symptomatic stenotic artery was the primary outcome. A blinded rater assessed infarct pattern: single perforator, territorial, borderzone, or mixed. We evaluated whether infarct pattern was a predictor of recurrent stroke using logistic regression adjusting for age, sex, prior stroke, initial NIHSS score, location of stenosis, degree of stenosis, and use of dual antiplatelet therapy at discharge. Results: Among 212 patients who met study criteria, the mean age was 68.2 (±12.2) years and median initial NIHSS score was 3 (interquartile range 1-6). Symptomatic ICAD was localized to the anterior circulation in 132 (64.2%) patients and 171 (80.7%) had stenosis >70%. Isolated borderzone infarcts were noted in 18 patients (8.5%) while they were present in 34 (16.0%) other patients with mixed pattern. At 3 months, 51 (24.1%) patients experienced recurrent stroke in the territory. Among patients with any borderzone infarct, 20 (38.7%) had recurrent stroke versus 31 (19.4%) in patients with other patterns (p=0.005). In adjusted analysis, presence of any borderzone infarct was independently associated with recurrent stroke (aOR 2.59, 95% CI 1.23-5.48, p=0.012). Conclusions: In a single-center observational cohort study, we found that a borderzone infarct pattern was a strong predictor of recurrent stroke at 3 months in patients with symptomatic ICAD. Our data suggest that hypoperfusion may be an important mechanism of recurrent stroke in this population.

Abstract 14021: Angiographic and Hemodynamic Features of Symptomatic Vertebrobasilar Disease: Baseline Data from the VERiTAS Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sepideh Amin-Hanjani ◽  
Xinjian Du ◽  
Linda Rose-Finnell ◽  
Dilip Pandey ◽  
DeJuran Richardson ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Stroke Risk ◽  
Posterior Circulation ◽  
Study Cohort ◽  
Collateral Flow ◽  
Flow Measurements ◽  
Hemodynamic Assessment ◽  
Basilar Arteries ◽  
Vessel Flow ◽  
Distal Flow

Introduction: Atherosclerotic vertebrobasilar disease (VBD) is a significant etiology of posterior circulation stroke. In addition to thromboembolism, regional hypoperfusion is considered an important potential contributor to stroke risk. To examine the role of hemodynamic compromise in VBD, a prospective observational multi-center study, Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS), has recently been conducted. Here we report baseline features and vessel flow measurements from the study cohort. Methods: Baseline demographic and clinical data was collected in patients with recent vertebrobasilar TIA or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral and/or basilar arteries. Large vessel flow in the vertebrobasilar territory was assessed using quantitative MRA (QMRA). Results: The cohort (n=75, 56% male) had a mean age of 65.5 (range 40 to 90) years; two thirds presented with ischemic stroke. Hypertension (93%) and hyperlipidemia (79%) were the most prevalent vascular risk factors. Vertebral and basilar artery flows correlated negatively with degree of stenosis in the affected vessel, and positively to the minimal diameter at the site of stenosis (p<0.01). A threshold effect was evident, with affected vessel flows dropping significantly in patients with ≥70% stenosis or occlusion (p<0.05). Tandem disease involving the basilar and either or both the vertebrals had the greatest impact on immediate downstream flow in the basilar artery (38 ml/min vs. 74 ml/min, p<0.01). Assessment of distal flow status, incorporating collateral flow, however correlated neither with multifocality of disease nor severity of the maximal stenosis. Conclusions: Flow in stenotic posterior circulation vessels correlate with residual diameter and stenosis and drop significantly in the setting of tandem disease. However, distal flow status, incorporating collateral capacity, is not well predicted by the severity or location of the disease. Final clinical outcome results from the ongoing VERiTAS study will further clarify the relevance of anatomic stenosis and hemodynamic assessment to predicting stroke risk in patients with vertebrobasilar disease.

scholarly journals Plaque morphology in acute symptomatic intracranial atherosclerotic disease

2020 ◽  
pp. jnnp-2020-325027
Author(s):  
Thomas W Leung ◽  
Li Wang ◽  
Xinying Zou ◽  
Yannie Soo ◽  
Yuehua Pu ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Three Dimensional ◽  
Morphological Features ◽  
Atherosclerotic Disease ◽  
Sensitivity Analyses ◽  
Plaque Morphology ◽  
Stroke Subtype ◽  
Anterior Circulation ◽  
Intracranial Atherosclerotic Disease ◽  
Ulcerative Lesions

BackgroundIntracranial atherosclerotic disease (ICAD) is globally a major ischaemic stroke subtype with high recurrence. Understanding the morphology of symptomatic ICAD plaques, largely unknown by far, may help identify vulnerable lesions prone to relapse.MethodsWe prospectively recruited patients with acute ischaemic stroke or transient ischaemic attack attributed to high-grade ICAD (60%–99% stenosis). Plaque morphological parameters were assessed in three-dimensional rotational angiography, including surface contour, luminal stenosis, plaque length/thickness, upstream shoulder angulation, axial/longitudinal plaque distribution and presence of adjoining branch atheromatous disease (BAD). We compared morphological features of smooth, irregular and ulcerative plaques and correlated them with cerebral ischaemic lesion load downstream in MRI.ResultsAmong 180 recruited patients (median age=60 years; 63.3% male; median stenosis=75%), plaque contour was smooth (51 (28.3%)), irregular (101 (56.1%)) or ulcerative (28 (15.6%)). Surface ulcers were mostly at proximal (46.4%) and middle one-third (35.7%) of the lesions. Most (84.4%) plaques were eccentric, and half had their maximum thickness over the distal end. Ulcerative lesions were thicker (medians 1.6 vs 1.3 mm; p=0.003), had steeper upstream shoulder angulation (56.2° vs 31.0°; p<0.001) and more adjoining BAD (83.3% vs 57.0%; p=0.033) than non-ulcerative plaques. Ulcerative plaques were significantly associated with coexisting acute and chronic infarcts downstream (35.7% vs 12.5%; adjusted OR 4.29, 95% CI 1.65 to 11.14, p=0.003). Sensitivity analyses in patients with anterior-circulation ICAD lesions showed similar results in the associations between the plaque types and infarct load.ConclusionsUlcerative intracranial atherosclerotic plaques were associated with vulnerable morphological features and had a higher cumulative infarct load downstream.

The Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis Trial: Reanalysis Using the FDA “On Label” Criteria

2020 ◽  
Vol 30 (6) ◽  
pp. 857-861
Author(s):  
Adnan I. Qureshi ◽  
Muhammad F. Ishfaq ◽  
Vamshi K. S. Balasetti ◽  
Iryna Lobanova ◽  
Guven Uzun ◽  
...  
Keyword(s):  
Medical Therapy ◽  
Arterial Stenosis ◽  
Intracranial Arterial Stenosis
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