Abstract

Background: Intracranial cerebral atherosclerosis (ICAS) is a leading etiology of ischemic stroke. The diagnosis and assessment of intracranial stenosis are shifting from anatomic to hemodynamic for better risk stratification. However, the relationships between lesion geometry and translesional pressure gradient have not been clearly elucidated.Methods: Patients with symptomatic unifocal M1 middle cerebral artery (M1-MCA) stenosis were consecutively recruited. The translesional pressure gradient was measured with a pressure wire and was recorded as both mean distal/proximal pressure ratios (Pd/Pa) and translesional pressure difference (Pa–Pd). Lesion geometry measured on angiography was recorded as diameter stenosis, minimal lumen diameter, and lesion length. The correlations between pressure-derived and angiography-derived indices were then analyzed.Results: Forty-three patients were analyzed. A negative correlation was found between Pd/Pa and diameter stenosis (r = −0.371; p = 0.014) and between Pa – Pd and minimal lumen diameter (r = −0.507; p = 0.001). A positive correlation was found between Pd/Pa and minimal lumen diameter (r = 0.411; p = 0.006) and between Pa – Pd and diameter stenosis (r = 0.466; p = 0.002).Conclusions: In a highly selected ICAS subgroup, geometric indices derived from angiography correlate significantly with translesional pressure gradient indices. However, the correlation strength is weak-to-moderate, which implies that anatomic assessment could only partly reflect hemodynamic status. Translesional pressure gradient measured by pressure wire may serve as a more predictive marker of ICAS severity. More factors need to be identified in further studies.

Highlights

  • Intracranial cerebral atherosclerosis (ICAS) is the most common cause of ischemic events worldwide, in Asian, Hispanics, and Africans, and may be underestimated in Caucasians [1,2,3,4]

  • Adult patients meeting the following criteria were enrolled for the current study: [1] presented with recurrent stroke or transient ischemic attack (TIA) within the past 6 months attributed to 50–99% unifocal M1 middle cerebral artery (M1-MCA) stenosis; [2] patients understood that the pressure measurements were part of a novel functional assessment of MCA stenosis for study purposes and give permission to the off-label use of a pressure wire; and [3] expected ability to traverse the lesion with a pressure wire

  • The present study demonstrated that in patients with symptomatic M1 stenosis, hemodynamic indices as assessed by pressure wire are significantly associated with anatomic indices on digital subtraction angiography (DSA)

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Summary

Introduction

Intracranial cerebral atherosclerosis (ICAS) is the most common cause of ischemic events worldwide, in Asian, Hispanics, and Africans, and may be underestimated in Caucasians [1,2,3,4]. In the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial, higher degrees of anatomic stenosis were identified as independent predictors of recurrent ischemic stroke [5, 6]. This inspired investigators to adopt more aggressive treatments, including balloon angioplasty or stenting, toward improved outcomes in patients with >70% stenosis. Hemodynamic insufficiency may be inferred from infarct pattern (i.e., watershed infarction) or various models of cerebral perfusion imaging (e.g., asymmetry between bilateral hemispheres). These are evaluations of brain parenchyma, and focal or arterial lesionrelated assessments of hemodynamics could have more important therapeutic implications. The relationships between lesion geometry and translesional pressure gradient have not been clearly elucidated

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