Abstract
PurposeEndovascular treatment in severe middle cerebral artery (MCA) stenosis is controversial owing to high rates of periprocedural complications, especially occlusion of the lenticulostriate arteries (LSA). The characteristics of LSAs and the spatial relationships between MCA plaques and LSAs using the fusion of three-dimensional (3D) digital subtraction angiography (DSA) and magnetic resonance imaging (3D DSA-MRI fusion) were investigated.MethodsWe retrospectively analyzed data from 32 ischemic stroke or transient ischemic attack patients with severe MCA stenosis, who underwent MRI and DSA within 2 weeks after symptom onset. The patients were divided into culprit and non-culprit MCA stenosis groups. The 3D DSA-MRI fusion was performed on dedicated workstations, which allowed automated overlays of the target vessels. The characteristics of LSAs, plaque distribution and lesion patterns, and their relationships were evaluated.ResultsThe 3D DSA-MRI fusion image was able to illustrate the spatial relationships between MCA plaques and LSA orifices. Of 42 LSA stems in 32 patients, 10 had MCA plaque over the LSA orifice and were all found in the culprit MCA stenosis group. Over half (51.9%) of the LSA stems in patients with culprit MCA stenosis originated from the stenotic MCA segment. The MCA plaque-LSA orifice spatial relationships were classified into four types, which were significantly different between the two groups (p = 0.016).ConclusionThe 3D DSA-MRI fusion technique enables visualization of the LSA orifice and MCA plaque and their spatial relationships. This classification of the type of spatial relationships can provide insights into the pathogenesis of MCA stroke and useful guides for treatment strategies.
Highlights
Intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide and the middle cerebral artery (MCA) is the most common site of ICAS among Asian populations [1, 2]
Understanding the spatial relationships between lenticulostriate arteries (LSA) and MCA plaque is important in understanding the stroke mechanisms, guiding clinical decisions regarding percutaneous transluminal angioplasty and stenting (PTAS) versus medical treatment, and determining risks of periprocedural complications of PTAS; so far evidence regarding their relationships is mostly from post-mortem studies rather than in vivo studies, which was investigated in the current study with coregistration of magnetic resonance imaging (MRI) and three-dimensional digital subtraction angiography (3D DSA), along with their relationships with patterns of lenticulostriate infarctions, among patients with atherosclerotic stenosis of MCA
We found no difference in the degree of MCA stenosis or the numbers of LSA stem(s) and branches between those with culprit and non-culprit MCA stenosis; patients with culprit MCA stenosis had more LSAs originating from the stenotic MCA segment and more presence of MCA plaques growing over the orifice of the LSA(s), than those with non-culprit MCA stenosis
Summary
Intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide and the middle cerebral artery (MCA) is the most common site of ICAS among Asian populations [1, 2]. The stenting and aggressive medical management for preventing recurrent stroke in intracranial arterial stenosis (SAMMPRIS) and the Vitesse intracranial stent study for ischemic stroke therapy (VISSIT) trials showed an increased risk of stroke with medical treatment plus percutaneous transluminal angioplasty and stenting (PTAS) compared with medical treatment alone, among patients with high-grade symptomatic K. Understanding the spatial relationships between LSAs and MCA plaque is important in understanding the stroke mechanisms, guiding clinical decisions regarding PTAS versus medical treatment, and determining risks of periprocedural complications of PTAS; so far evidence regarding their relationships is mostly from post-mortem studies rather than in vivo studies, which was investigated in the current study with coregistration of magnetic resonance imaging (MRI) and three-dimensional digital subtraction angiography (3D DSA), along with their relationships with patterns of lenticulostriate infarctions, among patients with atherosclerotic stenosis of MCA
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