Intracranial Arterial Stenosis In Patients Research Articles

Application Value of the Apolipoprotein in the Prediction of Acute Ischemic Death and in the Assessment of Functional Outcomes.

In recent years, research on the apolipoprotein E (APOE) gene has gradually proven that many diseases, including atherosclerosis, coronary heart disease, and neurological diseases, are closely related to ApoE gene diversity. However, the relationship between the APOE gene and the prediction and prognosis evaluation of ischemic stroke has not been determined or unified so far. The purpose of this study was to investigate the application value of APOE allele-4 combined with high-resolution vascular wall imaging in predicting the occurrence and prognosis of acute ischemic stroke. A total of 511 patients with acute ischemic stroke (AIS), who were admitted from January 2022 to December 2023, were included in the study, including 317 patients with intracranial artery stenosis. Blood lipids, lipoproteins, apolipoprotein E (including allelic typing), and lipoproteins (a) were measured in all cases, and high-resolution magnetic resonance imaging of the vascular walls was performed. At 6 months, the functional outcomes of the AIS patients were followed up, assessed by using the modified Rankin Scale (mRS) (a score of 2 - 6 was rated as poor prognosis), and the high-definition vascular wall imaging results were followed up as well. High-definition vascular wall imaging ensures the accurate location of vascular stenosis and the accurate diagnosis of acute stroke. There were no significant differences in the total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, or lipoprotein (a) in patients with and without intracranial artery stenosis, but the plasma apolipoprotein E (APOE) levels were significantly reduced in patients with intracranial artery stenosis (ICAS). At the 6-month follow-up, 230 patients with the APOE-ε4 gene were enrolled, out of which 104 had a poor prognosis (mRS score ≥ 2), accounting for 45.22%. Among 281 patients without the APOE-ε4 gene, 45 had a poor prognosis (mRS score ≥ 2), accounting for 16.01%. Patients with the APOE-ε4 gene had a worse functional prognosis after 6 months. It is suggested that low plasma APOE levels may be a high risk factor for ICAS in patients with acute ischemic stroke, and carrying the APOE-ε4 gene may be a high risk factor for a poor functional prognosis in AIS patients. The APOE-ε4 genotype, combined with high-resolution vascular wall imaging, has certain clinical application value in predicting the occurrence of acute ischemic death and evaluating the functional outcome.

The diagnosis of intracranial artery stenosis in patients with stroke by transcranial Doppler ultrasound: A meta-analysis.

Strokes are the most common cause of death and the leading cause of acquired disability in adults worldwide. The present study aimed to investigate the value of transcranial Doppler ultrasound (TCD) in the diagnosis of intracranial vascular stenosis in patients with a history of stroke. This is a meta-analysis study of diagnostic tests. PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP databases were systematically searched. Diagnostic tests using TCD or transcranial colour Doppler ultrasound (TCCD) for detecting intracranial arterial stenosis in patients with a history of stroke were included, with reference standards of intracranial angiography, computed tomography angiography (CTA), or magnetic resonance angiography. The risk bias map was drawn by Revman v5.3, the sensitivity and specificity forest plot was drawn by Stata v16.0, the receiver operating characteristic curve was drawn, and the area under the curve (AUC) was calculated. A total of 812 patients with stroke in 12 studies were included in the meta-analysis. The estimated sensitivity of TCD or TCCD for the detection of intracranial vascular stenosis was 0.77-1.00, and the combined sensitivity was 0.96 (95% confidence interval [CI]: 0.88-0.99); the estimated specificity was 0.32-1.00, and the combined specificity was 0.94 (95% CI: 0.82-0.98); the positive likelihood ratio was 15.8 (95% CI: 5.1-48.6); and the negative likelihood ratio was 0.04 (95% CI: 0.01-0.14). The AUC was 0.99 (95% CI: 0.97-0.99). Doppler ultrasound has good consistency with conventional methods for the diagnosis of intracranial artery stenosis in patients with a history of stroke. Different reference standards may affect sensitivity and specificity; when CTA was used as the reference standard, the consistency of the TCD in the diagnosis of intracranial artery stenosis in stroke patients was relatively good.

Prevalence, clinical characteristics and prognosis of intracranial artery atherosclerosis in heterozygous familial hypercholesterolemia: insights from magnetic resonance angiography imaging analysis

Abstract Introduction Heterozygous familial hypercholesterolemia (HeFH) exhibits substantially atherogenic substrate which involves coronary and peripheral arteries. Whether atherosclerosis in HeFH propagates to intracranial arteries causing stroke remains to be determined. Purpose To characterize intracranial artery stenosis (IAS) in subjects with HeFH. Methods 148 HeFH subjects who underwent MRI/MRA imaging to evaluate intracranial arteries were analyzed. IAS was defined as the presence of stenosis with its % diameter stenosis ≥25%. Clinical demographics and cardiovascular events (all-cause death, ACS, stroke and PAD) were compared in those with and without IAS. Results IAS was observed in 24.3% (=36/148) of study subjects. It was more frequently located at middle cerebral artery (30.6%=11/36), followed by internal carotid artery (25.0%=9/36). 47.2% of IAS exhibited % diameter stenosis ≥75%. Furthermore, 58.3% of HeFH patients with IAS exhibited concomitance of CAD, PAD or carotid stenosis. They were more likely to be older (Table). While there was no significant difference in LDL-C level, an elevated triglyceride level was observed in those with IAS (Table). Of note, during the observational period (median=14.1 years), IAS was associated with a greater likelihood of experiencing not only stroke but other cardiovascular events (all-cause death + ACS + PAD) (picture). Multivariate analysis demonstrated triglyceride level ≥1.7mmol/l as an independent predictor of IAS in HeFH patients (HR=5.53, 95% CI: 1.85–16.5, p=0.002). Conclusions Around one-fourth of HeFH patients harboured IAS, which was associated with concomitance of atherosclerosis in other vascular beds and the occurrence of stroke and other cardiovascular events. Given the relationship of IAS with hypertriglyceridemia, this lipid feature may be an important contributor to atherosclerotic formation which involves intracranial artery in HeFH patients. Clinical outcome Funding Acknowledgement Type of funding source: None

Prevalence of Intracranial Artery Stenosis in Patients with Acute Ischemic Stroke in a Tertiary Care Hospital of China.

Intracranial artery stenosis is the most common cause of acute ischemic stroke, especially among people in Asia. About its epidemiology, however little is understood. The goal of our research is to establish the prevalence of intracranial artery stenosis in patients with acute ischemic stroke in a tertiary care hospital. A descriptive cross-sectional study was done in 1006 acute ischemic stroke patients at Affiliated Zhongda Hospital, School of Medicine, Southeast University China from May 2018 to May 2019. Ethical approval was taken from the Ethical review committee of the institution. A convenient sampling method was done. Intracranial artery stenosis was diagnosed when evidence of acute ischemic stroke was found in the territory of approximately 2 50% stenosis identified by Transcranial Doppler ultrasound and confirmed by magnetic resonance angiography or computed tomography. Statistical analysis was done using the Statistical Package for the Social Sciences version 20. The prevalence of intracranial artery stenosis was found in 331 (32.90%) patients at 95% Confidence interval (0.24-0.42%). Among 331 cases the anterior circulation artery stenosis was present on 201 (19.98%) patients, followed by posterior circulation artery stenosis on 80 (7.95%) patients, then anterior plus posterior circulation artery stenosis on 50 (4.97%) patients. Intracranial artery stenosis is one of the most causes of acute ischemic stroke in China. The proportion of anterior circulation artery stenosis was higher than that in the posterior circulation.

Association of antinuclear antibodies with the risk of intracranial arterial stenosis.

The prevalence of intracranial arterial stenosis (IAS) as well as antinuclear antibody (ANA) positivity was found to be higher in Asians than that in the Western population. To investigate the relation of ANAs with IAS in patients with acute ischemic cerebrovascular disease, we enrolled 2492 patients with acute ischemic stroke or transient ischemic attack into the study. All the patients were categorized into 3 groups according to the IAS burden. Multinomial logistic regression analyses were used in statistical analysis. The positive rate of ANAs in the IAS ≥ 2 group was higher than that in the single IAS group and the no IAS group (p<0.001). The adjusted odds ratio (OR) for IAS ≥ 2 in ANAs-positive patients was 3.737 (95%CI=2.676-5.220, p<0.001) compared with the ANAs-negative patients. ANAs were associated with multiple IAS rather than single IAS in both male and female subgroups. Besides, ANAs were significantly associated with single and multiple IAS in individuals ≤ 60 years. However, ANAs were only associated with two or more IAS in two age groups (between 61 to 75 years and >75 years old). In summary, ANAs are associated with IAS in patients with acute ischemic cerebrovascular disease.

The prevalence of intracranial stenosis in patients at low and moderate risk of stroke.

Background:Previous studies assessing the risk of stroke in the general population performed screening with Doppler ultrasonography only for high-risk patients and neglected low- and moderate-risk patients. The aims of this study were to explore the current prevalence of intracranial arterial stenosis (ICAS) and analyze its association with different levels of stroke risk and risk factors based on the risk assessment scale for stroke used in China.Methods:A total of 3654 participants who underwent transcranial Doppler ultrasound (TCD) were eligible for inclusion. Information regarding demographic characteristics and risk factors such as alcohol consumption and hypertension was collected through interviews and questionnaires and used to analyze the association of ICAS with different levels of stroke risk and risk factors.Results:The mean age of 501 subjects diagnosed with at least one ICAS was higher than that of participants without ICAS (57.13 ± 9.56 years and 55.52 ± 9.35 years, respectively). After adjusting for confounding factors, gender, education, residence, hypertension and personal history of stroke were associated with ICAS. The odds ratios for ICAS in patients with hypertension and a personal history of stroke were 1.655 [95% confidence interval (CI): 1.341–2.043] and 1.854 (95% CI: 1.371–2.508), respectively. In addition, participants in the low- and moderate-risk stroke groups accounted for an unexpectedly high proportion of individuals with ICAS (up to 38.3%). Results from multivariate analyses indicated that the adjusted odds ratios for ICAS in patients with moderate and high stroke risks versus those with a low stroke risk were 1.603 (95% CI: 1.171–2.195) and 1.612 (95% CI: 1.272–2.042), respectively.Conclusion:The prevalence of ICAS is high in northeast China and increases with the level of stroke risk. However, the proportion of patients with ICAS among those with low and moderate stroke risks should also be noted.

Abstract TMP7: Endovascular Recanalization of Intracranial Arterial Stenosis in Patients With Recurrent or Progressive Symptoms Despite Medical Management

Background and Objective: The optimal management of intracranial arterial stenosis is unclear, particularly in patients who have failed medical management. We report a multicenter real-world experience of endovascular recanalization of intracranial atherosclerotic stenosis refractory to aggressive medical therapy. Methods: Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (TIA or stroke) who had failed medical therapy were identified. All of the patients were considered to be at high risk with unstable symptomatic intracranial stenosis and progression or recurrence of symptoms despite the best medical management and underwent endovascular intervention either with stenting and/or balloon angioplasty. Results: 98 patients presented with recurrent TIAs (n= 40) or recurrent or progressive strokes (n= 58) and were treated in 8 stroke centers from 2009 to 2017. All patients were treated either with dual antiplatelet therapy (84%) or anticoagulation and all had statin therapy prior to recurrence or progression of their symptoms. There was one periprocedural perforation resulting in patient death. There were 3 patients who had periprocedural strokes and 2 patients had symptomatic intraparenchymal hemorrhage with a total of four (4%) periprocedural mortality. The all-cause mortality rate at discharge was 6%. At 90-day follow-up, 7 (10%) patients had TIAs and 2 (3%) patients had ipsilateral strokes, and 78% of patients had mRS of 2 or less. Conclusion: Endovascular recanalization of unstable intracranial atherosclerotic stenosis who have failed medical therapy is feasible and safe.

Limb Ischemic Conditioning Improved Cognitive Deficits via eNOS-Dependent Augmentation of Angiogenesis after Chronic Cerebral Hypoperfusion in Rats.

Intracranial and extracranial arterial stenosis, the primary cause of chronic cerebral hypoperfusion (CCH), is a critical reason for the pathogenesis of vascular dementia and Alzheimer’s disease characterized by cognitive impairments. Our previous study demonstrated that limb remote ischemic conditioning (LRIC) improved cerebral perfusion in intracranial arterial stenosis patients. The current study aimed to test whether LRIC promotes angiogenesis and increases phosphorylated endothelial nitric oxide synthase (p-eNOS) activity in CCH rat model. Adult male Sprague-Dawley rats were randomly assigned to three different groups: sham group, bilateral carotid artery occlusion (2VO) group and 2VO+LRIC group. Cerebral Blood Flow (CBF) was measured with laser speckle contrast imager at 4 weeks. Cognitive testing was performed at four and six weeks after 2VO surgery. We demonstrated that LRIC treatment increased cerebral perfusion and improved the CCH induced spatial learning and memory impairment. Immunohistochemistry confirmed that LRIC prevented cell death in the CA1 region, and increased the number of vessels and angiogenesis in the hippocampus after 2VO. Western blot analysis shows that LRIC therapy significantly increased p-eNOS expression in the hippocampus when compared with 2VO rats. Moreover, eNOS inhibitor reduced the effect of LRIC on angiogenesis in the hippocampus and spatial learning and memory function. Our data suggested that LRIC promoted angiogenesis, which is mediated, in part, by eNOS/NO.

BP.01.03] ASSOCIATION OF INTER-ARM BLOOD PRESSURE WITH AYSMPTOMATIC INTRACRANIAL AND EXTRACRANIAL ARTERIAL STENOSIS IN HYPERTENSION PATIENTS

Objective: Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites.Design and method: We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated for the presence and severity of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by the Vascular profiler 1000 device. Results: In the continuous study, ICAS was associated with age, male, average arm SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, the subjects with the top quartile of inter-arm DBP difference (>4 mmHg) showed significantly higher risk of ICAS (OR = 2.038; 95% CI, 1.347∼4.177). The risk of ICAS in patients with inter-arm DBP difference >= 5 mmHg was 103% higher (P = 0.009). And the participants with the top quartile of inter-arm SBP difference (>6 mmHg) showed higher risk of ECAS (OR = 2.031; 95% CI, 1.195∼3.452). The risk of ECAS in patients with inter-arm SBP difference >= 10 mmHg was 225% higher. Conclusions: In conclusion, we here reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study.

Risk Factors of Subacute Thrombosis After Intracranial Stenting for Symptomatic Intracranial Arterial Stenosis.

We aimed to explore the risk factors of subacute thrombosis (SAT) after intracranial stenting for patients with symptomatic intracranial arterial stenosis. From January to December 2013, all symptomatic intracranial arterial stenosis patients who underwent intracranial stenting in Beijing Tiantan Hospital were prospectively registered into this study. Baseline clinical features and operative data were compared in patients who developed SAT with those who did not. Binary logistic regression model was used to determine the risk factors associated with SAT. Of the 221 patients enrolled, 9 (4.1%) cases had SAT 2 to 8 days after stenting. Binary logistic analysis showed that SAT was related with tandem stenting (odds ratio [OR], 11.278; 95% confidence interval [CI], 2.422-52.519) and antiplatelet resistance (aspirin resistance: OR, 6.267; 95% CI, 1.574-24.952; clopidogrel resistance: OR, 15.526; 95% CI, 3.105-77.626; aspirin and clopidogrel resistance: OR, 12.246; 95% CI, 2.932-51.147; and aspirin or clopidogrel resistance: OR, 11.340; 95% CI, 2.282-56.344). Tandem stenting and antiplatelet resistance might contribute to the development of SAT after intracranial stenting in patients with symptomatic intracranial arterial stenosis.

Correlation between hemodynamic change of extracranial cerebral vessels evaluated by ultrasound and intracranial arterial stenosis

Objective By analyzing the correlation between Doppler spectrum of extracranial cerebral vessels (ECV) and intracranial arterial stenosis (IAS), to identify the value of hemodynamic change of ECV in predicting IAS. Methods One hundred and four patients with moderate to severe IAS or intracranial arterial occlusion were enrolled in the case group, while 32 patients without obvious cerebrovascular disease in the same period were enrolled in the control group. Ultrasound examinations of ECV were performed for all patients, the hemodynamic parameters of bilateral common carotid artery (CCA), internal carotid artery (ICA) and vertebral artery (VA) were recorded and compared between case and control group. Results Compared with control group, the ECV of patients with IAS had lower velocity and higher resistance index(RI). Of all the parameters, end diastolic velocity(EDV) of ICA and EDV of VA were most accurate in predicting IAS, with best cut off value of 21.3 cm/s, 9.6 cm/s and accuracy of 76.1%, 81.0% respectively. Conclusions The ECV of IAS patients tend to have lower velocity and higher RI.Analysis of hemodynamic parameters of ECV might be useful in predicting IAS. Key words: Ultrasonography; Carotid arteries; Hemodynamics; Intracranial arterial stenosis

Abstract TP213: Accuracy of Transcranial Color-coded Sonography for the Detection and Measurement of Intracranial Arterial Stenosis When Compared to CT Angiography in Patients With Acute Ischemic Stroke and Transient Ischemic Attack

Introduction: Transcranial Color-Coded Sonography (TCCS) including B-mode imaging and color-coded Duplex is non-invasive, bedside and inexpensive tool for the assessment of the intracranial circulation. TCCS can be used to assess intracranial stenosis but its accuracy has not been systematically compared to CT angiography in acute stroke patients. Hypothesis: TCCS has high accuracy when compared to CT angiography for the detection and measurement of intracranial arterial stenosis in patients with acute ischemic stroke. Methods: In this prospective study 43 patients (67% male; mean age: 59.8 ± 11 years) with acute ischemic stroke or Transient Ischemic Accident (TIA) underwent examinations of the intracranial arteries by TCCS and CT angiography. Different examiners that were blinded to test results performed the exams. TCCS and CT angiography were performed during the hospital stay. All stenotic segments of intracranial vessels were classified into 4 groups: normal or mild (&lt;50%), moderate (50%-70%), severe (≥70%) and subocclusion/occlusion. Results: 580 of 645 arterial segments in 43 patients were evaluated. The sensitivity, specificity, positive predictive value, and negative predictive value of TCCD in comparison with CT angiography for the detection of moderate to severe intracranial stenosis (≥50%) were 81.5%, 100%, 100%, and 76% respectively. The Cohen’s kappa between TCCS and CT angiography was 0.76 (p&lt;0.001). Conclusions: TCCS is a bedside non-invasive tool that can be used to evaluate intracranial arteries with high accuracy for moderate to severe stenosis when compared to CT angiography. Moderate agreement was found between TCCS and CT angiography for the evaluation of intracranial stenosis in patients with acute ischemic stroke or TIA.

High Frequency of Intracranial Arterial Stenosis and Cannabis Use in Ischaemic Stroke in the Young

Background: Leading aetiologies of ischaemic stroke in young adults are cervico-cerebral arterial dissections and cardio-embolism, but the causes remain undetermined in a considerable proportion of cases. In a few reports, intracranial arterial stenosis has been suggested to be a potential cause of ischaemic stroke in young adults. The aim of our work was to evaluate the frequency, characteristics and risk factors of intracranial arterial stenosis in a prospective series of young ischaemic stroke patients. Methods: The study was based on a prospective consecutive hospital-based series of 159 patients aged 18-45 years who were admitted to our unit for an acute ischaemic stroke from October 2005 to December 2010. A structured questionnaire was used in order to assess common vascular risk factors such as hypertension, diabetes, hypercholesterolemia, use of tobacco, alcohol and illicit drugs, migraine, and, in women, oral contraceptive use. A systematic screening was performed, including the following: brain magnetic resonance imaging or, if not feasible, brain computed tomography scan, carotid and vertebral Duplex scanning and trans-cranial Doppler sonography, 3D time-of-flight magnetic resonance cerebral angiography or cerebral computed tomography angiography. Long-duration electrocardiography, trans-thoracic and trans-oesophageal echocardiography were performed and laboratory blood investigations were extensive. Urine samples were screened for cannabinoids, cocaine, amphetamine and methylene-dioxy-methamphetamine. When this initial work-up was inconclusive, trans-femoral intra-arterial selective digital subtraction angiography with reconstructed 3D images was performed. Results: In this series, 49 patients (31%) had intracranial arterial stenosis. Other defined causes were found in 91 patients (57%), including cardio-embolism in 32 (20%), cervical dissection in 23 (14%), extracranial atherosclerosis in 7 (4%), haematological disorders in 7 (4%), small vessel disease in 1, and isolated patent foramen ovale in 21 (13%); in 19 patients (12%), ischaemic stroke was related to an undetermined aetiology. Comparing risk factors between patients with intracranial arterial stenosis and those with other definite causes showed that there were only two significant differences: a lower age and a higher frequency of vasoactive substances (especially cannabis) in patients with intracranial arterial stenosis. All intracranial arterial stenosis in patients who used vasoactive substances were located in several intracranial vessels. Conclusions: Intracranial arterial stenosis may be an important mechanism of stroke in young patients and it should be systematically investigated using vascular imaging. Strong questioning about illicit drug consumption (including cannabis) or vasoactive medication use should also be performed. It should be emphasized for health prevention in young adults that cannabis use might be associated with critical consequences such as stroke.

Association Between Ambulatory Systolic Blood Pressure During the Day and Asymptomatic Intracranial Arterial Stenosis

It is unclear at what time-window of the day blood pressure (BP) is most closely associated with cerebrovascular damage. In this cross-sectional study, we examined the strength of association between intracranial arterial stenosis (ICAS) and systolic BP (SBP) across different time-windows using 24-hour ambulatory BP monitoring in 757 consecutively recruited patients with hypertension. ICAS was diagnosed with computerized tomographic angiography in 127 (16.8%) patients, of whom 64 (50.4%) had stenosis ≥50% and 82 (64.6%) had ICAS in ≥2 vessels. Patients with ICAS (142 mm Hg), especially of multiple vessels (145 mm Hg), compared with patients without ICAS (126 mm Hg), had significantly (P<0.001) higher early morning (05:00-07:59 am) SBP. The differences remained significant (P≤0.015) after adjustment for cardiovascular risk factors and SBPs at other time-windows of the day. Multivariate regression analysis showed that consecutive 3-hourly mean SBPs during the day were significantly associated with ICAS (odds ratio for each 10-mm Hg increase, 1.28-1.38; P≤0.001). However, only mean SBP obtained between 05:00 am and 07:59 am remained significant for ICAS (odds ratio, 1.30; P=0.019) when all consecutive 3-hourly mean SBPs were forced into a single multivariate model. In conclusion, the present study showed a significant association between early morning SBP and asymptomatic ICAS in patients with hypertension after accounting for conventional cardiovascular risk factors. Our findings highlight the importance of morning SBP as a cardiovascular risk factor and should be validated in prospective studies.

Plasma Levels of Apolipoprotein E and Risk of Intracranial Artery Stenosis in Acute Ischemic Stroke Patients

Aims: We aimed to determine the potential blood markers responsible for the risks of intracranial artery stenosis (ICAS) in Korean ischemic stroke patients. Methods: One hundred and sixteen patients diagnosed with ICAS and 188 patients without cerebral atherosclerotic stenosis were examined. All subjects were diagnosed as acute ischemic stroke patients based on brain magnetic resonance imaging results and were admitted within 7 days of symptom onset. Blood lipids, lipoproteins, apolipoproteins including apolipoprotein CIII and apolipoprotein E (apoE), and lipoprotein(a) were measured. Results: No significant differences in total cholesterol, triglyceride, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol were observed between the groups. Also, plasma levels of apolipoprotein CIII and lipoprotein(a) were similar between the groups. On the other hand, patients with ICAS had significantly lower plasma levels of apoE (p < 0.001). Logistic regression and multiple linear regression analysis revealed that plasma apoE levels influenced the risk of ICAS after adjusting for age, body mass index, gender, associated lipid measures, medications and coexisting condition including hypertension, diabetes mellitus and previous stroke. Conclusions: Plasma concentrations of apoE were significantly lower in Korean subjects with ICAS, indicating that a low plasma apoE level may be a risk factor for ICAS in patients with acute ischemic stroke.

High Glycated Hemoglobin Levels and Intracranial Artery Stenosis Are Predictive Factors for Early Motor Worsening Events in Patients with Penetrating Artery Infarction

Background: The purpose of this study was to identify typical clinical characteristics to predict early motor worsening (EMW) of patients with penetrating artery infarction. Methods: We reviewed 65 consecutive patients with pure motor hemiparesis, sensorimotor stroke, and ataxic hemiparesis. EMW was defined as deterioration by ≥1 point on the National Institutes of Health Stroke Scale for motor function within 5 days of admission. Results: EMW was observed in 22 patients (34%). HbA1c levels were higher in patients with EMW than in those without EMW (7.9 ± 2.6 vs. 6.3 ± 1.6%; p < 0.01). The percentage of EMW patients with intracranial artery stenosis (ICAS) was greater than that of non-EMW patients with ICAS (13/22 patients, 59% vs. 8/43 patients, 19%; p < 0.01). Multivariate logistic regression analysis indicated that HbA1c levels ≥7.0% (OR 3.0, 95% CI 1.5–6.8; p < 0.005) or ICAS (OR 2.3, 95% CI 1.2–4.8; p < 0.05) increased the risk of EMW, and the combination of these factors increased the risk in an additive manner (OR 7.6, 95% CI 2.5–40; p < 0.005). Conclusion: HbA1c levels ≥7.0% and/or ICAS in patients with penetrating artery infarction are associated with EMW.

Detection of Intracranial Arterial Stenosis Using Transcranial Color-Coded Duplex Sonography, Computed Tomographic Angiography, and Digital Subtraction Angiography

The aim of this retrospective study was to compare intracranial arterial stenosis in patients with stroke using 3 different methods: transcranial color-coded duplex sonography, computed tomographic (CT) angiography, and digital subtraction angiography in a common clinical practice. Sixty-seven patients (47 male and 20 female; age range, 23-79 years; mean age ± SD, 62.0 ± 9.5 years) were enrolled in this study over 40 months. All patients underwent examinations of the intracranial arteries using transcranial color-coded sonography, CT angiography, and digital subtraction angiography. Findings were divided into 4 groups: normal, mild stenosis (<50%), severe stenosis (50%-99%), and occlusion. Because of technical reasons or an insufficient bone window, 465 of 536 arterial segments in 67 patients were evaluated; 12 stenotic and 15 occluded segments were detected using digital subtraction angiography. The sensitivity, specificity, positive predictive value, and negative predictive value of transcranial color-coded sonography and CT angiography in comparison with digital subtraction angiography as a reference standard were 88.9%, 94.8%, 51.1%, and 99.3% and 81.5%, 98.7%, 78.6%, and 98.6%, respectively. The agreement between transcranial color-coded sonography and CT angiography was 93.8% (κ = 0.559); between transcranial color-coded sonography and digital subtraction angiography, it was 93.9% (κ = 0.588); and between CT angiography and digital subtraction angiography, it was 96.6% (κ = 0.697). Moderate agreement was found between CT angiography, transcranial color-coded sonography, and digital subtraction angiography in the evaluation of intracranial stenosis. Computed tomographic angiography and digital subtraction angiography are sufficient for assessment of the diagnosis.

Cerebrovascular Disease and Intracranial Artery Stenosis in Patients with Symptomatic Peripheral Artery Disease

Patients with symptomatic peripheral artery disease (PAD) have an elevated prevalence of internal carotid artery (ICA) stenosis and cerebral infarction, although the correlations between the severity of PAD and cerebral infarction, cerebral white matter lesion (WML), or intracranial or extracranial artery stenosis are unclear. We evaluated the prevalence of cardiovascular risk factors, cerebral infarction, and WML on magnetic resonance imaging and intracranial and extracranial carotid artery stenoses on magnetic resonance angiography in patients with symptomatic PAD (n = 136; males/females [M/F] 109/27) and a control group comprised of patients without PAD (n = 92; M/F 57/35). PAD was classified by Fontaine stage (stage II, n = 46; stage III, n = 20; stage IV, n = 70). Cerebral infarctions were classified into symptomatic or asymptomatic groups. WMLs were evaluated according to Fazekas stage. Artery stenosis was classified as normal (no stenosis), mild (stenosis <50%), moderate (stenosis ≥ 50%), severe (tight stenosis), and obstruction on magnetic resonance angiography. Diabetes mellitus (DM), dyslipidemia, coronary artery disease (CAD), and chronic kidney disease (CKD), as well as symptomatic cerebral infarction and WML, were more frequent in patients with Fontaine III/IV PAD than without PAD. The prevalence rates of cerebral infarction and WML in patients with Fontaine stage II PAD were between those of the control and Fontaine III/IV PAD patients. Supraclinoid and cervical ICA stenoses (>50%) were more frequent in patients with Fontaine stage IV PAD than without PAD. Our results indicate that patients with advanced PAD have an increased prevalence of symptomatic cerebral infarction, WML, and intracranial and cervical ICA stenosis as well as DM, CAD, and CKD.

Diagnostik und endovaskuläre Therapie intrakranieller arterieller Stenosen

Approximately 6 - 50% of all ischemic strokes are caused by intracranial arterial stenosis (IAS). Despite medical prevention, patients with symptomatic IAS have a high annual risk for recurrent ischemic stroke of about 12%, and up to 19% in the case of high-grade IAS (≥ 70%). Digital subtraction angiography remains the gold standard for the diagnosis and grading of IAS. However, noninvasive imaging techniques including CT angiography, MR angiography, or transcranial Doppler and duplex ultrasound examinations are used in the clinical routine to provide additional information about the brain structure and hemodynamic. However, for technical reasons, the grading of stenoses is sometimes difficult and inaccurate. To date, aspirin is recommended as the treatment of choice in the prevention of recurrent ischemic stroke in patients with IAS. IAS patients who suffer a recurrent ischemic stroke or transient ischemic attack while taking aspirin can be treated with endovascular stenting or angioplasty in specialized centers. The periprocedural complication rate of these endovascular techniques is about 2 - 7% at experienced neuro-interventional centers. The rate of re-stenosis is reported between 10 and 40% depending on patient age and stenosis location. Further randomized studies comparing medical secondary prevention and endovascular therapy are currently being performed. With regard to the improvement of endovascular methods and lower complication rates, the indication for endovascular therapy in IAS could be broadened especially for stenosis in the posterior circulation.

Diagnostik, Prognose und Therapie von symptomatischen intrakraniellen Stenosen

In Caucasians, approximately 6.5 to 8 % of ischaemic strokes are caused by intracranial arterial stenosis (IAS). In spite of medical prevention, patients with symptomatic IAS have a high annual risk for recurrent ischaemic stroke of about 12 %. High-grade IAS (≥ 70 %) is associated with the highest recurrent stroke risk (19 %), compared to 6 % in patients with a stenosis 140 mm Hg and total cholesterol > 200 mg / dl. Digital subtraction angiography remains the gold standard for diagnosis and grading of IAS but is not appropriate as a screening tool. Non-invasive imaging techniques include computed tomography (CT), magnetic resonance (MR) angiography, or transcranial Doppler and duplex ultrasound examinations. CT angiography is preferred over MR angiography due to its higher sensitivity and specifity. Bedside transcranial Doppler and Duplex ultrasound can reliably exclude IAS in patients with acute cerebral ischaemia and is a non-invasive method for follow-up examinations. The Warfarin versus Aspirin for Symptomatic Intracranial Stenosis trial (WASID) showed that aspirin was as effective as warfarin in the prevention of recurrent stroke or vascular death, but had a significantly lower rate of major haemorrhage and mortality. IAS patients who suffer a recurrent ischaemic stroke or transient ischaemic attack under aspirin can be treated with endovascular stenting or angioplasty in specialised centres. The periprocedural complication rate of these endovascular techniques is about 6-7 % in experienced neuro-interventional centres. To date, no randomised study comparing medical secondary prevention and endovascular therapy has been completed.