Intracranial Atherosclerotic Stenosis Patients Research Articles

Biomarker study of symptomatic intracranial atherosclerotic stenosis in patients with acute ischemic stroke

Biomarker study of symptomatic intracranial atherosclerotic stenosis in patients with acute ischemic stroke

Assessing the Adequacy of Superficial Temporal Artery Blood Flow in Korean Patients Undergoing STA-MCA Anastomosis.

Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is conducted for flow augmentation. In this study, we measured the STA cut flow of a Korean population and evaluated the relationship between STA cut flow and long-term patency of the bypass. A retrospective study was conducted. Intraoperative measurement of STA flow was conducted using a microvascular flow meter on patients who underwent STA-MCA. After cutting the distal end, the STA flow rate was measured with no resistance and recorded. After finishing anastomosis, STA flow was measured and recorded. The cut flow index was calculated by dividing post anastomosis flow by cut flow in intracranial atherosclerotic stenosis patients. The median STA cut flow was 35.0 mL/min and the post anastomosis flow was 24.0 mL/min. The cut flow of STA decreased with aging (p=0.027) and increased with diameter (p=0.004). The cut flow showed no correlation with history of hypertension or diabetes mellitus (p=0.713 and p=0.786), but did correlate a positively with history of hyperlipidemia (p=0.004). There were no statistical differences in cut flow, STA diameter, and post anastomosis flow between the frontal and parietal branches (p=0.081, p=0.853, and p=0.990, respectively). The median STA cut flow of a Korean population was 35 mL/min. Upon reviewing previous articles, it appears that there are differences in the STA cut flow between Western and Asian patients.

Clinical features of ischemic stroke in patients with nonvalvular atrial fibrillation combined with intracranial atherosclerotic stenosis.

Nonvalvular atrial fibrillation (NVAF) and intracranial atherosclerotic stenosis (ICAS) are major causes of ischemic stroke. Relatively few studies have focused on the risk factors and clinical features of ischemic stroke caused by NVAF combined with ICAS. We retrospectively evaluated NVAF and/or ICAS in patients with acute ischemic stroke admitted within 72h after stroke. All patients with acute ischemic stroke underwent diffusion-weighted magnetic resonance imaging (DWI), magnetic resonance angiography (MRA), computed tomography angiography (CTA), and/or digital subtraction angiography (DSA). NVAF was detected by routine electrocardiogram or 24-h Holter examination, Doppler echocardiography, and contrast echocardiography of the right heart. Among the 635 enrolled patients, NVAF, ICAS, and NVAF+ICAS were diagnosed in 170 (26.77%), 255 (40.16%), and 210 (33.07%) patients, respectively. Patients in the NVAF+ICAS group were older (p<.001), specifically aged ≥75 years (p<.001). The admission time of the NVAF+ICAS group was shorter (p<.001) than that of the ICAS group. The admission NIHSS score of the NVAF group was higher than that of the NVAF+ICAS group (p<.001). HsCRP, NTpro-BNP, and LEVF levels were significantly different among the three groups (p<.001). NVAF+ICAS ischemic stroke occurred mainly in the right hemisphere (52.4%). NVAF with ICAS ischemic stroke is more likely to occur in older patients. Infarctions occurred mainly in the right cerebral hemisphere. Neurological deficits in NVAF are more severe than those in NVAF combined with ICAS and in simple ICAS ischemic strokes. HsCRP, LEVF, andNTpro-BNP seem to be closely associated with NVAF+ICAS ischemic stroke.

Functional evaluation of intracranial atherosclerotic stenosis by pressure ratio measurements

BackgroundFractional flow reserve is widely used for the functional evaluation of coronary artery stenosis. Some studies have similarly used the translesional pressure ratio measurements for the functional evaluation of intracranial atherosclerotic stenosis. In this paper, we aimed to investigate the relationship between pressure ratio and cerebral tissue perfusion by MR perfusion imaging and provided a non-invasive method for evaluating the functional significance of intracranial atherosclerotic stenosis. MethodsA total of 18 consecutive patients with intracranial atherosclerotic stenosis patients including 19 stenotic vessels were recruited. The pressure was measured using a pressure guidewire, the pressure ratio before and after the endovascular intervention was calculated and compared with the severity of diameter stenosis and perfusion-derived MR (the time to maximum tissure residue function (Tmax)). Moreover, the DSA-derived pressure ratio was computed using a novel computational fluid dynamics-based model, termed CFD-PR, and was compared with the actual pressure ratio to assess its diagnostic accuracy. ResultsThe pressure ratio increased after percutaneous transluminal angioplasty or stenting, while the correlation between pressure ratio and diameter stenosis was not significant. The pressure ratio was negatively correlated with Tmax (r = −0.73, P < 0.01), and a 95% confidence interval for the cutoff value of pressure ratio = 0.67 (95% confidence interval: 0.58–0.76) was suggested. There was a good correlation (mean = 0.02, Spearman's correlation coefficient r = 0.908, P < 0.001) and agreement (limits of agreement: -0.157 to 0.196, P = 0.954) between CFD-PR and the actual pressure ratio. ConclusionsThis exploratory study indicates the pressure ratio may correlate with the perfusion status. The pressure ratio can be calculated through a non-invasive method using a computational fluid dynamics-based method.

A retrospective study of individualized endovascular treatment for symptomatic intracranial atherosclerotic stenosis in patients with ischemic stroke/transient ischemic attack.

Endovascular treatment (EVT) is one of the effective treatment procedure for the symptomatic intracranial atherosclerotic stenosis (sICAS). We evaluated the efficacy and safety of individualized endovascular treatment for sICAS patients. Clinical and imaging follow-ups were carried out to collect the data of 29 sICAS patients after 6 months of individualized endovascular treatment. Different treatment strategies are selected based on arterial access and lesion morphology of patients. If standard surgical path, narrow artery straight, stenosis length ≤10 mm, then the appropriate specifications of balloon-mounted stent (BMS) treatment. the surgical path is tortuous, the narrow artery is curved, the angle is apparent, the diameter of the near and far ends is significantly different, or the length of the stenosis is >10 mm, self-expanding stent (SES) with appropriate specifications is selected for treatment. If the narrowed artery is hyper flexed and the surgeon deems stenting inappropriate, balloon dilation angioplasty (BDA) treatment is chosen. 31 lesions of 29 sICAS patients received endovascular treatment. The median age was 61 years (IQR 54-69 years). The median preoperative stenosis was 90% (IQR 80-95%), and the mean stenosis length was (8.10 ± 3.27) mm. The most commonly used surgical procedure was Balloon-Mounted Stent (BMS) in 19 cases (65.52%), Self-expanding Stent (SES) in seven cases (24.14%), Balloon Dilation Angioplasty (BDA) in three cases (10.34%). (11.86 + 1.46 mm) was greater than that in the BMS group (6.14 + 1.59 mm) (P < 0.001). The median stenosis was 90% (IQR 80-92.5%) in the BMS group, lower than 99% (IQR 95-100%) in the SES group (P < 0.001). The median post-operative residual stenosis was 20% (IQR 15-25%), significantly improved compared with preoperative (P < 0.001). The success rate of the surgical technique was 93.10% (27/29). One patient (3.45%) had IS recurrence within 48 h after surgery, and the restenosis rate within 6 months after surgery was 6.90% (2/29). No patient died or had recurrent IS. Our data demonstrated that individualized endovascular treatment method could be potentially significant and safe for sICAS patients. This study will provide an important reference for the endovascular treatment of sICAD.

Glucose-6-phosphate dehydrogenase deficiency and intracranial atherosclerotic stenosis in stroke patients.

Intracranial atherosclerotic stenosis (ICAS) is a major cause of stroke in Asian countries. Glucose-6-phosphate dehydrogenase (G6PD) deficiency, a hereditary enzyme defect prevalent in Asian countries, has been associated with atherosclerotic cardiovascular disease and worse poststroke outcomes. However, the impact of G6PD deficiency on ICAS remains unclear. We aimed to compare the risk of ICAS in stroke patients with and without G6PD deficiency in a Chinese cohort. We prospectively and consecutively recruited stroke patients from four centers in China. All patients received intracranial artery assessment by magnetic resonance/computed tomography angiography or digital subtraction angiography, as well as G6PD enzyme evaluation. The prevalence, burden, and characteristics of ICAS were compared between patients with and without G6PD deficiency using multivariate regression analysis. Among 1593 patients, 116 (63.7%) of 182 patients with G6PD deficiency and 714 (50.6%) of 1411 patients with normal G6PD levels were identified as ICAS. Age, hypertension, diabetes, and G6PD deficiency were independent predictors of ICAS. Among patients with ICAS, G6PD-deficient individuals were more likely to have multiple (≥2 segments) intracranial stenosis (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.25-2.81, p= 0.002). G6PD deficiency increased the risk of ICAS in patients who were male (OR=1.82, 95% CI=1.24-2.66, p= 0.002), aged ≥70 years (OR=2.40, 95% CI=1.33-4.31, p= 0.004), or hypertensive (OR=1.88, 95% CI=1.28-2.77, p= 0.001). Stroke patients with G6PD deficiency have a higher prevalence and ICAS burden than those with normal G6PD, particularly those who are male, older, and hypertensive.

Value of transcranial color-code Doppler in evaluating intracranial atherosclerotic stenosis in patients with diabetes mellitus type 2: a comparison of transcranial Doppler and computed tomography angiography.

There are several imaging assessment methods for intracranial atherosclerotic stenosis (ICAS). This study investigated the most efficient method by which to diagnose ICAS in patients with diabetes mellitus. One hundred seven patients with type 2 diabetes mellitus were enrolled as the experimental group and 68 healthy subjects were designated as the control group. The experimental group was examined with transcranial color-code Doppler (TCCD) and transcranial Doppler (TCD). Sixty-five patients in the experimental group were diagnosed by computed tomography angiography (CTA) on a voluntary basis. The 68 subjects in the control group were examined by TCCD alone. Based on TCCD examinations, the ICAS positivity rate was 71.0% (76/107) in the experimental group, which was greater than the 42.6% (29/68) in the control group (χ2=13.954, P<0.001). The middle cerebral artery was most frequently affected by ICAS (χ2=4.684, P=0.030), with a higher incidence of moderate and severe stenosis (χ2=4.510, P=0.034). The ICAS positivity rate was 64.6% (42/65) by TCCD, 75.4% (49/65) by CTA, and 53.8% (35/30) by TCD. There was a statistically significant difference between the TCCD and CTA (χ2=1.795, P=0.180) and between the TCD and CTA (χ2=6.594, P=0.010) positivity rates. ICAS is expected to occur in patients with diabetes mellitus more often than healthy subjects, and to involve the middle cerebral artery with moderate-to-severe stenosis. The ICAS positivity rate evaluated by TCCD was lower than CTA and higher than TCD.

Predictors of risk of intracerebral hemorrhage after intracranial artery intervention in intracranial atherosclerotic stenosis patients

To investigate the relationship between clinical characters of intracranial atherosclerotic stenosis patients and occurrence of cerebral hemorrhage after intracranial artery intervention. Clinical data of total 501 patients who underwent endovascular therapy for ischemic stroke or transient ischemic attack were retrospectively reviewed. Median (interquartile range, IQR) of the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral score was higher in intracerebral hemorrhage (ICH) group (P < 0.001). Cerebral blood flow (CBF) reducing, cerebral blood volume (CBV) reducing, time to peak (TTP) delaying and mean transit time (MTT) delaying in the lesion side comparing the contralateral side were higher in ICH group (P = 0.018, P = 0.046, P = 0.012, P = 0.038). ASITN/SIR ≤ 2, CBF reducing ≥ 40%, CBV reducing ≥ 30%, TTP delaying ≥ 2 s, MTT delaying ≥ 1 s, infarction volume ≥ 20 mL were probably the independent predictors of ICH following endovascular therapy.

Elevated homocysteine as an independent risk for intracranial atherosclerotic stenosis.

To investigate the association of homocysteine concentration with intracranial atherosclerotic stenosis (ICAS), we assessed 933 acute ischemic stroke patients (346 with ICAS, 587 without ICAS) and 798 non-stroke controls (175 with ICAS, 623 without ICAS) with magnetic resonance angiography (MRA). Homocysteine concentration was found to be significantly higher in participants with ICAS than those without ICAS. In logistic regression analyses, homocysteine concentration was significantly associated with ICAS both in patients (OR: 1.04; 95% CI: 1.01–1.08; P=0.008) and controls (OR: 1.10; 95% CI: 1.06–1.15; P<0.001) for 1 μmol/L increment in homocysteine. Compared with the lowest quartile, the second (OR:1.53; 95% CI: 1.01-2.33), third (OR:1.71; 95% CI: 1.14 -2.60) and fourth (OR:2.48; 95%CI: 1.63-3.81) quartiles were independent predictors of ICAS in patients (P for trend<0.001); the third (OR:1.99; 95% CI: 1.18-3.40) and fourth (OR:2.36; 95%CI: 1.38-4.10) quartiles were independent predictors of ICAS in controls (P for trend<0.001). Hence, elevated homocysteine might be an independent risk for ICAS.

Microcatheter "First-Pass Effect" Predicts Acute Intracranial Artery Atherosclerotic Disease-Related Occlusion.

The differentiation between intracranial atherosclerotic stenosis (ICAS) and intracranial embolism as the immediate cause of acute ischemic stroke requiring endovascular therapy is important but challenging. In cases of ICAS, we often observe a phenomenon we call the microcatheter "first-pass effect," which is temporary blood flow through the occluded intracranial artery when the angiographic microcatheter is initially advanced through the site of total occlusion and immediately retrieved proximally. To evaluate whether this microcatheter first-pass effect can be used to differentiate ICAS from intracranial embolism. A total of 61 patients with acute ischemic stroke resulting from large intracranial artery occlusion and in whom recanalization was achieved by endovascular treatment were included in the study. The microcatheter first-pass effect was tested in these patients. The sensitivity, specificity, positive predictive values (PPV), and accuracy of the microcatheter first-pass effect for prediction of ICAS were assessed. The microcatheter first-pass effect was more frequently observed in patients with ICAS than in those with intracranial embolism (90.9% vs 12.8%, P<.001). For identifying ICAS, sensitivity, specificity, PPV, and accuracy of the microcatheter first-pass effect were 90.9%, 87.2%, 80.0%, 88.5%, respectively. The sensitivity and PPV of the microcatheter first-pass effect are high for prediction of ICAS in patients with acute symptoms.

Endovascular Recanalization of Symptomatic Intracranial Arterial Stenosis Despite Aggressive Medical Management

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. Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (transient ischemic attack [TIA] or stroke) intracranial stenosis who had failed medical therapy. Patients were divided into 2 groups: patients with recurrent TIA or stroke despite medical management (group 1) versus patients presenting with a stroke and worsening symptoms (progressive or crescendo stroke) despite medical management (group 2). A total of 101 patients were treated in 8 stroke centers from August 2009 to May 2017. Sixty-nine presented with recurrent TIA or stroke and 32 with stroke and worsening symptoms. Successful recanalization was achieved in 84% of patients. Periprocedural stroke occurred in 3 patients and 2 had a recurrent ischemic stroke at the 90-day follow-up. Symptomatic intraparenchymal hemorrhage secondary to reperfusion injury occurred in 3 patients and 1 had a hemorrhagic stroke after discharge. There were 2 periprocedural perforations that resulted in death. At 90 days, 86% of patients (64/74) did not have a recurrence of stroke and the 90-day cumulative ischemic stroke rate was 6.7% with 90-day mortality of 11.2%. The 90-day favorable outcome (modified Rankin Scale score, ≤2) rate was 77.5%. Endovascular recanalization of unstable intracranial atherosclerotic stenosis in patients who have failed medical therapy is feasible. Future randomized trials need to determine if recanalization is of any value for this population.

Acute Basilar Artery Occlusion: Differences in Characteristics and Outcomes after Endovascular Therapy between Patients with and without Underlying Severe Atherosclerotic Stenosis.

Prediction of underlying intracranial atherosclerotic stenosis before endovascular therapy might be helpful for appropriate therapeutic planning in patients with acute ischemic stroke. This study aimed to compare the characteristics and treatment outcomes in patients with acute basilar artery occlusion relative to the existence or nonexistence of underlying intracranial atherosclerotic stenosis. Sixty-two patients with acute basilar artery occlusion underwent multimodal endovascular therapy. All patients underwent stent-retriever thrombectomy as a first-line endovascular therapy. Patients with underlying intracranial atherosclerotic stenosis underwent additional intracranial angioplasty and stent placement. The clinical and imaging characteristics and treatment outcomes were retrospectively analyzed and compared between patients with and without intracranial atherosclerotic stenosis. Underlying intracranial atherosclerotic stenosis was identified at the occlusion site in 15 patients (24.1%). Occlusion in the proximal segment of the basilar artery was more common in patients with intracranial atherosclerotic stenosis (60% versus 6.4%, P < .001), whereas occlusion in the distal segment was more common in those without it (91.5% versus 26.7%, P < .001). Bilateral thalamic infarction on a pretreatment DWI was less common in patients with intracranial atherosclerotic stenosis (0% versus 27.7%, P = .027) compared with those without it. There were no significant differences in the rates of successful revascularization, favorable outcome, symptomatic hemorrhage, and mortality between the 2 groups. Underlying intracranial atherosclerotic stenosis was not uncommon in patients with acute basilar artery occlusion. The occlusion segment of the basilar artery and the presence or absence of bilateral thalamic infarction on a pretreatment DWI might be helpful for predicting underlying intracranial atherosclerotic stenosis in patients with acute basilar artery occlusion. Patients with and without underlying intracranial atherosclerotic stenosis who underwent endovascular therapy had similar outcomes.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery for Refractory Symptomatic Intracranial Atherosclerotic Stenosis.

To evaluate blood flow changes after bypass surgery for refractory symptomatic intracranial atherosclerotic stenosis (ICAS). We examined a cohort of consecutive patients with symptomatic ICAS. Superficial temporal artery-middle cerebral artery (MCA) bypass was performed in refractory patients with poor perfusion. Angiograms were graded systematically for antegrade, collateral, and bypass flow, and clinical variables were collected preoperatively, at 7 days postoperatively, and 3, 6, and 12 months postoperatively. Among 185 consecutive cases with ICAS, 15 patients who were unsuitable for or did not respond to the best medical therapy or stenting underwent bypass surgery. No patients had new ischemic deficits within 7 days postoperatively. The mean follow-up period was 30.2 ± 12.3 months. Within this period, all anastomoses were patent by methods of ultrasound or computed tomography angiography. In 2 patients, stenotic lesions exhibited early postoperative occlusion conversion at 7 days on digital subtraction angiography. In 2 patients, stenotic lesions showed progression of occlusion at 6 and 8 months. The 2 lesions with early occlusion were both located in the MCA. The extent of retrograde blood flow via bypass anastomosis was correlated with early occlusion conversion. For refractory ICAS in patients with compromised hemodynamics, direct bypass might induce early occlusion of a stenotic area. MCA lesions may have a greater tendency toward early occlusion conversion.

Remote limb ischemic conditioning treatment for intracranial atherosclerotic stenosis patients.

The recurrence rate of ischemic stroke remains high among symptomatic intracranial atherosclerotic stenosis patients with either ischemic stroke or transient ischemic attack. The aim of our study is to evaluate whether remote limb ischemic conditioning (RLIC) prevents cerebral ischemic events in symptomatic intracranial atherosclerotic stenosis patients. Symptomatic intracranial atherosclerotic stenosis patients with either ischemic stroke or transient ischemic attack will be recruited from more than 60 hospitals in China to participate in a randomized, double-blind, parallel-controlled clinical trial that will compare the efficacy and safety of RLIC for the prevention of recurrent stroke. Following randomization, patients allocated to the RLIC group (n = 1500) will receive RLIC once daily for 12 months, with treatment consisting of five cycles of 5 min of pressure treatment at 200 mm Hg, followed by 5 min of reperfusion. The sham group (n = 1500) will be treated identically, with the exception of pressure treatment at 60 mm Hg. The primary endpoint will be an ischemic stroke event during the study period. Secondary endpoints will include composite fatal and nonfatal stroke, fatal and nonfatal myocardial infarction, and transient ischemic attack. Patients will be assessed periodically over a approximate 3-year study period using the modified Rankin Scale, National Institutes of Health Stroke Scale, and Barthel Activities of Daily Living Index. We predict that RLIC treatment for 12 months will safely reduce the ischemic stroke recurrence rate.

A Polymorphism in RNF213 Is a Susceptibility Gene for Intracranial Atherosclerosis.

BackgroundBoth intracranial atherosclerotic stenosis (ICAS) and moyamoya disease (MMD) are prevalent in Asians. We hypothesized that the Ring Finger protein 213 gene polymorphism (RNF213), a susceptibility locus for MMD in East Asians, is also a susceptibility gene for ICAS in patients whose diagnosis had been confirmed by conventional angiography (absence of basal collaterals) and high-resolution MRI (HR-MRI, presence of plaque).MethodsWe analyzed 532 consecutive patients with ischemic events in the middle cerebral artery (MCA) distribution and relevant stenotic lesion on the distal internal carotid artery or proximal MCA, but no demonstrable carotid or cardiac embolism sources. Additional angiography was performed on 370 (69.5%) patients and HR-MRI on 283 (53.2%) patients.ResultsBased on angiographic and HR-MRI findings, 234 patients were diagnosed with ICAS and 288 with MMD. The RNF213 variant was observed in 50 (21.4%) ICAS patients and in 119 (69.1%) MMD patients. The variant was observed in 25.2% of patients with HR-MRI-confirmed ICAS. Similarly, 15.8% of ICAS patients in whom MMD was excluded by angiography had this variant. Among the ICAS patients, RNF213 variant carriers were younger and more likely to have a family history of MMD than non-carriers were. Multivariate testing showed that only the age of ICAS onset was independently associated with the RNF213 variant (odds ratio, 0.97; 95% CI, 0.944–0.99).ConclusionsRNF213 is a susceptibility gene not only for MMD but also for ICAS in East Asians. Further studies are needed on RNF213 variants in ICAS patients outside East Asian populations.

Complication of Stenting in Intracranial Arterial Stenosis.

To evaluate the perioperative complications and long-term restenosis rates following percutaneous transluminal angioplasty and stenting (PTAS) in patients with intracranial atherosclerotic stenosis (ICAS). A retrospective analysis was performed on the clinical data of 102 ICAS patients (103 cases of stenosis) who underwent PTAS. The perioperative complications and long-term restenosis rates were analyzed. The success rate of PTAS was 100%. Six patients (5.83%, 6/103) had perioperative complications. Six cases (6.52%, 6/92) of restenosis occurred and one patient (1.09%) died. Five of the 6 restenosis cases (5.43%) occurred in the blood-supplying region and were associated with ischemic symptoms and one patient (1.09%) had no ischemic symptom. The postoperative restenosis rates at 6, 6 - 12, and 12 - 74 months were 3.26%, 2.56%, and 2.38%, respectively. The postoperative restenosis rates had a significant difference between the residual stenosis rate ≥ 20% and < 20% (P < 0.05), and between postoperative regular medication and non-regular medication (P < 0.05). The postoperative restenosis risk in patients with age ≥ 60 years was 13.481 times to that in patients with age < 60 years. The postoperative restenosis risk in patients with residual stenosis rate < 20% was 31.25 times to that in patients with residual stenosis rate ≥ 20%. The postoperative restenosis risk in patients with regular medication was 12.65 times to that in patients without regular medication. The vasospasm, arterial dissection, arterial occlusion and acute thrombosis are common perioperative complications following PTAS in patients with ICAS. The medium- and long-term postoperative restenosis rate is low. Age is the risk factor for postoperative restenosis.

Negative Susceptibility Vessel Sign and Underlying Intracranial Atherosclerotic Stenosis in Acute Middle Cerebral Artery Occlusion.

The role of MR imaging in predicting underlying intracranial atherosclerotic stenosis before endovascular stroke therapy has not been studied. Our aim was to determine the diagnostic value of the negative susceptibility vessel sign on T2*-weighted gradient-echo MR imaging for predicting underlying intracranial atherosclerotic stenosis in patients with acute MCA occlusion. Ninety-one consecutive patients with acute stroke because of MCA occlusion underwent gradient-echo MR imaging and MRA before endovascular therapy. The negative susceptibility vessel sign was defined as an absence of a hypointense signal change within the occluded MCA on gradient-echo imaging. Underlying intracranial atherosclerotic stenosis was determined by conventional angiography. The sensitivity, specificity, predictive values, and accuracy of the negative susceptibility vessel sign for predicting the presence of underlying intracranial atherosclerotic stenosis were assessed. The negative susceptibility vessel sign was identified in 42 (46.1%) of 91 patients, and 18 (19.8%) patients had an underlying intracranial atherosclerotic stenosis responsible for acute ischemic symptoms. The negative susceptibility vessel sign was more frequently observed in patients with intracranial atherosclerotic stenosis than in those without it (100% versus 32.9%, P < .001). In the prediction of an underlying intracranial atherosclerotic stenosis, the negative susceptibility vessel sign had 100% sensitivity, 67.1% specificity, 42.9% positive predictive value, 100% negative predictive value, and an accuracy of 73.6%. The negative susceptibility vessel sign on gradient-echo MR imaging is a sensitive marker with a high negative predictive value for the presence of an underlying intracranial atherosclerotic stenosis in patients with acute ischemic stroke because of MCA occlusions. The susceptibility vessel sign can be used in decision-making when performing subsequent endovascular revascularization therapy in patients with acute MCA occlusions.

Outcome of Patients With ≥70% Symptomatic Intracranial Stenosis After Wingspan Stenting

There were limited data on the long-term outcome of patients with symptomatic intracranial atherosclerotic stenosis ≥70% after Wingspan stenting. Using our Wingspan cohort data and the data from the Warfarin and Aspirin for Symptomatic Intracranial Atherosclerotic Disease (WASID) as a historical control, we tested the hypothesis that stenting provided no benefit over antithrombotic therapy alone for these high-risk patients. Between January 2007 and February 2009, 100 consecutive patients with intracranial atherosclerotic stenosis ≥70% and symptoms within 90 days were enrolled into this prospective single-center Wingspan cohort study and followed up until the end of February 2010. Stenosis was measured per the WASID criteria. One-year risk of primary end point (any stroke or death within 30 days and ipsilateral ischemic stroke afterward) was compared with that of ipsilateral ischemic stroke in the WASID patients with ≥70% stenosis. The stent placement success rate was 99%. All patients but 1 had clinical follow-up of ≥12 months. During a mean follow-up of 1.8 years, 9 patients developed primary end point events (5 within 30 days and 4 afterward). The 1-year risk of the outcome events was lower than that in similar WASID patients: 7.3% (95% CI, 2.0% to 12.5%) versus 18% (95% CI, 13% to 24%; P<0.05). The clinical outcome of Wingspan stenting for high-risk intracranial atherosclerotic stenosis patients in this high-volume center study compares favorably with that of antithrombotic therapy alone. A randomized trial comparing medical therapy alone with medical therapy plus Wingspan stenting, conducted at high-volume centers, is needed to confirm the stenting benefit.