Intracranial Large Artery Research Articles

Abstract P546: Emergent Carotid Artery Stenting and Intracranial Thrombectomy for Acute Stroke With Tandem Occlusion

Introduction: Safety of emergent carotid artery stenting (CAS) during endovascular thrombectomy (EVT) for acute strokes with intracranial large vessel and cervical internal carotid artery tandem occlusion is still unclear. Given the potential risk of symptomatic intracranial hemorrhage (ICH) with anti-thrombotic medications required in the setting of CAS, the decision between CAS versus carotid artery angioplasty (CAA) alone remains controversial. In this study, we aimed to identify the optimal endovascular carotid revascularization approach in this patient population, using a large, nationally representative dataset. Methods: We utilized the Nationwide Readmissions Database 2016-2017 to identify patients admitted due to acute ischemic stroke who underwent anterior circulation EVT as well as CAS or CAA on the same day. Survey design methods were used to generate national estimates. Logistic regression analysis was used to compare the in-hospital outcomes between patients who underwent CAS versus CAA. Survival analysis was used to estimate the 30-day readmissions. Results: We identified 2,042 hospitalizations meeting the study inclusion criteria (mean±SD age: 66.0±12.5 years, female 31.3%). Of these, 1,391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar except patients with CAS were more likely to be on anti-thrombotics and were less likely to have received intravenous thrombolysis (tPA) as compared to those with CAA. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, and hospital charges between the two groups in unadjusted analysis and after adjustment for the demographics and tPA use. All-cause 30-day readmission rate was similar between the two groups [hazards ratio (HR) 0.98, 95% confidence interval (CI) 0.64-1.51, p-value 0.924]. Patients with CAS had more readmissions due to ICH (HR 2.72, 95% CI 0.30-24.74) and less readmissions due to ischemic events (HR 0.78, 95% CI 0.12-5.08), although the difference was not statistically significant. Conclusion: Emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.

Abstract P653: Intracranial Artery Calcification Variations by Stroke Subtypes

Introduction: Intracranial artery calcification (IAC) is a common radiological finding on Computed Tomography (CT) scan. Although IAC occurs with aging, it is uncertain whether IAC varies by stroke subtypes. Method: We included patients admitted to our hospital with acute stroke. We quantified calcification volume of both clinoid and siphon carotid arteries, vertebral arteries at the V4 segment, and the basilar artery using an in-house quantification tool for non-contrast brain CT. Stroke etiological subtypes were determined according to the Trial of Organon in Acute Stroke Trial (TOAST) classification system independent of the calcification quantification. Demographic and clinical information was extracted from the medical records. We determined the prevalence of IAC in 51% of patients. (31% anterior, 7% posterior, and 14 % in both circulations) Result: We included 694 patients with stroke history (mean age 68 ± 16, range 21-101, 55% women, 71% nonwhite or mixed). IAC was associated with male sex (OR 1.47 [95%-CI 1.41-2.08), older age (OR 1.05 [95%-CI, 1.04-1.06]), hypertension (OR 1.55 [95%-CI, 1.01-2.36], dyslipidemia (OR 1.54 [95%-CI, 1.06-2.25]), and smoking (OR 1.79 [95%-CI, 1.18-2.71]). Anterior IAC was associated with dyslipidemia (OR 1.57 [95%-CI, 1.08-2.28], smoking (1.9 [95%-CI, 1.25-2.88]), and older age (OR 1.05 [95%-CI, 1.36-1.66). Posterior IAC was associated with myocardial infarction (OR 1.58 [95%-CI, 1.01-2.47] and older age (OR 1.02 [95%-CI, 1.01-1.03]. In multivariate analyses, any IAC was associated with small artery disease stroke (OR 1.01[95%-CI, 1.41-3.98]). Stratifying by circulations, however, demonstrated that the association was only with posterior (OR 1.22[95%-CI, 1.02-2.28]) and not anterior IAC (OR 1.20[95%-CI, 0.86-1.1.69]). There was no association between IAC and intracranial large artery stenoses OR (1.22[95%-CI, 0.78-1.1.92]). Conclusion: IAC is a marker of arterial disease, and its prevalence relates to vascular risk factors and small artery disease strokes. Understanding the mechanism by which IAC may relate to small artery disease may help us understand small artery stroke physiopathology and discover novel therapies for its treatment.

Characterisation of symptomatic intracranial plaque without substantial stenosis using high-resolution vessel wall MRI

To characterise symptomatic intracranial plaque without substantial stenosis using three-dimensional (3D) high-resolution contrast-enhanced black-blood magnetic resonance imaging (BBMRI) and to determine plaque features associated with recent cerebrovascular events. The institutional review board approved this retrospective study. The case notes from patients with evidence of intracranial atherosclerosis in a large intracranial artery with preceding BBMRI were reviewed retrospectively. Symptomatic and asymptomatic plaques with substantial luminal stenosis (<50%) were matched by plaque location and patient age. All MRI images were de-identified and interpreted by two neuroradiologists who were blinded to the history of symptoms. Qualitative analyses including the presence of intraplaque haemorrhage (IPH), eccentricity, surface irregularity, and grade of plaque enhancement were recorded. Quantitative analyses including normal wall index and degree of contrast enhancement were calculated. Multivariate regression analysis was performed to identify the association with cerebrovascular ischaemic events. A total of 38 pairs of symptomatic and asymptomatic plaques from 74 patients were analysed. Compared to asymptomatic plaques, symptomatic plaques demonstrated higher degree of contrast enhancement (29.77±19.23 versus 18.21±12.18%, p=0.039) and presence of IPH (26% versus 8%, p=0.032). No significant differences were detected regarding eccentricity, surface irregularity, and normal wall index. Events were associated with contrast enhancement (OR, 1.212; 95% confidence interval [CI], 1.086-1.352) after controlling for age, sex, cardiovascular risk factors, and stenosis degree. IPH was not associated with events. Contrast enhancement in the intracranial plaque without substantial stenosis is associated with previous events, and may serve as the vulnerable feature, thereby stratifying stroke risk not achievable by luminal stenosis.

Efficacy and safety of mechanical thrombectomy for cardioembolic stroke: A protocol for systematic review and meta-analysis.

Background:Several randomized clinical trials have demonstrated the safety and efficiency of mechanical thrombectomy in the management of acute ischaemic stroke caused by larger vessel occlusion. According to the trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, acute ischaemic stroke can be divided into cardioembolic stroke and non-cardioembolic stroke. Previous studies have shown that mechanical thrombectomy in cardioembolic stroke with intracranial large artery occlusion has a poor prognosis. The reason may be that the old emboli are hard, making it difficult to remove. However, recent evidence shows that mechanical thrombectomy is also effective and safe in patients with cardioembolic stroke. Therefore, the aim of this study is to evaluate the efficacy and safety of mechanical thrombectomy for cardioembolic stroke.Methods:The electronic database, including PubMed, Cochrane Library, EMBASE, the China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), VIP database, and Wan-fang database, were thoroughly retrieved from inception to December 1, 2021, without language restrictions. All randomized controlled trials that evaluated the efficacy and safety of mechanical thrombectomy in the treatment of cardioembolic stroke will be included. Primary outcomes will include vascular recanalization rate and score scale. Two authors will independently scan the articles searched, extract the data from articles included, and assess the risk of bias by Cochrane tool of risk of bias. Disagreements will be resolved by discussion among authors. All analysis will be performed based on the Cochrane Handbook for Systematic Reviews of Interventions. Dichotomous variables will be reported as risk ratio or odds ratio with 95% confidence intervals and continuous variables will be summarized as mean difference or standard mean difference with 95% confidence intervals.Results:This review will be to assess the efficacy and safety of mechanical thrombectomy for cardioembolic stroke.Conclusions:The results of our findings may be helpful for clinicians and health professionals to re-examine the clinical decision-making in the treatment of cardioembolic stroke, promising way for treatment of patients with cardioembolic stroke.Systematic review registration number:INPLASY2020120035

Vertebral artery hypoplasia influences age-related differences in blood flow of the large intracranial arteries.

Our purpose was to compare cerebral blood flow in the large intracranial vessels between healthy adults with (VAH+) and without (No VAH) vertebral artery hypoplasia. We also evaluated age-related differences in regional blood flow through the large cerebral arteries. Healthy young (n = 20; age = 25 ± 3 years) and older adults (n = 19; age = 61 ± 5 years) underwent 4D flow MRI scans to evaluate blood flow in the internal carotid arteries (ICA) and basilar artery (BA). VAH was determined retrospectively from 4D flow MRI using both structural (vessel diameter ≤ 2 mm) and flow criteria (flow ≤ 50 mL/min). We identified 5 young and 5 older adults with unilateral VAH (prevalence = 26%). ICA flow was lower in the VAH+ group compared with the No VAH group (367 ± 75 mL/min vs. 432 ± 92 mL/min, respectively; p < 0.05). There was no difference in BA flow between VAH+ and No VAH (110 ± 20 mL/min vs. 126 ± 40 mL/min, respectively; p = 0.24). When comparing age-related differences in blood flow in the No VAH group, older adults demonstrated lower BA flow compared with young adults (111 ± 38 mL/min vs. 140 ± 38 mL/min, respectively; p < 0.05) but not ICA flow (428 ± 89 mL/min vs. 436 ± 98 mL/min, respectively; p = 0.82). In contrast, in the VAH+ group, older adults had lower ICA flow compared with young adults (312 ± 65 mL/min vs. 421 ± 35 mL/min, respectively; p < 0.01), but not BA flow (104 ± 16 mL/min vs. 117 ± 23 mL/min, respectively; p = 0.32). Our results suggest that the presence of VAH is associated with lower ICA blood flow. Furthermore, VAH may contribute to the variability in the age-related differences in cerebral blood flow in healthy adults.

РЕЗУЛЬТАТЫ ПРИМЕНЕНИЯ КТ-АНГИОГРАФИИ БРАХИОЦЕФАЛЬНЫХ АРТЕРИЙ У ПАЦИЕНТОВ С ОНМК ПО ИШЕМИЧЕСКОМУ ТИПУ И ИХ СВЯЗЬ С ТЯЖЕСТЬЮ НЕВРОЛОГИЧЕСКОЙ СИМПТОМАТИКИ ПО ШКАЛЕ NIHSS

To determine the detection of large intracranial artery thrombosis by CT angiography (CTA) in patients with acute ischemic stroke, depending on the severity of neurological symptoms at the international NIHSS score. Materials and methods. Study population are patients, hospitalized to the M.P. Konchalovsky City clinical hospital in Moscow during 2019 with ischemic stroke and underwent CTA scans of extra-and intracranial arteries: total 173 patients (94 women (54.3%), man 79 (45,7 %), average age – 70 years) with a diagnosis of acute ischemic stroke, who were in all cases, NIHSS scale was used to assess the severity of neurological symptoms. Intravenous fibrinolytic therapy (FT) or intra-arterial mechanical thrombectomy (TE) was performed in all cases. The Spearman rank correlation was used to measure the correlation. Results. In 63 of 173 patients (36%) NIHSS score was 6 points or less. Occlusions of large intracranial arteries were detected in 27.7% (n=46) of cases, of which only 61% (n=28) patients reached the stage of TE. FT was performed in 54% of cases (n=94). Of 46 cases with occlusion of large intracranial arteries only 2 patients (4%) had NIHSS score 6 or less. Of all patients, who underwent the CTA, only 2 (1.2%) had NIHSS score 6 or less. There was a significant positive correlation between NIHSS score and the detection of intracranial artery thrombosis. Spearman's rank correlation coefficient Rs is 0.55 (p&lt;0.0001). For one patient brought to the TE stage, there were 6 CTA of extra-and intracranial arteries. Conclusion. There is a strong relationship between NIHSS score and the detection of intracranial artery thrombosis by CTA. With the low values of the NIHSS score (less than 6), the probability of detection of thrombosis is extremely small. It is advisable to prescribe CTA for patients with NIHSS score of 7 or more only.

Multiple hypointense vessels on susceptibility-weighted imaging predict early neurological deterioration in acute ischaemic stroke patients with severe intracranial large artery stenosis or occlusion receiving intravenous thrombolysis

Background and purposeEarly neurological deterioration (END) is a common feature in patients with acute ischaemic stroke (AIS) receiving thrombolysis. This study aimed to investigate whether the presence of multiple hypointense...

Association Between Occlusion Type and Etiology of Acute Intracranial Large Artery Occlusion.

Objective: To investigate the diagnostic efficiency of truncal-type occlusion and branching-site occlusion in determining the etiology of intracranial large artery occlusion related acute ischemic stroke (AIS).Methods: Patients with intracranial large artery occlusion related AIS who received stent retriever (SR) thrombectomy from November 2014 to June 2019 were included in the study. All patients underwent angiography before SR thrombectomy, which was used to evaluate the occlusion type. Differences in the distribution of occlusion types in intracranial atherosclerosis (ICAS) and embolism were assessed, and the diagnostic indicators, including the area under the ROC curve (AUC), sensitivity, and specificity were calculated.Results: Of the 115 AIS patients with intracranial large artery occlusion, 42 were classified as having ICAS, and 73 having an embolism. In the ICAS group, branching-site occlusion was responsible for 3 (7%) cases and truncal-type occlusion for 39 (93%) cases, while in the embolism group, branching-site occlusion was responsible for 66 (90%) cases and truncal-type occlusion for 7 (10%) cases; the difference was statistically significant (all P < 0.01). The AUC for ICAS predicted by truncal-type occlusion was 0.916, with a sensitivity of 92.86%, and specificity of 90.41%.Conclusion: Truncal-type occlusion showed a high predictability of ICAS. Determine the etiology of intracranial large artery occlusion related AIS before SR thrombectomy may be most helpful in setting up optimal endovascular treatment strategies.

Cerebrovascular complications and vasculopathy in patients with herpes simplex virus central nervous system infection

ObjectiveHerpes simplex viruses (HSV) are neurotropic and known to cause central nervous system (CNS) infections. We aimed to describe the clinical and imaging features of cerebrovascular complications in patients with HSV CNS infections. MethodsWe reviewed records of patients with HSV infections by querying acyclovir use in a clinical registry of parenteral anti-infective therapy at a tertiary medical center from January 2010 until September 2018. One patient who met the inclusion criteria is subsequently added. Diagnostic criteria for HSV CNS infection were intrathecal presence of viral DNA with clinical signs of CNS involvement. ResultsOf 36 patients who met the criteria for HSV CNS infections, cerebrovascular complications occurred in 6 patients (17%). Two patients with HSV-1 encephalitis had cerebrovascular complications (1 ischemic stroke, 1 intraparenchymal hemorrhage). Four patients had HSV-2 infection without encephalitis had cerebrovascular complications (3 ischemic strokes, 1 cerebral vein thrombosis). All 3 patients with ischemic strokes without encephalitis had pattern of vasculitis on vessel imaging on MRI with segmental narrowing and vessel wall irregularities of large intracranial arteries with circumferential wall enhancement. ConclusionCerebrovascular complications of HSV can occur with encephalitis or as isolated events with vasculitis.

Antegrade Blood Flow on 4-Dimensional Computed Tomography Angiography Predict Stroke Subtype in Patients With Acute Large Artery Occlusion.

BackgroundThe purpose of this study was to determine whether the presence of antegrade blood flow was related to stroke subtype in patients with acute intracranial large artery occlusion.Methods and ResultsThe prospectively collected data for consecutive patients who had occlusion of the unilateral M1 segment of the middle cerebral artery with or without internal carotid artery and received reperfusion therapy were retrospectively reviewed. Stroke causes were determined according to the Trial of ORG 10172 in Acute Stroke Treatment standard. We defined antegrade flow as early opacification at the distal interface of the clot with subsequent distal extension on 4‐dimensional computed tomography angiography. A total of 387 large artery occlusion patients were analyzed (229 men and 158 women; mean age, 71±14 years), including 77 (19.9%) with large artery atherosclerosis (LAA), 206 (53.2%) with cardioembolism, and 104 (26.9%) with undetermined causes. Antegrade flow was found in 206 (53.2%) patients, and 181 (46.8%) presented with retrograde flow. The rate of antegrade flow was much higher in patients with LAA than in those with cardioembolism (85.7% versus 42.2%, P<0.001). Multivariable logistic regression revealed that presence of antegrade flow was significantly associated with cuse of LAA after adjusting for confounding factors, when setting cardioembolism as reference (odds ratio, 5.650; 95% confidence interval, 2.451–13.158; P<0.001). The sensitivity, specificity, and positive and negative predictive values of the antegrade flow for predicting LAA were 43.1%, 91.5%, 85.7%, and 57.8%, respectively.ConclusionsUsing 4‐dimensional computed tomography angiography, antegrade flow can be identified in more than half of acute anterior large artery occlusion patients and occurs more frequently in those with LAA as the cause of stroke.

High neutrophil-to-lymphocyte ratio is a predictor of poor short-term outcome in patients with mild acute ischemic stroke receiving intravenous thrombolysis.

IntroductionVery few studies have investigated the specific relationship between neutrophil‐to‐lymphocyte ratio (NLR) and the short‐term outcomes of patients suffering from mild acute ischemic stroke (AIS) and receiving intravenous thrombolysis (IVT). This study aimed to investigate whether a high NLR is associated with a poor short‐term outcome in patients with mild AIS after IVT.MethodsWe retrospectively analyzed data that were prospectively acquired from patients with AIS treated with IVT. Mild AIS was defined as a National Institutes of Health Stroke Scale (NIHSS) score ≤ 7 on admission. The NLR was based on a blood test performed prior to IVT and was classified as ‘high’ when exceeding the 75th percentile. Follow‐ups were performed at discharge and 3 months after onset. A poor outcome was defined as a modified Rankin scale (mRS) ≥3.ResultsA total of 192 patients were included in this study. The median NLR was 3.0 (interquartile range [IQR]: 2.0–3.9). Fifty‐one patients (26.6%) had a high NLR (≥3.9) on admission. Forty‐one patients (21.4%) had a poor outcome at discharge, while 34 patients (17.7%) had a poor outcome at 3 months. Patients with a poor outcome at discharge, and at 3 months after onset, were more likely to have a high NLR at discharge (42.9% vs. 21.9%; p = .005) and at 3 months (44.1% vs. 22.8%; p = .011), compared with those with a better outcome. After adjustment for NIHSS score on admission, ipsilateral severe intracranial large artery occlusion, and atrial fibrillation, logistic regression analyses revealed that a high NLR was a significant predictor of poor outcome at discharge and at 3 months after onset.ConclusionsA high NLR on admission could be a useful marker for predicting poor short‐term outcome in patients with mild AIS following IVT.

Caliber of Intracranial Arteries as a Marker for Cerebral Small Vessel Disease.

Background: The dilation of intracranial large arteries caliber, may transfer more hemodynamic burden to the downstream brain capillaries, which, in the long run, results in cerebral small vessel disease (CSVD). This study aimed to investigate the relationship between intracranial artery calibers and small vessel disease.Methods: Patients with first-ever ischemic stroke of lacunar infarction subtype were enrolled via Nanjing Stroke Registry Program. An intracranial arterial Z-score, named the brain arterial remodeling (BAR) score, was calculated by averaging the calibers of the seven main intracranial arteries. Among the enrolled patients, those with a BAR score < −1 SD were deemed to have small intracranial artery calibers; those with a BAR score >1 SD were deemed to have large intracranial artery calibers and those with a between BAR score were deemed to have normal intracranial artery calibers. Imaging markers of CSVD, including lacuna, white matter hyperintensity (WMH), enlarged perivascular spaces (EPVS) and cerebral microbleeds (CMBs) were rated and then summed to obtain a total CSVD score.Results: A total of 312 patients were involved in this study, patients with BAR score >1 SD were older (P = 0.039), and more prone to having a history of myocardial infarction (P = 0.033). The Spearman's rank correlation coefficient between the BAR score and total CSVD score is 0.320 (P < 0.001). Binary logistic regression found that BAR score >1 SD was correlated with lacuna (OR = 1.987; 95% CI, 1.037–3.807; P = 0.039); severe WMH (OR = 1.994; 95% CI, 1.003–3.964; P = 0.049); severe EPVS (OR = 2.544; 95% CI, 1.299–4.983; P = 0.006) and CSVD (OR = 2.997; 95% CI 1.182–7.599; P = 0.021). Ordinal logistic regression analysis found that age (OR = 1.028; 95% CI, 1.007–1.049; P = 0.009), hypertension (OR = 3.514; 95% CI, 2.114–5.769; P < 0.001) and BAR score >1 SD (OR = 2.418; 95% CI, 1.350–4.330; P = 0.003) were correlated with the total CSVD score.Conclusions: Patients with large intracranial arterial calibers may have heavier CSVD burden. The mechanisms of this association warrant further study.

Moyamoya Disease: A Review of Current Literature.

Moyamoya disease (MMD) is an infrequent disease of cerebral vasculature characterized by long-standing and progressive occlusion of large intracranial arteries. It is seen predominantly in the East Asian population. Most of the cases of MMD are sporadic, but there is a small percentage that is familial. The mode of inheritance is reported to be autosomal dominant with incomplete penetrance. Studies show that the susceptibility gene of MMD is located on chromosome 17. The clinical presentation is variable and is influenced by the age and geographic region of the patient. Children mainly present with ischemia-related neurologic episodes whereas MMD in adults can manifest as either an ischemic event or an intracranial hemorrhage (ICH). The gold standard investigation for diagnosis is cerebral angiography which reveals a smoky appearance of arteries at the base of the skull, thus granting the disease its name. The treatment is mostly surgical and includes direct and indirect revascularization procedures, which prevent the recurrence of both ischemic and hemorrhagic strokes. However, combination revascularization procedures are now on the rise due to studies showing better long-term outcomes. The aim of the article is to critically analyze the current literature and updates on various aspects of MMD including, but not limited to, etiology, diagnosis, and treatment.

Intracranial Large Artery Abnormalities and Association With Cerebral Small Vessel Disease in CADASIL.

Background and objective: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited systemic arteriopathy, the classic feature of which is small vessel lesions. Studies on intracranial large arteries in CADASIL are not common. We aim to evaluate intracranial large arteries, describing the characteristics of large arteries in CADASIL and their association with cerebral small vessel associated lesions.Methods: Consecutive CADASIL patients from a single-center prospective cohort were analyzed. Brain magnetic resonance imaging and magnetic resonance angiography were performed to assess the intracranial large arteries and cerebral small vessels associated lesions' neuroimaging.Results: The study included 37 CADASIL patients. Of the patients, 28 of them (75.7%) had intracranial large artery abnormalities. Eighteen (48.6%) had congenital variations such as fenestration, vertebral artery (VA) hypoplasia and agenesis, or common trunk and fetus posterior cerebral artery. Seventeen (45.9%) had acquired anomalies such as arterial stenosis, prolongation, or tortuosity (seven of them had both congenital and acquired anomalies). CADASIL patients with anterior circulation middle cerebral artery (MCA) or internal cerebral artery (ICA) severe stenosis were more likely to have ipsilateral asymmetric white matter hyper-density (WMH) distribution. Patients with posterior circulation VA hypoplasia had a higher prevalence of posterior subcortical zone dominant WMH distribution.Conclusion: CADASIL patients can demonstrate various intracranial large artery abnormalities which might influence the development of microangiopathy. Assessment of great vessels seems essential in CADASIL.

Direct angioplasty for acute ischemic stroke due to intracranial atherosclerotic stenosis-related large vessel occlusion.

Intracranial artery atherosclerotic stenosis (ICAS) is among the causes of intracranial large artery occlusion (LVO). The optimal treatment strategy for patients with ischemic stroke due to ICAS-related LVO remains unclear. In this retrospective case series, we discussed our experience with direct angioplasty as frontline therapy for ICAS-related LVO. We extracted data for patients who had a known pre-existing ICAS and undergone direct angioplasty as frontline therapy for ICAS-related LVO in the anterior circulation at our institution between January 2019 and December 2019. We analysed procedural details, the degree of reperfusion, functional outcomes, and complications. Successful reperfusion was defined as a modified Treatment in Cerebral Ischemia (mTICI) score of 2 b - 3. Functional outcomes at 90 days were assessed using modified Rankin Scale (mRS) scores (good outcome: mRS of 0-2). We analysed data for five patients (mean age: 51.6 ± 11 years). The mean time from symptom onset to recanalization was 371 ± 38.6 min. Occlusions involved the first segment of the middle cerebral artery in four patients and the intracranial internal carotid artery in one patient. Successful reperfusion was achieved in four (80%) patients. The remaining patient (20%) underwent intracranial stenting as rescue therapy, achieving a final mTICI of 2a. No re-occlusion was observed on follow-up images. Four patients (80%) achieved good outcomes at 90 days. There were no cases of symptomatic intracranial hemorrhage, although asymptomatic intracranial haemorrhage was observed in one patient. Direct angioplasty may represent an alternative treatment strategy in patients with acute ischemic stroke due to known ICAS-related LVO.

Usefulness of stent strut deformity during thrombectomy for predicting the stroke etiology in acute large artery occlusion

BackgroundStent retriever thrombectomy has been regarded as the standard treatment for acute intracranial large artery occlusion. As fast recanalization is the most important factor for favorable outcomes in patients with stroke, defining the etiology is important for the treatment of acute large vessel occlusion. We aimed to investigate whether full-length stent visibility during thrombectomy could provide information on the stroke etiology or the clot characteristics using the stent strut deformity during thrombectomy. Materials and methodsIntra-arterial thrombectomy was performed on 46 patients with Trevo stent as the first endovascular thrombectomy device. Patients were assigned to the full expansion group or the stent deformity group based on the shape of the stent strut during the endovascular procedure. The presence of stent deformity during the procedure, underlying intracranial atherosclerotic stenosis (ICAS), and residual stenosis at the occlusion site on the final conventional angiography, follow-up magnetic resonance angiography, or computed tomography angiography were retrospectively assessed. ResultsRecanalization without underlying arterial stenosis at the occlusion site was observed in 92.9 % (26/28 patients) and 50.0 % (8/16 patients) of the full expansion and stent deformity groups (p = 0.002), respectively. A significantly lower proportion of patients in the full expansion group demonstrated ICAS-related occlusion compared with that in the stent deformity group (3.6 % vs. 43.8 %, respectively; p = 0.002). ConclusionsThe degree of stent expansion during thrombectomy in acute large artery occlusion can be a useful predictor of the stroke etiology and potentially helpful to the operator for endovascular treatment planning.

Luminal and Wall Changes in Intracranial Arterial Lesions for Predicting Stroke Occurrence.

Luminal imaging (degree of stenosis) currently serves as the gold standard to predict stroke recurrence and guide therapeutic strategies in patients with intracranial large artery diseases (ILADs). We comparatively evaluated the importance of vessel wall and luminal changes in predicting stroke occurrence. Consecutive patients with ILAD in the proximal middle cerebral artery or distal internal carotid artery without proximal sources of embolism from the carotid and heart underwent time-of-flight magnetic resonance angiography, high-resolution magnetic resonance imaging, and the ring finger protein 213 (RNF213) gene variant test. Patients were followed up for >3 months. Of the 675 patients, 241 (35.7%) had atherosclerotic ILAD and 434 (64.3%) showed nonatherosclerotic ILAD (315 [46.7%] moyamoya disease cases and 119 [17.6%] dissection cases). The RNF213 variant was detected in 74.9%, 33.6%, and 3.4% patients with moyamoya disease, atherosclerosis, and dissection, respectively. Three hundred (44.4%) patients had asymptomatic ILAD, whereas 375 (55.6%) patients had symptomatic ILAD. Multivariate analysis showed that vessel enhancement and etiological subtypes, not degree of stenosis, determined by high-resolution magnetic resonance imaging and RNF213 gene variant analysis were independently associated with symptomatic ILAD. The presence of the RNF213 variant was also independently associated with recurrent cerebrovascular events. This study demonstrates the prevalence of nonatherosclerotic ILAD in East Asian patients with ILAD. Unlike luminal changes, wall changes determined by high-resolution magnetic resonance imaging and presence of the RNF213 variant could predict stroke occurrence in patients with ILADs.

Arterial Stiffness is Associated with Intracranial Arterial Stenosis other than Dolichoectasia in the General Population.

Aims: The relationship between central arterial stiffness and aging-related intracranial arteriopathy is not well investigated in the general population. In a population-based study, we investigated arterial stiffness in relation to intracranial atherosclerotic stenosis and intracranial arterial dolichoectasia.Methods: This study was a cross-sectional analysis on 1,123 subjects (aged 56.0 ± 9.3 years, 37.9% men) of the population-based Shunyi study in China. Arterial stiffness was assessed by measuring brachial-ankle pulse wave velocity (baPWV). Intracranial atherosclerotic stenosis and intracranial arterial dolichoectasia were evaluated via brain magnetic resonance angiography. Multivariate regression models were constructed to investigate the association between baPWV and intracranial large artery diseases.Results: Increased baPWV was significantly associated with higher prevalence of intracranial atherosclerotic stenosis (odds ratio for the highest quartile of baPWV compared with the lowest quartile, 3.66 [95% confidence interval, 1.57–8.54]), after adjustment for cardiovascular risk factors in multivariate analysis. BaPWV was not associated with the presence of basilar artery dolichoectasia and dilation of basilar artery and internal carotid artery. When the diameters of intracranial arteries were regarded as continuous variables, increased baPWV was inversely related to the internal carotid artery diameter in fully adjusted models (β ± SE, −0.083 ± 0.042, p = 0.047).Conclusions: This population-based study demonstrates that arterial stiffness was more likely associated with intracranial stenotic arteriopathy other than intracranial dilative arteriopathy.

Carotid artery webs in embolic stroke of undetermined source with large intracranial vessel occlusion.

Whether carotid artery web can be considered as a potential source of arterial thromboembolism in ischemic stroke remains uncertain. In a large sample of individuals with large intracranial artery occlusion, we compared the prevalence of carotid artery webs between patients with and without embolic stroke of undetermined source. In a single-center study of consecutive patients with anterior circulation ischemic stroke referred for mechanical thrombectomy, the presence of carotid artery web was systematically assessed by two independent readers. Thereafter, its prevalence was compared between patients with and without embolic stroke of undetermined source. Among 466 patients of whom 12% were considered to have had an embolic stroke of undetermined source, ipsilateral carotid artery web was detected in 1.9% (confidence interval 95% = 0.7-3.1). Ipsilateral carotid artery web was more frequent in embolic stroke of undetermined source than in the rest of the sample (10.7% (confidence interval 95% = 2.7-18.7] vs. 0.7% (0-1.5), P < 0.001). This difference remains significant after adjustment for sex, age, and vascular risk factor (odds ratio: 12.5 (2.1-72), P = 0.005) or after exclusion of patients with any other bulb wall thickening (P = 0.025). In contrast, the difference of prevalence of contralateral carotid artery web between the two groups did not reach statistical significance (2.4% vs. 1.9%, P = 0.6). Our results suggest that the presence of a carotid artery web might be considered as a potential source of large intracranial artery embolism. Longitudinal studies are needed to assess the exact risk of recurrence associated with these lesions.

Asymmetrical cortical vessel sign predicts prognosis after acute ischemic stroke.

IntroductionTo assess whether the asymmetrical cortical vessel sign (ACVS) on susceptibility‐weighted imaging (SWI) could predict 90‐day poor outcomes in anterior circulation acute ischemic stroke (AIS) patients treated with recombinant tissue plasminogen activator (r‐tPA).MethodsClinical data of consecutive patients with anterior circulation AIS treated with r‐tPA were retrospectively analyzed. Clinical variables included age, sex, vascular risk factors, NIHSS score, onset to treatment time, and initial hematologic and neuroimaging findings. Follow‐up was performed 90 days after onset. Poor outcome was defined as a modified Rankin scale (mRS) ≥3 at 90 days.ResultsA total of 145 patients were included, 35 (24.1%) patients presented with ACVS (≥Grade 1) on SWI. Fifty‐three (36.6%) patients had a poor outcome at 90 days. ACVS (≥Grade 1) occurred in 21 (39.6%) patients with poor outcome compared with 14 (15.2%) patients with favorable outcome (p = .001). Univariate analysis indicated that age, NIHSS score on admission, previous stroke, hemorrhagic transformation, severe intracranial large artery stenosis or occlusion (SILASO), and ACVS were associated with 90‐day poor outcome (p < .05). Since SILASO and ACVS were highly correlated and ACVS had different grades, we used three logistic regression models. Results from the three models showed that ACVS was associated with 90‐day poor outcome.ConclusionsIn r‐tPA‐treated patients with anterior circulation AIS, ACVS might be a helpful neuroimaging predictor for poor outcome at 90 days.