Intracranial Arterial Lesions Research Articles

Prevalence of carotid artery stenosis and intra-cranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation and postoperative neurological outcomes.

Although aortic aneurysm is associated with vascular aging and atherosclerosis, carotid and intracranial vascular disease prevalence in patients with aortic arch aneurysm remains unclear. Similarly, the effect of carotid and intracranial lesions on postoperative outcomes is unknown. This study aimed to investigate the prevalence of carotid artery stenosis and intracranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation (rScO2) and postoperative neurological outcomes, including delirium and cerebral infarction. This retrospective observational study included 133 patients with true aortic arch aneurysm who underwent preoperative magnetic resonance imaging (MRI). We evaluated the prevalence of carotid and intracranial arterial lesions. Symptomatic cerebral infarction and delirium, defined by the confusion assessment method for the intensive care unit, were evaluated for their association with preoperative cerebrovascular lesions. Additionally, changes in regional saturation of the cerebral tissue at different surgical phases were evaluated for patients with and without cerebrovascular lesions. Fifteen (11.3%) patients experienced symptomatic cerebral infarction, and 64 (48.1%) had postoperative delirium. Preoperative MRI showed old infarction, microbleeds, significant carotid artery stenosis, and intracranial lesions in 21.1%, 14.3%, 10.5%, and 7.5% of the patients, respectively. White matter hyperintensities with Fazekas scale 2 were observed in 40.6% of the patients, while Fazekas scale 3 were observed in 18.8% of the patients. Preoperative MRI findings and postoperative neurological outcomes were not significantly different. Seventy-six patients underwent rScO2 monitoring intraoperatively. Changes in rScO2 in patients with and without carotid/cerebrovascular lesions were not significantly different. However, rScO2 was significantly lower in patients who developed cerebral infarction. Significant carotid artery stenosis and intracranial lesions were observed in 10.5% and 7.5% of the patients, respectively. Although preoperative MRI findings and changes in rScO2 or postoperative outcomes showed no significant association, patients with postoperative cerebral infarction showed significantly lower rScO2 intraoperatively.

Automated Detection of Steno-Occlusive Lesion on Time-of-Flight MR Angiography: An Observer Performance Study.

Intracranial steno-occlusive lesions are responsible for acute ischemic stroke. However, the clinical benefits of artificial intelligence (AI)-based methods for detecting pathologic lesions in intracranial arteries have not been evaluated. We aimed to validate the clinical utility of an AI model for detecting steno-occlusive lesions in the intracranial arteries. Overall, 138 TOF-MRA images were collected from 2 institutions, which served as internal (n = 62) and external (n = 76) test sets, respectively. Each study was reviewed by 5 radiologists (2 neuroradiologists and 3 radiology residents) to compare the usage and nonusage of our proposed AI model for TOF-MRA interpretation. They identified the steno-occlusive lesions and recorded their reading time. Observer performance was assessed by using the area under the jackknife free-response receiver operating characteristic curve (AUFROC) and reading time for comparison. The average AUFROC for the 5 radiologists demonstrated an improvement from 0.70 without AI to 0.76 with AI (P = .027). Notably, this improvement was most pronounced among the 3 radiology residents, whose performance metrics increased from 0.68 to 0.76 (P = .002). Despite an increased reading time by using AI, there was no significant change among the readings by radiology residents. Moreover, the use of AI resulted in improved interobserver agreement among the reviewers (the intraclass correlation coefficient increased from 0.734 to 0.752). Our proposed AI model offers a supportive tool for radiologists, potentially enhancing the accuracy of detecting intracranial steno-occlusion lesions on TOF-MRA. Less experienced readers may benefit the most from this model.

Intracranial steno-occlusive lesion detection on time-of-flight MR angiography using multi-task learning.

Steno-occlusive lesions in intracranial arteries refer to segments of narrowed or occluded blood vessels that increase the risk of ischemic strokes. Steno-occlusive lesion detection is crucial in clinical settings; however, automatic detection methods have hardly been studied. Therefore, we propose a novel automatic method to detect steno-occlusive lesions in sequential transverse slices on time-of-flight magnetic resonance angiography. Our method simultaneously detects lesions while segmenting blood vessels based on end-to-end multi-task learning, reflecting that the lesions are closely related to the connectivity of blood vessels. We design classification and localization modules that can be attached to arbitrary segmentation network. As blood vessels are segmented, both modules simultaneously predict the presence and location of lesions for each transverse slice. By combining outputs from the two modules, we devise a simple operation that boosts the performance of lesion localization. Experimental results show that lesion prediction and localization performance is improved by incorporating blood vessel extraction. Our ablation study demonstrates that the proposed operation enhances lesion localization accuracy. We also verify the effectiveness of multi-task learning by comparing our approach with those that individually detect lesions with extracted blood vessels.

Endovascular Treatment of Arterial Steno-Occlusive Lesions in Symptomatic Moyamoya Disease.

The efficacy and safety of endovascular treatment (EVT) for moyamoya disease (MMD) have rarely been investigated. The objective of this study was to summarize the clinical outcomes of EVT for MMD and determine the potential role of EVT in treating symptomatic steno-occlusive lesions in MMD. Reports from January 2000 to December 2021 describing EVT in MMD were collected through a literature search. The search terms included "moyamoya", "stent", "angioplasty", and "endovascular". Data regarding baseline demographics, previous medical history, treated vessel, periprocedural complications, and angiographical recurrence were retrieved. This review included 10 studies with details of 19 patients undergoing a total of 31 EVT procedures. Twenty-one EVTs were performed as initial treatments for MMD, and 10 were performed as additional treatments for angiographical recurrence. The mean follow-up period of the initial EVTs was 9.0±11.9 months, with angiographical recurrence in 11 (68.8%) cases. The mean follow-up period of additional EVTs was 4.3±3.9 months, and seven (70.0%) EVTs showed restenosis of the re-treated vessel. Across all initial and additional EVTs, there were no differences in characteristics between the recurrence and non-recurrence groups. Overall, two periprocedural complications (9.5%) occurred, one vessel rupture and one massive intracerebral hemorrhage with subarachnoid hemorrhage. EVT plays a limited role in the management of symptomatic intracranial arterial steno-occlusive lesions of MMD. Recent advances in understanding the pathomechanism of MMD may urge neuro-interventionists to find a new endovascular approach with better balloon angioplasty or stenting mechanisms.

Automated detection of intracranial artery stenosis and occlusion in magnetic resonance angiography: A preliminary study based on deep learning

Background and objectivesIntracranial atherosclerotic stenosis of a major intracranial artery is the common cause of ischemic stroke. We evaluate the feasibility of using deep learning to automatically detect intracranial arterial steno-occlusive lesions from time-of-flight magnetic resonance angiography. MethodsIn a retrospective study, magnetic resonance images with radiological reports of intracranial arterial stenosis and occlusion were extracted. The images were randomly divided into a training set and a test set. The manual annotation of lesions with a bounding box labeled “moderate stenosis,” “severe stenosis,” “occlusion,” and “absence of signal” was considered as ground truth. A deep learning algorithm based on you only look once version 5 (YOLOv5) detection model was developed with the training set, and its sensitivity and positive predictive values to detect lesions were evaluated in the test set. ResultsA dataset of 200 examinations consisted of a total of 411 lesions—242 moderate stenoses, 84 severe stenoses, 70 occlusions, and 15 absence of signal. The magnetic resonance images contained 291 lesions in the training set and 120 lesions in the test set. The sensitivity and positive predictive values were 64.2 and 83.7%, respectively. The detection sensitivity in relation to the location was greatest in the internal carotid artery (86.2%). ConclusionsApplying deep learning algorithms in the automated detection of intracranial arterial steno-occlusive lesions from time-of-flight magnetic resonance angiography is feasible and has great potential.

Sex Differences in Intracranial Atherosclerotic Plaques Among Patients With Ischemic Stroke.

ObjectiveHigh-risk intracranial arterial plaques are the most common cause of ischemic stroke and their characteristics vary between male and female patients. However, sex differences in intracranial plaques among symptomatic patients have rarely been discussed. This study aimed to evaluate sex differences in intracranial atherosclerotic plaques among Chinese patients with cerebral ischemia.MethodsOne hundred and ten patients who experienced ischemic events underwent 3T cardiovascular magnetic resonance vessel wall scanning for the evaluation of intracranial atherosclerotic disease. Each plaque was classified according to its likelihood of causing a stroke (as culprit, uncertain, or non-culprit). The outer wall area (OWA) and lumen area of the lesion and reference sites were measured, and the wall and plaque areas, remodeling ratio, and plaque burden (characterized by a normalized wall index) were further calculated. The composition (T1 hyperintensity, enhancement) and morphology (surface irregularity) of each plaque were analyzed. Sex differences in intracranial plaque characteristics were compared between male and female patient groups.ResultsOverall, 311 plaques were detected in 110 patients with ischemic stroke (81 and 29 male and female patients, respectively). The OWA (P < 0.001) and wall area (P < 0.001) of intracranial arterial lesions were significantly larger in male patients. Regarding culprit plaques, the plaque burden in male patients was similar to that in female patients (P = 0.178, odds ratio [OR]: 0.168, 95% confidence interval [CI]: −0.020 to 0.107). However, the prevalence of plaque T1 hyperintensity was significantly higher than that in female patients (P = 0.005, OR: 15.362, 95% CI: 2.280–103.49). In the overall ischemic stroke sample, intracranial T1 hyperintensity was associated with male sex (OR: 13.480, 95% CI: 2.444–74.354, P = 0.003), systolic blood pressure (OR: 1.019, 95% CI: 1.002–1.036, P = 0.031), and current smoker (OR: 3.245, 95% CI: 1.097–9.598, P = 0.033).ConclusionFor patients with ischemic stroke, the intracranial plaque burden in male patients was similar to that in female patients; however, the plaque characteristics in male patients are associated with higher risk, especially in culprit plaques.

Clinical features and risk factors of intracranial artery disease in patients with Takayasu arteritis.

It has been known that aorta, subclavian, and extracranial arteries are commonly involved in Takayasu arteritis (TA). However, the involvement of intracranial artery in TA has not been well explored. The purpose of this study was to describe the clinical characteristics of intracranial artery lesions in TA patients and identify associated risk factors. A total of 160 patients diagnosed with TA at Beijing Anzhen Hospital from November 2012 to November 2019 were retrospectively enrolled in this study and assigned to different groups according to the presence or absence of intracranial artery lesions. Our data showed that 20% of the enrolled 160 patients developed intracranial artery lesions and the right internal carotid artery (ICA) was the most common involved artery (53%). The average age of patients with intracranial artery lesions was significantly older compared to that of patients without intracranial artery involvement (43.56 ± 11.40 vs 36.41 ± 12.22, p = 0.003). In addition, more patients in the intracranial artery group had concomitant disease histories of stroke and/or hypertension (p = 0.010, 0.033). Chest tightness, chest pain, palpitation, coronary artery lesions, and extracranial segment lesions of ICA were more commonly observed in patients with intracranial artery lesions (p < 0.001, 0.017, 0.015, < 0.001, 0.003). Furthermore, we discovered that patients with coronary artery involvement, extracranial segment lesions of ICA, and higher Vasculitis Damage Index (VDI) score had an increased risk of developing intracranial artery lesions (p = 0.013, 0.019, 0.019). Our study showed that the intracranial artery disease was common in TA and was associated with coronary artery lesions, extracranial segment lesions of ICA, and higher VDI score. Key Points • Intracranial artery disease in TA patients had advanced age and higher triglyceride level. • Besides coronary artery lesions, intracranial artery disease in TA patients was associated with the extracranial segment lesions of ICA and higher VDI score.

Three-Dimensional Intraarterial Vaso Computed Tomography Depiction of Pipeline Flex with Shield Technology Flow Diverter Stent in Ruptured Blister Aneurysm of Supraclinoid Internal Carotid Artery

AbstractBlister aneurysms are intracranial arterial lesions originating at nonbranching sites of the dorsal supraclinoid internal carotid artery and basilar artery.1 Among different treatment options, the use of flow-diverting devices is gaining popularity and has the potential for becoming the standard of care.2 Radiological evaluation of flow diverter braid expansion and vessel wall apposition during procedure has become useful in preventing life-threatening complications. Incomplete coverage of an aneurysm neck, kinking, or incomplete expansion and malapposition of a stent carries a significant risk for thromboembolic events.3 4

Cerebral vasospasm resulted in "stent shortening" after pipeline assisted coil embolization for blood blister aneurysms.

Blood blister aneurysms (BBAs) are intracranial arterial lesions appearing in nonbranching sites of the supraclinoid internal carotid artery as well as the basilar artery. Endovascular treatment of BBAs is still not well established because of the rarity of these lesions. We report incidences of BBAs with associated vasospasms. Treatment of the BBAs and associate vasospasms with single Pipeline Flex embolization device (PLED) assisted coiling resulted in seemly shorting of the PLEDs in 3 patients.A retrospective analysis of patients with BBAs who were treated with single PLED assisted coiling from July 2018 to October 2019 was conducted. Patients’ ethnic and medical records, aneurysmal characteristics, intraoperative-rupture, cerebral vasospasm (CVS), postprocedure contrast filling, follow-up imaging, and results were analyzed. Neurological examination at baseline and outcome based on modified Rankin scale (mRS) at discharge as well as follow-ups were also documented.Six patients consisting of 5 females and 1 male, with a mean age of 48.3 years (range from 34–67) were identified during our analysis. All the BBAs were located in nonbranching site of supra-clinoidal segment of internal carotid artery with a mean neck width of 4.5 mm and mean aneurysm size of 4.23 mm. PLED assisted coiling's were performed in all of them. CVS was observed in 3 patients while 1 patient had an intraoperative-rupture of the BBA. Postprocedure contrast filling was still present in 1 patient. All the patients had good outcomes with discharge and follow-up mRS scores ≤ 2 except 1 patient with mRS score = 3 with aphasia.PLED assisted endovascular coiling is very safe and efficient in treating patients with BBAs. Resolution of CVSs after treatment made the PLEDs seemly shorter. Furthermore, a combination of arterial lengthening after gaining their tensile strength back and radical expansion of the PLED could account for the shortening.

Preventive Effect of Bypass Surgery on Rebleeding in Patients with Hemorrhagic Twiglike Middle Cerebral Artery

Aplastic or twiglike middle cerebral artery (Ap/T-MCA) is a rare cerebrovascular anomaly correlated to stroke. The most common characteristic of the disease is intracerebral hemorrhage. However, treatment measures that can prevent rebleeding have not yet been established. We sought to validate whether extracranial-intracranial (EC-IC) bypass is effective in preventing recurrent intracerebral hemorrhage in patients with Ap/T-MCA. Ap/T-MCA was defined on the basis of the following criteria: 1) M1 occlusion with plexiform vessels, 2) unilateral MCA involvement without progression to the contralateral side, 3) no significant stenosis in the M2 segment, and 4) no stenoocclusive lesions in other intracranial major arteries. The clinical features, surgical procedures, radiologic changes, and treatment outcomes of patients with Ap/T-MCA who presented with ipsilateral intracerebral hemorrhage at our institution from April 2004 to December 2019 were retrospectively reviewed. Seven patients fulfilled the criteria for hemorrhagic Ap/T-MCA. Female preponderance was observed, and the mean age at the time of onset was 38 (range: 28-47) years. Three patients presented with pure intraventricular hemorrhage and 4 with intraparenchymal hemorrhage. Of the 4 patients, 2 had intraventricular extension. All patients underwent EC-IC bypass and did not present with stroke during the follow-up period (median: 36 [range: 5-140] months). Follow-up magnetic resonance imaging revealed regression of the twiglike vessels or periventricular choroidal anastomosis within 1 year after surgery in all patients. EC-IC bypass may be a treatment option that can prevent rebleeding in patients with hemorrhagic Ap/T-MCA.

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.

Rupture of aneurysm of the middle cerebral artery along with stenosis of the internal carotid and coronary arteries

This article presents the results of treatment of a patient with rupture of a giant intracerebral aneurysm of the left middle cerebral artery (MCA), hemodynamically significant stenosis of the internal carotid artery on the left and the trunk of the left coronary artery with multiple lesions of the coronary arteries (anterior descending artery, diagonal branch, right coronary artery). A phased surgical correction was performed, with the time period between stages being 2 months, as follows:Stage 1 — open microsurgical clipping of the aneurysm of the left MCA and removal of intracerebral hematoma. The usage of the standard treatment volume in the form of 3H therapy (hypertension, haemodilution and hypervolemia), as well as slow calcium channel blockers in the postoperative period, was associated with a high risk of developing cardiovascular complications due to the presence of occlusal–stenotic lesions of the coronary and brachiocephalic channels. In the postoperative period, the patient received antiplatelet therapy (acetylsalicylic acid 100 mg at lunch), lipid-lowering therapy (rosuvastatin 20 mg in the evening) and anti-hypertensive therapy (bisoprolol 2.5 mg in the morning; perindopril 2.5 mg in the evening; spironolactone 25 mg in the morning; torasemide 10 mg in the morning; valparin XP 500 mg 2 times a day). On day 14, the patient was transferred from the intensive care unit, and on day 20, the patient was discharged from the hospital in satisfactory condition.Stage 2 — a combined operation in the amount of carotid endarterectomy (CEE) with plastic surgery of the biological patch on the left with plastic reconstruction of the reconstruction zone with a patch from the xenopericardium and coronary bypass grafting (CABG). Tactics were confirmed as optimal, taking into account the stratification of the risk of complications in the postoperative period when applying the new interactive program ‘Program support for the decision-making process for choosing a surgical re-vascularisation strategy for multifocal atherosclerosis’ (certificate of registration of a computer program RU 2017619457). Brain protection during CEE was achieved by invasive measurement of retrograde pressure (60 % of systemic blood pressure (BP)) and intraoperative increase in blood pressure to 180/90 mm Hg. CABG was performed using cardiopulmonary bypass. An epiaortic ultrasound scan was used to select the position of the implantation of a venous shunt into the aortic wall. Intraoperative flowmetry was used to regulate the quality of the implanted shunts.The patient was discharged 10 days after the surgery from the hospital in satisfactory condition. Conservative therapy, initiated after stage 1 of re-vascularisation, was continued.Clipping of intracerebral arterial aneurysm during its rupture and reconstructive interventions on the internal carotid artery and coronary arteries could be performed combined with the possibility of endovascular correction. However, due to the presence of an unstable atherosclerotic plaque, the possibility of interventional correction of the internal carotid artery was excluded, and the condition of the coronary bed at the time of stage 1 remained unknown. An additional argument in favour of open microsurgical clipping of the aneurysm was the need for the removal of intracerebral hematoma.The treatment strategy chosen here was found to be safe and effective. Satisfactory outcome of the surgery was achieved due to a complete range of perioperative examinations. The implemented tactics prevented the development of complications. The data obtained here would form the basis for the development of recommendations for selecting the optimal tactics of re-vascularisation in combined lesions of intracranial, extracranial and coronary arteries. Received 21 April 2020. Revised 27 April 2020. Accepted 28 April 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and design: А.N. Kazantsev, R.S. TarasovLiterature review: K.P. Chernykh, N.E. Zarkua, R.Y. Leader, G.Sh. BagdavadzeDrafting the article: А.N. KazantsevIllustrations: А.N. Kazantsev, K.P. Chernykh, N.E. Zarkua, R.Y. Leader, G.Sh. BagdavadzeCritical revision of the article: N.E. Zarkua, R.S. Tarasov, Y.P. LinetsFinal approval of the version to be published: А.N. Kazantsev, R.S. Tarasov, K.P. Chernykh, N.E. Zarkua, R.Y. Leader, G.Sh. Bagdavadze, Y.P. Linets

Essential autophagic protein Beclin 1 localizes to atherosclerotic lesions of human carotid and major intracranial arteries

Macrophage autophagy has been shown to exert a protective role in atherosclerosis. Beclin 1 is an essential autophagic protein, and the Beclin-1-interacting complex promotes the formation of autophagosomes. However, the localization of Beclin 1 in human atherosclerotic lesions has not been clarified to date. We hence investigated the immunolocalization of Beclin 1 in atherosclerotic lesions of human carotid and major intracranial arteries. Furthermore, we investigated the colocalization of Beclin 1 with the 14–3-3 eta isoform and high mobility group box 1 (HMGB1). Beclin 1 was observed in the cytoplasm of many foamy macrophages located near to or in the periphery of lipid-rich necrotic cores. Beclin 1 colocalized with the 14–3-3 eta isoform in carotid plaques, and also colocalized with HMGB1 in carotid plaques. This is the first demonstration of Beclin 1 immunolocalization in human carotid and main cerebral artery plaques. We believe that our results will contribute towards understanding the role of autophagy in atherosclerosis and towards the prevention of stroke.

Correlation between the hemodynamic parameters of extracranial vertebral artery and the severity and location of intracranial vertebral artery stenosis

Objective To analyze the effects of the degree and location of intracranial vertebral artery(VA) lesions on the hemodynamic parameters of extracranial VA. Methods A total of 275 consecutive patients who were diagnosed as posterior circulation ischemic stroke or transient ischemic attack (TIA) with unilateral intracranial VA stenosis or occlusion in the Department of Neurology and Neurosurgery of Capital Medical University Xuanwu Hospital from January 2015 to December 2017 were enrolled. All patients were examined by head and neck vascular ultrasound, CT angiography (CTA) and/or digital subtraction angiography (DSA) within one week. According to the results of DSA or CTA, the patients were divided into mild stenosis group(53 patients), moderate stenosis group(62 patients), severe stenosis group(58 patients) and occlusion group(102 patients). The inner diameter (D), peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) of the extracranial segment (V2 segment) of the VA were recorded and analyzed. Results The PSV and EDV in the severe stenosis group and the occlusion group were significantly lower than those in the mild stenosis group and the moderate stenosis group (P=0.000), and the PSV and EDV in the occlusion group were significantly lower than those in the severe stenosis group[ (31±10) cm/s vs (46±12)cm/s, (5±4)cm/s vs (15±7)cm/s; all P=0.000], RI was significantly higher than the other three groups (0.85±0.12, 0.70±0.10, 0.66±0.07, 0.64±0.06, respectively; all P=0.000); RI in the severe stenosis group were not significantly different from those in the mild to moderate stenosis groups (P=0.044, 0.223). There were no significant differences in the inner diameter, PSV, EDV and RI between the subgroups in the severe stenosis group before or after the PICA (posterior inferior cerebellar artery)(P=0.130, 0.322, 0.865, 0.227). However, the EDV decreased and RI increased in the occlusive subgroup before the PICA when compared the subgroup after the PICA (all P=0.000). Conclusions The location and degree of intracranial VA lesions directly affect the changes of blood flow velocity and vascular resistance of extracranial VA, and the changes of low-speed and high-resistance hemodynamics of extracranial VA may indicate the existence of occlusive lesions in intracranial VA. Key words: Ultrasonography; Vertebral artery stenosis; Occlusive diseases; Hemodynamics; Extracranial segment; Intracranial segment

FREQUENCY OF CERVICAL AND INTRACRANIAL ARTERIES LESIONS AND ASSOCIATED CLINICAL SYMPTOMS IN PATIENTS WITH CONFIRMED RENAL FIBROMUSCULAR DYSPLASIA - ARCADIA-POL STUDY

Objective: To assess the frequency of cervical and intracranial arteries involvement and associated clinical symptoms in consecutive patients with renal fibromuscular dysplasia (FMD) enrolled into ARCADIA-POL study. Design and method: From 183 patients with FMD enrolled into ARCADIA-POL study since 2015 (Polish-French collaboration) all consecutive 157 patients (132F, 25 M, mean age:45.1 ± 15.1 years) with renal FMD were analyzed. All patients underwent clinical evaluation: ABPM, biochemical evaluation, biobanking, duplex Doppler of cervical and abdominal arteries and whole body angio-CT including cervical and intracranial arteries. Results: Among 157 patients with renal FMD, 38 (24.2%) had coexisting FMD lesions in cervical and/or intracranial arteries and/or intracranial aneurysms: 17 (10.8%) patients in carotid, 7 (4.5%) patients in vertebral and 24 (15.3%) patients had lesions in intracranial arteries. Dissections of carotid arteries were present in 3 (1.9%) patients and vertebral artery dissections in 3 (1.9%) patients. In 10 (6.4%) pts internal carotid artery aneurysm and in 2 (1.3%) patients vertebral artery aneurysm were found. 18 (11.5%) patients had intracranial aneurysms: 15 (9.6%) patients had one aneurysm, 2 (1.3%) pts 2 aneurysms and 1 (0.6%) patient had 3 aneurysms. Patients with and without cervical and/or intracranial FMD lesions didn’t differ in terms of age, gender, clinical and ambulatory blood pressure levels, hypertension prevalence and number of antihypertensive medications. There were no significant differences in the prevalence of symptoms such as headaches, tinnitus, dizziness and cervical bruits between the patients with and without cervical and/or intracranial FMD. There was only a significant difference in the presence of Horner's syndrome between patients with and without cervical and/or intracranial FMD (16.7% vs.1.9%; p = 0.001, respectively). There was no difference in the prevalence of stroke, transient ischemic attack or intracranial bleeding between the groups. Conclusions: There were no specific clinical features suggesting the presence of FMD lesions and vascular complications in cervical and/or intracranial arteries in patients with confirmed renal FMD included into ARCADIA-POL STUDY. Our study showed that systematic evaluation of cervical and intracranial arteries in patients with renal FMD results in revealing relatively high prevalence of FMD lesions and vascular complications in cervical and/or intracranial arteries.

Predictors of Stroke Events in Patients with Transient Ischemic Attack Attributable to Intracranial Stenotic Lesions.

Objective The purpose of this study was to identify the predictors of subsequent ischemic stroke events in patients with transient ischemic attack (TIA) attributable to intracranial arterial occlusive lesions. Methods The study population included 82 patients (55 men; mean age, 69.3±12.1 years) with TIA caused by intracranial arterial occlusive lesions who were admitted to our stroke care unit within 48 h of the onset of a TIA between April 2008 and November 2015. TIA was diagnosed if focal neurological symptoms ascribable to a vascular etiology lasted less than 24 h, irrespective of the presence of ischemic insults on imaging. The primary endpoint was an ischemic stroke event within 90 days of the onset of a TIA. Results The 90-day risk of ischemic stroke after the onset of a TIA was 14.6% [95% confidence interval (CI): 8.6-23.9%]. Cox proportional hazards multivariate analyses revealed that diffusion-weighted imaging (DWI) positivity [hazard ratio (HR), 8.73; 95%CI, 2.20-41.59; p=0.002], prior ischemic stroke (HR, 4.03; 95%CI, 1.07-15.99; p=0.040), and a high serum level of alkaline phosphatase (ALP) on admission (HR, 1.15; 95%CI, 1.05-1.26; p=0.002, for every +10 U/L) were significant independent predictors of ischemic stroke within 90 days after the onset of a TIA. Conclusion Our results suggested that patients with a TIA attributable to intracranial artery disease who showed DWI lesions, prior ischemic stroke, or high serum levels of ALP on admission were at high risk of subsequent ischemic stroke events.

PP.19.10] THE ARCADIA-POL STUDY– INVOLVEMENT OF CERVICAL AND INTRACRANIAL ARTERIES IN RELATION TO VASCULAR COMPLICATIONS AND ASSOCIATED CLINICAL SYMPTOMS IN PATIENTS WITH RENAL FMD

Objective: To assess the involvement of cervical and intracranial arteries and associated clinical symptoms in patients with renal fibromuscular dysplasia (FMD) enrolled into ARCADIA-POL study. Design and method: From 144 patients with confirmed FMD enrolled into ARCADIA-POL study in 2015, 127 patients (104F, 23 M, mean age:44.8 ± 15.9 years) were analyzed. All patients underwent clinical evaluation: ABPM, biochemical evaluation, biobanking, duplex Doppler of cervical and abdominal arteries and whole body angio-CT including cervical and intracranial arteries. Results: Among 127 patients with renal FMD, 31 (24.4%) had coexisting FMD lesions in cervical and/or intracranial arteries and/or intracranial aneurysms: 15 (11.8%) pts in carotid, 4 (3.1%) pts in vertebral and 19 (15.0%) pts in intracranial arteries. Dissections of carotid arteries were found in 4 (3.2%) pts and vertebral artery dissections in 3 (2.4%) pts. In 3 (2.4%) pts internal carotid artery aneurysm was found. 12 (9.5%) pts had intracranial aneurysms: 9 (7.1%) pts had one aneurysm, 2 (1.6%) pts 2 aneurysms, 1 (0.8%) pts 3 aneurysms and 1 (0.8%) pt 4 intracranial aneurysms. Patients with and without cervical and/or intracranial FMD lesions didn’t differ in terms of age, gender, clinical and ambulatory blood pressure levels, hypertension prevalence and number of antihypertensive medications. There was also no difference in the incidence of cervical and/or intracranial FMD lesions in patients with multifocal and unifocal lesions in renal arteries. There were no significant differences in the prevalence of symptoms such as headaches, tinnitus, dizziness and cervical bruits between the patients. There was only a significant difference in the presence of Horner's syndrome between patients with and without cervical and/or intracranial FMD (12.9% vs.2.4%; p = 0.017, respectively). There was no difference in the prevalence of stroke, transient ischemic attack or intracranial bleeding between the groups. Conclusions: There were no specific clinical features suggesting the presence of FMD lesions and vascular complications in cervical and/or intracranial arteries in patients with confirmed renal FMD included into ARCADIA-POL STUDY. Our study showed that systematic evaluation of cervical and intracranial arteries in patients with renal FMD resulted in revealing relatively high prevalence of FMD lesions and vascular complications in cervical and/or intracranial arteries.

Previous Statin Use and High-Resolution Magnetic Resonance Imaging Characteristics of Intracranial Atherosclerotic Plaque

Although statin use has been linked to the stabilization of systemic atherosclerosis, its effect on symptomatic intracranial atherosclerotic plaques has yet to be explored. We hypothesized that premorbid statin use is associated with plaque instability in intracranial arteries and may lead to differential patterns (size and distribution) of ischemic lesions in patients with acute intracranial atherosclerotic stroke. One hundred and thirty-six patients with acute infarcts caused by intracranial atherosclerotic stroke underwent high-resolution magnetic resonance imaging. Patients were categorized into 3 groups based on their premorbid statin use: nonuser, low-dose user, and high-dose user, according to the 2013 American College of Cardiology/American Heart Association guidelines on blood cholesterol. Symptomatic lesions in intracranial arteries were analyzed using high-resolution magnetic resonance imaging for vascular morphology (degree of stenosis, remodeling index, and wall index) and plaque activation (pattern and volume of enhancement). The cortical distribution and volume of ischemic brain lesions were measured using diffusion-weighted imaging. Among the enrolled patients, 38 (27.94%) were taking statins before the index stroke (22 low-dose statins and 16 high-dose statins). The degree of stenosis, remodeling index, and wall index did not differ between the 3 groups. However, the volume of plaque enhancement was significantly lower in statin users (nonuser, 33.26±40.72; low-dose user, 13.15±17.53; high-dose user, 3.13±5.26; P=0.002). Premorbid statin use was associated with a higher prevalence of nonembolic stroke and a decrease in large cortical infarcts (P=0.012). Premorbid statin usage is independently associated with reduced plaque enhancement and a decrease in large cortical lesions in patients with intracranial atherosclerotic stroke.

Abstract WP136: Clinical, Laboratory, and Imaging Characteristics Oof Transient Ischemic Attack Caused by Large Artery Lesion: A Comparison Between Carotid and Intracranial Artery

Background: The purpose of this study was to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 hours of TIA onset between April 2008 and December 2013, 85 patients (63 men, 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 days and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared to those in the extracranial group. Eleven patients in the extracranial group and no patient in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2% vs. 0%, p = 0.044) and 90-day risk (17.1% vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions among our patients with TIA caused by large artery disease. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Site and degree of intracranial arterial stenosis in acute stroke patients with metabolic syndrome among a sample of Egyptian patients

Background Type 2 diabetes mellitus (T2DM) has various effects on the vascular tree, both macrovascular and microvascular and both intracranial and extracranial circulation. Metabolic syndrome is a combination of medical disorders that, when occurring together, increases the risk of developing cardiovascular diseases including stroke. Objectives In this study, we aimed to estimate the site and degree of intracranial arterial stenosis among patients clinically diagnosed as acute ischemic stroke patients with metabolic syndrome with or without T2DM. Patients and methods This cross-sectional study included 100 patients admitted in Ain Shams University Specialized Hospital-Stroke Unit with the diagnosis of clinically first-ever cerebral infarction and metabolic syndrome with or without T2DM. All patients were subjected to detailed medical history, thorough general and neurological examination, full laboratory investigations, computerized tomography, MRI, and magnetic resonance angiography of the brain, carotid duplex, ECG, and echocardiography. Results Small vessel disease (lacune) was present more frequently in patients with T2DM than in those without T2DM, and this showed a statistically significant difference ( P = 0.008). It was found that intracranial stenosis was statistically significantly higher compared with extracranial carotid stenosis in patients with T2DM with total or near-total occlusion, with P values less than 0.05. These stenoses or occlusions also tend to be multiple in the same group of patients with T2DM ( P = 0.033). Conclusion Diabetic patients with acute ischemic stroke have a higher severity of intracranial arterial stenosis, higher incidence of multiple intracranial arterial stenoses, and lastly higher tendency to have obstructive intracranial arterial lesions.