Symptomatic Intracranial Artery Research Articles

Perioperative Complications of Recanalization and Stenting for Symptomatic Nonacute Vertebrobasilar Artery Occlusion

Endovascular recanalization and stenting has been used to treat patients with symptomatic nonacute intracranial vertebrobasilar artery occlusion (VBAO) refractory to aggressive medical treatment. This study was performed to analyze the perioperative complications of the procedures. Between February 2010 and March 2012, 27 consecutive patients (24 men, 3 women; age: 57 ± 10 years) with symptomatic, nonacute intracranial VBAO including 12 basilar artery occlusions and 15 vertebral artery occlusions were collected and retrospectively analyzed. The median time between symptom onset and recanalization was 1.5 months (interquartile range [IQR]: 0.7-3.4) and between imaging-documented occlusion and recanalization was 9.5 days (IQR: 6-18 days). Recanalization was achieved in 96% of patients (26/27). Five (5/27; 19%) perioperative complications occurred. Two patients had dissections: 1 dissection resulted in termination of the procedure without successful recanalization, and the other was handled by the placement of 2 stents. There was 1 intraprocedural acute thrombosis that was successfully treated with balloon angioplasty. One patient experienced thrombus disruption and translocation during the procedure: thrombus was dislodged after disruption by the guidewire. There was 1 acute reocclusion after procedure: while recanalization was achieved again, there was no improvement in clinical outcome. This study revealed that recanalization and stenting for nonacute VBAO may be technically feasible but that it is accompanied by a high risk of complication. The causative factors for perioperative complications need future study.

Reconstruction of intracranial vertebral artery with radial artery and occipital artery grafts for fusiform intracranial vertebral aneurysm not amenable to endovascular treatment: technical note

Symptomatic fusiform intracranial vertebral artery aneurysms pose a formidable treatment challenge when not amenable to endovascular treatment. In this paper, we illustrate the microsurgical management of such an aneurysm. To prevent neurological deterioration, anatomical reconstruction preserving all vessels including posterior inferior cerebellar artery and perforators is essential. In this case illustration, the occipital artery was used as a donor to a perforator originating from the aneurysmal segment. This bypass was performed in an end-to-side fashion. Subsequently, the aneurysmal component of the vertebral artery was resected and an end-to-side (V4 to V3) bypass was performed using a radial artery graft. The patient achieved complete resection of the aneurysm preserving normal anatomy of the posterior circulation without any ischemic complications. Complex cerebral artery bypass techniques are essential in the armamentarium of cerebrovascular for the treatment of complex lesions not amenable to endovascular therapy.

High-resolution Magnetic Resonance Imaging Reveals Hidden Etiologies of Symptomatic Vertebral Arterial Lesions

Symptomatic intracranial vertebral artery (VA) disease has various clinical features and poor neurological outcomes. The disease is believed to result from atherosclerotic stenosis, occlusion, or spontaneous VA dissection. The underlying histopathology of symptomatic intracranial VA disease has only been studied at postmortem, and no invivo imaging investigation has been conducted despite the increased sophistication of imaging techniques. The authors performed high-resolution magnetic resonance imaging (HR-MRI) of intracranial vertebral arteries in 9 patients, suspected of a VA pathology by magnetic resonance imaging (MRI), magnetic resonance angiography, and digital subtraction angiography. HR-MRI allowed the authors to determine the following: (1) atherosclerotic plaque is composed of a large lipid core with intraplaque hemorrhage and calcification, (2) nonstenotic atherosclerosis exhibits diffuse vessel wall thickening and plaque protruding toward perforating arteries, and (3) spontaneous VA dissection exhibits large intramural hematoma in a false lumen with complete occlusion of the true lumen. In addition, VA hypoplasia was easily differentiated from atherosclerotic stenosis, by direct visualization of a narrow lumen diameter without arterial wall thickening. Furthermore, etiologic diagnoses based on classical MRI, angiography, and digital subtraction angiography were changed in 3 patients after HR-MRI. Additional information on plaque stability, indicating the possibility of unstable plaque, was found in 4 patients. The application of HR-MRI in stroke patients with VA pathologies enabled the authors to determine the underlying pathophysiologies. These findings could be used to improve risk stratification and treatment decision making in symptomatic intracranial VA disease.

Abstract WP423: Final Results of Cilostazol-Aspirin Therapy Against Recurrent Stroke with Intracranial Artery Stenosis (CATHARSIS)

Background: The Cilostazol-Aspirin Against Recurrent Stroke with Intracranial Artery Stenosis (CATHARSIS) (Clinicaltrials.gov identifier: NCT 00333164) was a randomized controlled trial to compare cilostazol plus aspirin with aspirin alone in patients with symptomatic intracranial artery stenosis (IAS). We presented final results of CATHARSIS. Methods: Subjects were patients at age of 45-85 years with ischemic stroke after two weeks to six months from onset and >50% stenosis in responsible intracranial arteries on MRA. They were randomly allocated either group of cilostazol 200 mg/day plus aspirin 100 mg/day (CA group) or aspirin 100 mg/day alone (A group), who were followed up for two years. Primary endpoint was progression of IAS after two years. Secondary endopoints included ischemic stroke, all strokes, all vascular events (ischemic stroke, MI, and other vascular events) and new silent brain infarcts. Results: A total of 165 patients (109 males, average 68 years) were randomized. Male (77.1% vs 53.8%), hypertension (83.1% vs 68.8%), and diabetes (48.2% vs 25.0%) were more frequent in CA than A group. There was no difference in the progression of IAS between both groups (9.6% [95 CI 3.9-18.8%] in CA group and 7.6% [95% CI 3.8-13.2%] in A group, p = 0.5326). Stroke recurrence occurred in 2.4%/year in CA group (ischemic 4, hemorrhagic 0) and 5.5%/year in A group (ischemic 6, hemorrhagic 2). Rate of stroke recurrence tended to be lower in CA than C group (adjusted HR 0.439, 95% CI 0.112-1.497, p = 0.191). Rate of vascular events also tended to be lower in CA than A group (adjusted HR 0.390, 95% CI 0.118-1.136, p = 0.085). New silent brain infarcts were observed in 4.8% in CA group and 10.0% in A group at two years (p = 0.2445). Conclusion: Rates of IAS progression and recurrent stroke were unexpectedly low in both treatment groups, which could be due to excellent medical management and have reduced statistical power. There was no difference in the progression of IAS between two groups. Rates of stroke recurrence, vascular events, and new silent brain infarcts tended to be lower in CA than A group.

Periprocedural Thromboembolic Events Associated with Angioplasty and Stenting of the Extra- and Intracranial Carotid Artery Assessed by Neurological Status and Diffusion-Weighted Magnetic Resonance Imaging (DWI)

Objective. The purpose of this study was to determine the frequency of thromboembolic events associated with angioplasty and stenting of the carotid artery with special regard to extra- or intracranial localization of stenosis. Methods. Twenty patients with symptomatic intracranial or extracranial internal carotid artery stenosis were treated with stenting and/or angioplasty. In 4 patients stenting was technically not feasible (all in the group with intracranial stenosis). All patients underwent diffusion-weighted imaging (DWI) and neurological examination within 48 hours before and after the procedure to detect periprocedural thrombembolic events. Results. Extracranial carotid angioplasty and stenting (eCAS) was technically feasible and successfull without procedure-related neurological complications in all cases. Intracranial stenting (iCAS) was not feasible in four cases including one patient with a fateful course. Concerning the restoration of the vessel diameter intracranial stenting was not as successful as eCAS, but more effective than balloon angioplasty alone. Incidence of thrombembolic events assessed by DWI was low. The detected periprocedural thrombembolic events were small and clinically silent. Conclusion. The risk of thromboembolic events during the endovascular treatment of symptomatic carotid artery stenosis was rather low for intra- and extracranial stenosis of the ICA in our patient sample, but one fatal course was observed.

T2′ Imaging Within Perfusion-Restricted Tissue in High-Grade Occlusive Carotid Disease

Quantitative T2' imaging presumably detects regional changes in the relation of oxygenated and deoxygenated hemoglobin. Regional differences in hemoglobin oxygenation might reflect areas with increased oxygen extraction for compensation of reduced perfusion pressure. We investigated quantitative T2' imaging in patients with high-grade stenoses of brain-supplying arteries and hypothesized that T2' values are lower in perfusion-restricted areas as compared with normally perfused tissue. Eighteen patients (15 men; mean age±SD, 54±12.8 years) with unilateral symptomatic or asymptomatic high-grade extracranial or intracranial internal carotid artery or proximal middle cerebral artery stenosis/occlusion were included. MR examination included perfusion-weighted imaging and quantitative, motion-corrected mapping of T2' time. Time-to-peak and mean transit time maps were thresholded for different degrees of perfusion delays (eg, >0 seconds, ≥2 seconds) compared with the contralateral hemisphere. Mean T2' values in areas of impaired perfusion were compared with T2' values in corresponding contralateral or ipsilateral, normoperfused areas. Mean size of perfusion-impaired areas in time-to-peak maps (time-to-peak delay>0 seconds) was 10.8 mL (±6.3) and 11.5 mL (±6.4) in mean transit time maps (mean transit time delay>0 seconds). T2' values were significantly (P<0.01) lower in all perfusion-restricted compared with corresponding contralateral brain areas (ipsilateral versus contralateral). For time-to-peak delay >0 seconds, T2' values were 115 ms (±9) versus 125 ms (±12). For mean transit time delay>0 seconds, T2' values were 115 ms (±9) versus 128 ms (±10). Differences in T2' values increased with the severity of the perfusion delay. Ipsilateral T2' values outside the perfusion-disturbed areas did not differ from contralateral T2' values. Motion-corrected T2' imaging presumably detects areas with increased oxygen extraction within perfusion-restricted tissue in patients with high-grade occlusive vessel disease.

Design of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

Patients with recent transient ischemic attack (TIA) or stroke caused by 70% to 99% stenosis of a major intracranial artery are at high risk of recurrent stroke on usual medical management, suggesting the need for alternative therapies for this disease. The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial is an ongoing, randomized, multicenter, 2-arm trial that will determine whether intracranial angioplasty and stenting adds benefit to aggressive medical management alone for preventing the primary endpoint (any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days) during a mean follow-up of 2 years in patients with recent TIA or stroke caused by 70% to 99% stenosis of a major intracranial artery. Aggressive medical management in both arms consists of aspirin 325 mg per day, clopidogrel 75 mg per day for 90 days after enrollment, intensive risk factor management primarily targeting systolic blood pressure <140 mm Hg (<130 mm Hg in diabetics) and low density cholesterol <70 mg/dL, and a lifestyle modification program. The sample size required to detect a 35% reduction in the rate of the primary endpoint from angioplasty and stenting based on the log-rank test with an alpha of 0.05, 80% power, and adjusting for a 2% loss to follow-up and 5% crossover from the medical to the stenting arm is 382 patients per group. Enrollment began in November 2008 and 451 patients have been enrolled as of March 31, 2011. This is the first randomized stroke prevention trial to compare angioplasty and stenting with medical therapy in patients with intracranial arterial stenosis and to incorporate intensive management of multiple risk factors and a lifestyle modification program in the study design. Hopefully, the results of the trial will lead to more effective therapy for this high-risk disease.

Drug Eluting Stents for Symptomatic Intracranial and Vertebral Artery Stenosis

The use of bare metal stents (BMS) to prevent recurrent stroke due to stenosis of the cerebral vasculature is associated with high rates of restenosis. Drug-eluting stents (DES) may decrease this risk. We evaluated the performance of DES in a cohort of patients treated at our institution.Consecutive patients treated with DES were identified by a case log and billing records; data regarding procedural details, clinical outcome and angiographic follow-up was obtained by retrospective chart review.Twenty-six patients (27 vessels; 14 vertebral origin (VO); 13 intracranial) were treated. Stenosis was reduced from mean 81% to 8% at the VO and 80% to 2% intracranially. No strokes occurred in the first 24 hours after stenting or at any time point in the VO group during a mean follow-up period of nine months. Among patients with intracranial stents, stroke with permanent disability occurred within 30 days in 1/12 (8%) and after 30 days in 1/11 (9%) with clinical follow-up (mean follow-up, 14 months). Follow-up catheter angiography was obtained in 14/14 (100%) in the VO group at mean eight months and in 8/11 surviving patients (73%) at a mean of ten months after stenting in the intracranial group. The restenosis rate was 21% at the VO (3/14) and 38% (3/8) for intracranial stents. Restenosis at the VO was less frequent than might have been expected from reports utilizing BMS, however, overall restenosis rates appeared higher than previously reported for patients with intracranial DES and comparable with restenosis rates for intracranial BMS.

Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection

We aimed to evaluate the long-term clinical outcomes and prognostic factors of symptomatic intracranial unruptured vertebrobasilar artery dissection (siu-VBD). A total of 191 patients (M:F = 127:64; median age, 46 years) with siu-VBD were treated between January 2001 and December 2008. Presentations, treatments, outcomes, and prognostic factors were retrospectively analyzed. Clinical manifestations were ischemic symptoms with headache (n = 97) or without headache (n = 13) and headache without ischemic symptoms (n = 81). Forty-six patients (24.1%) underwent endovascular treatment. The remaining 145 patients (75.9%) were medically treated with anticoagulants (n = 49), antiplatelets (n = 48), or analgesics alone (n = 48). Clinical follow-up data were available in 178 patients (102 ischemic and 76 nonischemic) at 15 to 102 months (mean, 46 months). None of the siu-VBD hemorrhaged. All 76 patients without ischemic presentation had favorable outcomes (modified Rankin Scale, 0-1). Of the 102 patients with ischemic presentation, outcomes were favorable in 92 and unfavorable in 10 patients. Four patients died; 3 died of causes unrelated to VBD, and one died as a result of basilar artery (BA) dissection. Old age (odds ratio [OR] 1.099; 95% confidence interval [CI] 1.103-1.204; p = 0.042) and BA involvement (OR 11.886; 95% CI 1.416-99.794; p = 0.023) were independent predictors of unfavorable outcomes in siu-VBD with ischemic presentation. Clinical outcomes for siu-VBD were favorable in all patients without ischemic symptoms and in most patients with ischemic presentation. None of the siu-VBD caused subarachnoid hemorrhage. Old age and BA involvement were independent predictors of unfavorable outcome in siu-VBD with ischemic presentation.

Cilostazol improves symptomatic intracranial artery stenosis - Evaluation of cerebral blood flow with single photon emission computed tomography

Background:To evaluate the effectiveness of cilostazol in patients with intracranial arterial stenosis, we used magnetic resonance angiography (MRA). The drug's effect on the cerebral blood flow (CBF) was examined by single photon emission computed tomography (SPECT).Methods:In this retrospective study, we evaluated the clinical outcomes of 20 patients with stenosis in the M1 segment of the middle cerebral artery (MCA) who had suffered ischemic stroke within 12 weeks or manifested asymptomatic stenosis exceeding 50%. All patients received cilostazol (100 mg twice daily). MRA and SPECT (at rest and after acetazolamide challenge) studies were performed before and 6 and 12 months after the start of cilostazol treatment.Results:In 5 patients the stenotic lesion showed improvement on MRA. Mean stenosis before cilostazol therapy was 71.7 ± 4.9%, which improved to 39.0 ± 3.2% at 6 months and to 27.2 ± 2.8% at 12 months. SPECT study showed that CBF was improved in 3 patients; in one there was improvement at rest and the other 2 manifested improvement upon acetazolamide challenge.Conclusions:Cilostazol had a remodeling effect on stenotic lesions due to arteriosclerotic changes and improved CBF in some patients.

Wingspan stent system in the treatment of symptomatic intracranial atherosclerotic stenosis

Objective To assess the safety, feasibility, short-and mid-term efficacy of wingspan stent for treating patients with symptomatic intracranial artery stenosis. Methods A total of 113 patients with severe symptomatic intracranial stenosis were enrolled and Gateway-wingspan stenting were performed on all patients. The technical success, the pre- and post-stenting stenosis, perioperative complications, clinical outcome and restenosis rates were recorded, and chi-square test was used for analysis of complication rate by comparing our results with the results of Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study and NIH multi-center Wingspan stenting trial. Results The technical success rate was 99. 1% ( 112/113). The mean pre and post-stent stenoses were (80.7 ± 9.3)% and (27.7 ± 9.7)% (χ2 =9.397,P < 0. 05 ). The total complication rate was 4.4% (5/113 ) during the follow-up ( mean 14. 5 months, range 1-28 months), and the frequency of restenosis was 12. 5% (5/40) at 6 months. The primary endpoint events, ischemic stroke, and lesion-related ischemic stroke were lower in our study (4.5%, 3.5%,3.5% ) compared with the results of WASID trial (21.1%, 20. 4%, 15.0% ,P<0. 05). For those with poor outcome in the three high-risk sub-groups which were with more than 70% stenosis, or last event from the treatment was less than 17 days, or NIHSS was above 1, a better outcome was observed in our group (4. 5% ,4. 7% and 2. 0% in our study, 19.0%, 17.0% and 19. 6% in previous study, P < 0. 05). The medium-term efficacy in this group (4. 5% ) significantly improved compared with NIH study ( 14. 0% ,P <0. 05 ). Conclusions Wingspan stenting for symptomatic intracranial arterial stenosis is with good safety,feasibility and low perioperative stroke rate and mortality. The incidence of primary endpoint events and the ischemic events are lower than those of medication group, and the efficacy of stenting is significantly better than medication even in high-risk population. Key words: Intracranial arteriosclerosis; Angioplasty; Stents

Treatment of symptomatic intracranial artery stenosis with Wingspan stent

Objective To study the role of wingspan stent in treatment of intracranial arterial stenosis,including its feasibility,safety,efficacy and operating skills.Method27 cases of intracranial arterial stenosis treated with wingspan stent was retrospectively studied.There was no response to drug control in all patients.The stenosis located in 3 internal arteries,13 middle cerebral arteries,4 vertebral arteries and 7 basal arteries.Results All stents were successfully deployed with satisfied opening of the narrow paragraph.All patients were followed up after the procedures.There was I case of occasional attack of TIA,1 case of asymptomatic cerebral infarction.There was no ischemic attack occurred in other patients.Conclusions Wingspan stent is safe and effective in treatment of intracranial artery stenosis. Key words: Cerebralvascular disorders; Carotid stenosis; Stents; Wingspan

Preoperative imaging evaluation of interventional therapy for patients with symptomatic intracranial artery stenosis

Objective To investigate the value of comprehensive preoperative imaging evaluation in determining indication of intervention for patients with symptomatic intracranial artery stenosis.Methods DSA,high-resolution MRI of plaque and computed tomography perfusion (CTP) or perfusion weighted imaging (PWI) were performed in 26 patients with symptomatic intracranial artery stenosis and the intracranial artery cavity,artery wall and cerebral perfusion were evaluated.For patients with atherosclerotic plaque,the plaque characterization was analyzed according to high-resolution MRI findings,and intervention was used for those with unstable plaque.However,medicine was used for patients with arteritis.All patients were followed up after therapy.Results Combining with DSA,the stenosis in 18 cases was thought to be associated with atherosclerotic plaque,which showed eccentric stenosis with mild or no enhancement on MRI;13 of them had symptomatic unstable plaques,1 case showed stable plaque but cerebral perfusion damaged severely,all of them were treated with interventional therapy;the other 4 cases had stable plaques and treated with medicine. The stenosis in 8 patients,which showed concentric hypertrophy of local endangium on MRI,was caused by arteritis and treated with medicine.No ischemic events occurred during the following 1-8 months [average (5.2±3.1) months]after therapy.Conclusion Comprehensive preoperative imaging evaluation for patients with symptomatic intracranial artery stenosis is of great value in guiding the therapy. Key words: Intracranial artery diseases; Magnetic resonance imaging; Tomography; X-ray computed

FP06-MO-02 Economy class stroke in Hong Kong

interest artery include intracranial segment of internal carotid, intracranial segment of vertebral artery, basilar artery, middle cerebral artery. The technical success rate, average stenosis before and after treatment, major complications and clinical outcome were recorded. Conventional angiography was performed at 6 months after stenting to evaluate the patency of stent. Results: The average pretreatment stenosis was 80.6±12.1%. After Wingspan stent deployment, the average stenosis was 14.3±10.2%. The technical success rate was 100%. The rate of ipsilater stroke within 30 days and 6 months was 6.3% and 12.5%, respectively. The symptoms were significantly improved in 68.8% patients. Five patients underwent CT angiography, and in-stent stenosis was detected in one patient with 80% restenosis. Conclusion: Symptomatic intracranial artery stenosis can be treated with Wingspan stent with a high rate of technical success, acceptable safety and favorable clinic outcome.

Catheter exchange technique for the Wingspan stent: technical note

Background and purposeThe only Food and Drug Administration-approved implant for managing intracranial stenosis is the Wingspan stent. Modification of the standard Wingspan stent delivery procedure has not been previously reported.Material...

Treatment of symptomatic intracranial atheromatous stenosis with the Gateway balloon and Wingspan stent system: short and medium term results

Objective To assess the safety, feasibility and short-mid term effectiveness of the Wingspan stent in the treatment of high-grade symptomatic intracranial atheromatous stenosis. Methods Sixty-three patients with symptomatic intracranial atheromatons stenosis (≥ 70%) were treated with the Gateway balloon-Wingspan stent system. The pre-and post-treatment improvement of symptoms, severity of stenosis, successful rate of treatment, complications were evaluated. Physician-reported follow-up in all 63 patients lasted an average period of 9. 3 months. The X2 test was used for statisties. Results Sixty-three lesions involved the intracranial internal carotid artery (n = 12), middle cerebral artery (n = 22), V4 segment vertebral artery (n = 15), basilar artery (n = 14). Sixty-two lesions were successfully treated with the deployment of the self-expanding Wingspan stent with residual stenosis ≤ 30%. One case failed because of intracranial hemorrhage during the operation. The successful rate of stenting is 98.0% (62/63). The mean stenosis was (82. 3 ± 9. 2) % before treatment, and it improved to (23.0 ± 11.2) % after stent placement. During the follow-up period, 1 patient died of postprocedural hyper-perfusion, one had ischemic stroke after procedure, one presented Homer syndrome at the 11th day, one had iachemic stroke at the 5th month after the procedure, while the other patients had significantly improved. The frequency of ≥50% restenosis on follow-up angiography or computed tomography was 10% (1/10). Conclusions Angioplasty and stenting for high-grade symptomatic intracranial artery stenosis with the Gateway-Wingspan stent system are safe and effective with high rate of technical success, but moderately high rate of residual stenosis and restenosis exist. With the improvement of operation skill and stent system, a better outcome in the future could be achieved. Key words: Vertebasilar insufficiency; Intracranial arteriosclerosis; Angioplasty; Stent

Does ABCD 2 Score Below 4 Allow More Time to Evaluate Patients With a Transient Ischemic Attack?

The National Institute for Clinical Excellence (NICE) recommends that patients with a transient ischemic attack and ABCD(2) score > or =4 and those with >2 transient ischemic attacks within 1 week be admitted for urgent complete etiologic evaluation within 24 hours and that those with an ABCD(2) score <4 be evaluated less urgently within 1 week. Using data from 1176 patients with a definite or possible transient ischemic attack or minor stroke included in the SOS-TIA registry (January 2003 to June 2007), we studied the usefulness of the conventional ABCD(2) score cutoff as well as the NICE criteria for urgent admission to a stroke unit defined as presence of symptomatic internal carotid artery stenosis > or =50%, symptomatic intracranial artery stenosis > or =50%, or major cardiac source of embolism. Among 697 patients with an ABCD(2) score <4, 20% required immediate consideration for emergency treatment (eg, symptomatic internal carotid stenosis > or =50% in 9.1% of patients, symptomatic intracranial stenosis in 5.0%, atrial fibrillation in 5.9%, other major cardiac source of embolism in 2.1%) in comparison to 31.6% of 497 patients with an ABCD(2) score > or =4. The sensitivity and specificity of ABCD(2) score > or =4 or NICE criteria for discriminating between patients requiring admission or not were <62% with low positive predictive values (<30%) and high negative predictive values (> or =80%). One in 5 patients with an ABCD(2) score <4 had high-risk disease requiring urgent treatment decision-making. When triaging on an ABCD(2) score, we recommend adding systematic carotid ultrasound (or a default angiographic CT scan) and electrocardiography within 24 hours before postponing complete transient ischemic attack evaluation.

Causes and Severity of Ischemic Stroke in Patients With Symptomatic Intracranial Arterial Stenosis

There are limited data on the causes and severity of subsequent stroke in patients presenting initially with TIA or stroke attributed to intracranial arterial stenosis. We evaluated the location, type (lacunar vs nonlacunar), cause, and severity of stroke in patients who had an ischemic stroke endpoint in the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. Of the 569 patients enrolled in the WASID trial, 106 patients (18.6%) had an ischemic stroke during a mean follow-up of 1.8 years. Stroke occurred in the territory of the symptomatic artery in 77 (73%) of 106 patients. Among the 77 strokes in the territory, 70 (91%) were nonlacunar and 34 (44%) were disabling. Stroke out of the territory of the symptomatic artery occurred in 29 (27%) of 106 patients. Among these 29 strokes, 24 (83%) were nonlacunar, 14 (48%) were attributed to previously asymptomatic intracranial stenosis, and 9 (31%) were disabling. Most subsequent strokes in patients with symptomatic intracranial artery stenosis are in the same territory and nonlacunar, and nearly half of the strokes in the territory are disabling. The most commonly identified cause of stroke out of the territory was a previously asymptomatic intracranial stenosis. Penetrating artery disease was responsible for a low number of strokes.

脳梗塞発症の頭蓋内椎骨動脈狭窄に対する血管拡張術の検討

脳梗塞発症の頭蓋内椎骨動脈狭窄に対する血管拡張術の検討

Progression of Symptomatic Intracranial Large Artery Atherosclerosis Is Associated With a Proinflammatory State and Impaired Fibrinolysis

The molecular pathways involved in the progression of intracranial large artery atherosclerosis (ILA) are largely unknown. Our objective was to prospectively study the relationship between circulating levels of inflammatory markers and fibrinolysis inhibitors, and the risk of progression of symptomatic ILA. Seventy-five consecutive patients with first-ever symptomatic intracranial atherostenosis were studied. Blood levels of C-reactive protein (CRP), E-selectin, monocyte chemoattractant protein-1, intercellular adhesion molecule-1, matrix metalloproteinases 1, 2, 3, 8, 9, 10, and 13, plasminogen activator inhibitor-1 (PAI-1), and lipoprotein(a) were measured 3 months after the qualifying stroke or transient ischemic attack. Thereafter, patients underwent long-term transcranial Doppler follow-up to detect progression of ILA. During a median follow-up time of 23 months, 25 (33%) patients showed ILA progression. Multivariable adjusted Cox regression models and Kaplan-Meier curves showed that high baseline level of CRP, E-selectin, intercellular adhesion molecule-1, matrix metalloproteinase 9, PAI-1, and lipoprotein(a) predicted ILA progression independently of vascular risk factors. Of them, only CRP (CRP>5.5 mg/L; HR, 5.4 [2.3 to 12.7]; P=0.0001) and PAI-1 (PAI-1>23.1 ng/mL; HR, 2.4 [1.0 to 5.8]; P=0.05) predicted ILA progression also independently of the other studied molecules. Progression of symptomatic ILA is associated with a proinflammatory state, as reflected by high levels of inflammatory markers, and with defective fibrinolysis, as indicated by raised concentrations of endogenous fibrinolysis inhibitors.