Symptomatic Intracranial Atherosclerotic Disease Research Articles

The resolute Onyx in TIA management (ROTIA).

First-line treatment for symptomatic intracranial atherosclerotic disease (ICAD) is medical management; however, interventional approaches are increasingly considered for refractory disease. The Resolute Onyx in TIA management (ROTIA) study is a post-market evaluation of the Resolute Onyx (R-Onyx) drug-eluting stent in the treatment of recurrent transient ischemic attacks (TIAs) due to refractory ICAD (off-label use). This is a single-center, retrospective case series of consecutive patients who underwent angioplasty and stenting with R-Onyx for treatment of recurrent TIAs due to refractory ICAD from October 2019 to November 2022. Included patients were ages 22-80, had a baseline modified Rankin Scale of ≤2, and had recurrent TIAs attributed to intracranial artery stenosis >70% despite maximal medical therapy. Primary outcomes of interest were peri-procedural complications (TIA, stroke, intracranial hemorrhage, mortality) up to 72 h post-stenting and ischemic stroke up to 18 months post-stenting. Twenty patients (mean age 66.84 ± 14; 25% female; 80% Hispanic) were included. A total of 21 stents were successfully deployed with no peri-procedural complications. There were no recurrent ischemic events at 30 days post-stenting. At 18 months post-stenting, there were no ischemic events and no patient exhibited in-stent restenosis. ROTIA demonstrates the feasibility of using the Resolute Onyx drug-eluting stent for the management of TIAs due to refractory ICAD, with high technical success and low peri-procedural complications. Limitations include the retrospective and single-center nature of this study. Future prospective, multi-center, randomized trials with extended observation periods are needed.

221 Submaximal Angioplasty Alone Versus Stenting Plus Angioplasty for Symptomatic Intracranial Atherosclerotic Disease a Propensity Score Matched Comparative Study With Long Term Follow-Up

INTRODUCTION: Symptomatic intracranial atherosclerotic disease (ICAD) remains an important cause of recurrent stroke and acute ischemic event. Although the high periprocedural risk of intracranial stenting from recent randomized studies has dampened enthusiasm for such interventions, submaximal angioplasty without stenting may represent a safer endovascular treatment option. METHODS: A prospectively maintained database was retrospectively searched for patients presenting with signs and symptoms of acute ischemic stroke or transient ischemic events. Patients subsequently underwent CT Stroke Study to confirm the diagnosis of symptomatic intracranial atherosclerotic disease. Patient baseline demographic characteristics, procedural details and post-procedure outcomes were recorded. A one-to-one matched propensity score analysis was performed to adjust for treatment selection bias using the nearest-neighbor matching technique without replacement for covariates (baseline comorbidities, previous stroke or TIA, antiplatelet use, anticoagulant use, and baseline percent diameter stenosis). Mann-Whitney U test was performed to compare the procedural parameters and the clinical outcomes between groups. RESULTS: We included 218 patients (Submaximal angioplasty:97 [97 after PSM]; Stenting plus angioplasty:121 [97 after PSM]). After PSM, no difference was seen between the two groups in terms of comorbidities, and initial stroke severity. Submaximal angioplasty group had significantly lower incidence of stroke/TIA secondary to restenosis on follow-up (6.2% vs. 20.6% (OR = 0.87; P = 0.003)), and longer length of follow-up after discharge (4.17 years vs. 2.88 years (OR = 0.98; P = 0.03)) when compared to stenting plus angioplasty group. Both groups had similar rates of intra- (2.1% vs. 6.2% (OR = 0.96; P = 0.15)) and post-procedural complications rates (6.2% vs. 11.3% (OR = 0.95; P = 0.21)). CONCLUSIONS: Submaximal angioplasty alone results in better long-term clinical outcomes in terms of stroke/TIA when compared with stenting and angioplasty for symptomatic intracranial atherosclerotic disease, and represents a potentially promising intervention.

Association between high-resolution magnetic resonance vessel wall imaging characteristics and recurrent stroke in patients with intracranial atherosclerotic steno-occlusive disease: A prospective multicenter study.

High-resolution magnetic resonance vessel wall imaging (HRMR-VWI) is a promising technique for identifying intracranial vulnerable plaques beyond lumen narrowing. However, the association between HRMR-VWI characteristics and recurrent stroke remains uncertain. This study aimed to investigate the association between HRMR-VWI characteristics and recurrent ipsilateral stroke in patients with symptomatic intracranial atherosclerotic steno-occlusive disease (ICAS). This multicenter, observational study recruited first-ever acute ischemic stroke patients attributed to ICAS (>50% stenosis or occlusion) within 7 days after onset. Participants were assessed by multiparametric magnetic resonance imaging (MRI) including diffusion-weighted imaging, three-dimension time-of-flight magnetic resonance angiography, and three-dimensional T1-weighted HRMR-VWI. The patients were recommended to receive best medical therapy and were systematically followed up for 12 months. The association between HRMR-VWI characteristics and the time to recurrent ipsilateral stroke was investigated by univariable and multivariable analysis. Two hundred and fifty-five consecutive patients were enrolled from 15 centers. The cumulative 12 month ipsilateral recurrence incidence was 4.1% (95% confidence interval (CI): 1.6-6.6%). Patients with recurrent ipsilateral stroke exhibited higher rates of intraplaque hemorrhage (IPH) (30.0% vs 6.5%) and eccentric plaque (90.0% vs 48.2%), and lower occurrence of occlusive thrombus (10.0% vs 23.7%). Plaque length (5.69 ± 2.21 mm vs 6.67 ± 4.16 mm), plaque burden (78.40 ± 7.37% vs 78.22 ± 8.32%), degree of stenosis (60.25 ± 18.95% vs 67.50% ± 22.09%) and remodeling index (1.07 ± 0.27 vs 1.03 ± 0.35) on HRMR-VWI did not differ between patients with and without recurrent ipsilateral stroke. In the multivariable Cox regression analysis, IPH (hazard ratio: 6.64, 95% CI: 1.23-35.8, p = 0.028) was significantly associated with recurrent ipsilateral stroke after adjustment.Conclusions:Our results suggest intraplaque hemorrhage (IPH) is significantly associated with recurrent ipsilateral stroke and has potential value in the selection of patients for aggressive treatment strategies. Data from this study are available and can be accessed upon request.

Abstract TP220: Intracranial Dotter Angioplasty Using Tenzing for Symptomatic Atherosclerotic Stenosis: Initial Experience

Introduction: Traditional endovascular treatment for acutely symptomatic intracranial atherosclerotic disease (ICAD) includes balloon angioplasty and stenting. Catheter mediated angioplasty (or “Dotter” angioplasty) has been previously described for extracranial carotid and peripheral arteries. The Tenzing 7 (Route 92 Medical, San Mateo, CA), a novel shelf-reducing delivery catheter, has an atraumatic tapered distal tip that progressively enlarges to a 0.062 inch (1.6 mm) outer diameter, which may enable catheter-mediated Dotter angioplasty of ICAD, or Tenzing-plasty. We report our initial experience in treating symptomatic ICAD using Tenzing-plasty. Methods: After IRB approval, we performed a retrospective review of patients undergoing endovascular treatment for symptomatic ICAD with Tenzing-plasty as a first approach at our stroke centers from 2021-2023. All patients were treated using the Tenzing 7 delivery catheter in an off-label fashion. The Tenzing was slowly inserted across the ICAD stenosis in each case under roadmap fluoroscopic guidance. Subsequent balloon angioplasty and/or stenting were at operator discretion. We examined clinical, imaging, and procedural data. Results: We identified 14 consecutive patients with symptomatic ICAD stenosis who underwent Tenzing-plasty, either as part of an emergent thrombectomy procedure, or if medical management of ICAD had failed. The median age was 62±11 years and 6 were female (43%). Stenosis location was: 1 ICA, 7 M1, 4 M2, 2 vertebral. The average pre-treatment ICAD stenosis was 95±7%, including 6 patients (43%) with complete occlusion. In 100% of cases, Tenzing-plasty resulted in improvement in arterial caliber after median 1 pass (IQR1-1), with average stenosis improving to 64±15%. Subsequent balloon angioplasty was performed in 3/14 cases (21%). Stenting was performed in 10 cases (using Atlas, Wingspan, Onyx Resolute, Onyx Frontier). There were no instances of arterial perforation or symptomatic intracranial hemorrhage. Conclusions: Intracranial Dotter angioplasty as a first approach using the novel tapered tip Tenzing 7 catheter may be a feasible and safe alternative for improving luminal caliber and flow restoration of symptomatic ICAD lesions. Further study is warranted.

Abstract 36: Association Between High-Resolution Magnetic Resonance Imaging Characteristics and Recurrent Stroke in Patients With Symptomatic Intracranial Atherosclerotic Steno-Occlusive Disease: A Prospective Multicenter Study

Background and Objectives: This study aimed to investigate the association between high-resolution magnetic resonance imaging (HR-MRI) characteristics and recurrent ipsilateral stroke in patients with symptomatic intracranial atherosclerotic steno-occlusive disease (ICAS). Methods: This multicenter, observational study recruited first-ever acute ischemic stroke patients attributed to ICAS (>50% stenosis or occlusion) within 7 days after onset. Participants were assessed by multi-parametric MRI including diffusion-weighted imaging, three-dimension time-of-flight magnetic resonance angiography, and three-dimensional T1-weighted HR-MRI. The patients were recommended to receive best medical therapy and were systematically followed up for 12 months. The association between HR-MRI characteristics and the time to recurrent ipsilateral stroke was investigated by univariable and multivariable analysis. Results: Two hundred and fifty-five consecutive patients were enrolled from 15 centers. The cumulative 12-month ipsilateral recurrence incidence was 4.1% (95% confidence interval [CI]: 1.6-6.6%). The plaque length (5.69±2.21 mm vs. 6.67±4.16 mm), plaque burden (78.40±7.37% vs. 78.22±8.32%), degree of stenosis (60.25±18.95% vs. 67.50±22.09%) and remodeling index (1.07±0.27 vs. 1.03±0.35) on HR-MRI did not exhibit discernible difference between patients with and without recurrent ipsilateral stroke. Patients with recurrent ipsilateral stroke exhibited higher rates of intraplaque hemorrhage (IPH) (30.0% vs. 6.5%) and eccentric plaque (90.0% vs. 48.2%), and lower occurrence of occlusive thrombus (10.0% vs. 23.7%). In the multivariable Cox regression analysis, IPH (hazard ratio: 7.05, 95% CI: 1.53-32.41, p=0.012) was significantly associated with recurrent ipsilateral stroke after adjustment. Discussion: We found IPH is significantly associated with recurrent ipsilateral stroke. Our results suggest IPH has potential value in the selection of patients for aggressive treatment strategies.

Epidemiology, Pathophysiology, and Imaging of Atherosclerotic Intracranial Disease.

Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide. Among people with stroke, those of East Asia descent and non-White populations in the United States have a higher burden of ICAD-related stroke compared with Whites of European descent. Disparities in the prevalence of asymptomatic ICAD are less marked than with symptomatic ICAD. In addition to stroke, ICAD increases the risk of dementia and cognitive decline, magnifying ICAD societal burden. The risk of stroke recurrence among patients with ICAD-related stroke is the highest among those with confirmed stroke and stenosis ≥70%. In fact, the 1-year recurrent stroke rate of >20% among those with stenosis >70% is one of the highest rates among common causes of stroke. The mechanisms by which ICAD causes stroke include plaque rupture with in situ thrombosis and occlusion or artery-to-artery embolization, hemodynamic injury, and branch occlusive disease. The risk of stroke recurrence varies by the presumed underlying mechanism of stroke, but whether techniques such as quantitative magnetic resonance angiography, computed tomographic angiography, magnetic resonance perfusion, or transcranial Doppler can help with risk stratification beyond the degree of stenosis is less clear. The diagnosis of ICAD is heavily reliant on lumen-based studies, such as computed tomographic angiography, magnetic resonance angiography, or digital subtraction angiography, but newer technologies, such as high-resolution vessel wall magnetic resonance imaging, can help distinguish ICAD from stenosing arteriopathies.

Abstract WP142: Investigating the Association of Intracranial Stenosis With Low Wall Shear Stress

Background: Intracranial atherosclerotic disease (ICAD) is associated with high recurrence rates of stroke despite aggressive medical management. Low wall shear stress (WSS) alters endothelial function and changes in WSS within the post-stenotic region of ICAD lesions is a potential driver of stroke recurrence. Methods: Using the SAMMPRIS imaging dataset, we identified medically managed patients with symptomatic middle cerebral artery (MCA) stenosis measured by CTA. WSS was calculated by creating a 3D volumetric mesh from CTA source imaging. Pulsatile flow profile reference standard boundary conditions were applied at pressure outlets to simulate normal hemodynamics. Arterial segments extending from the stenosis to the MCA bifurcation were captured and quantified. Contralateral arterial segments were matched by length and area. The ratio of area with low WSS (<4 dyne/cm 2 ) on both sides was then calculated. Differences in the mean arterial area with low WSS and ratio of area with low WSS were compared using paired Student’s t-test with data presented as mean ± SD. Results: Of 451 cases in SAMMPRIS, the medical management arm had 105 MCA cases of which 47 cases had CTA available and 33 cases were able to be analyzed by computational flow dynamics. Symptomatic ICAD lesions demonstrated significant differences in post stenosis area with low WSS (24.7±43.4 mm 2 vs 2.8±3.4 mm 2 p=0.003) and differences in the low WSS ratio (0.25±0.26 vs0.04±0.05 p<0.001). There was no statistically significant difference in the length and area of the arterial segment post stenosis to the bifurcation and the control length on the contralateral side (11.6±7.4 mm vs 10.6±6.1 mm p=0.566; 80.7±55.0 mm 2 vs 95.4±58.3 mm 2 p=0.298). Conclusion: Area with low WSS after ICAD stenoses is increased in the SAMMPRIS imaging dataset and may be a marker of symptomatic ICAD. Further studies are needed to evaluate the association of post stenotic WSS with symptomatic recurrent stroke.

Abstract TP185: Resolute Onyx Stent for Symptomatic Intracranial Stenosis: Short and Long-Term Results (R.O.S.S.I.S. Study) With 18-month Follow-Up

Introduction: The Resolute Onyx stent has shown promise as an effective treatment for symptomatic intracranial atherosclerotic disease (sICAD), with positive clinical outcomes and low procedural complication rates. However, previous studies were limited by small sample sizes and lacked long-term follow-up. Methods: In this retrospective analysis, we examined patients who underwent Resolute Onyx stent placement for sICAD. Primary outcomes included stroke, intracerebral hemorrhage (ICH), and mortality rates at 1-, 6-, 12-, and 18-month follow-ups, and in-stent restenosis. Multivariable logistic regression identified predictors of stroke and mortality. Subgroup analyses assessed patients who underwent stenting at least 8 days after the qualifying event to ensure comparability with WEAVE registry data. Results: Our study included 77 patients with 84 procedures. The mean age was 61.9±13.0, with 35% being female. The median time from qualifying event to procedure was 5 days (IQR: 2-11). Among adherent patients, no disease-related deaths occurred after the first month. However, one ICH and two strokes occurred within 6 and 12 months, respectively. Comparison of WEAVE-matched and non-matched patients revealed no significant difference in complications during short- and long-term follow-up. Postprocedural complications within 72 hours were <2% in the non-WEAVE group and 3% in the WEAVE group. Conclusions: The Resolute Onyx stent demonstrates safety and effectiveness in treating intracranial stenosis, with potentially lower rates of peri- and post-procedural complications compared to other stents. Our findings challenge the practice of delaying stent placement, emphasizing the importance of early intervention and questioning the validity of the WEAVE criteria.

Abstract 17474: Factors Affecting Cognitive Status in Patients With Intracranial Atherosclerosis After Surgical Revascularization: A Post Hoc Analysis of ERSIAS Phase-2 Performance Criterion (PC) Trial

Introduction: Cognitive decline affects a large proportion of patients with ischemic stroke. Intracranial atherosclerotic disease (ICAD) is a common stroke etiology associated with a high and prolonged risk of recurrence. In the ERSIAS phase-II trial, patients with symptomatic ICAD received revascularization with encephaloduroarteriosynangiosis (EDAS) plus intensive medical management (IMM) of stroke risk factors. We present a subgroup analysis of features affecting cognitive outcomes. Hypothesis: To evaluate the factors contributing to cognitive decline in patients who underwent revascularization for symptomatic ICAD. Methods: ERSIAS patients without aphasia that completed at least one year of follow-up were included. Cognitive status was evaluated using MoCA at baseline and each follow-up and classified as improved/preserved vs. worsened. Classification and Regression Tree Analysis (CART) was used to identify factors associated with changes in cognitive function. Factors considered were age, sex, stenosis vs. occlusion, baseline-mRS, good collateralization and compliance with diabetes (DM) hypertension (HTN), and hyperlipidemia (HLD) treatments. Results: In ERSIAS, the mean MoCA at baseline was 22.4 (SD 4.9), and 23.9 (SD 4.9) at one-year follow-up in the complete population. Thirty-nine patients were included in this analysis. Median age was 46 (IQR 37.0-56.0), and 27 (69.2%) were female. MoCA improved or remained stable in 33 (84.6%) patients and declined in 6 (15.4%). CART analysis revealed that the most relevant factors for improved MoCA were compliance with DM treatment (94.5%(yes) vs.74.2%(no) p=0.02) HLD treatment (83.3% (yes) 60.5%(no) p=0.2) and stenosis 99.1% vs. occlusion 80.9%, p=0.6 Other factors where not found to be contributory. Conclusions: Compliance with DM treatment is a significant predictor of cognitive preservation in symptomatic ICAD patients. Our findings emphasize the importance of IMM of stroke risk factors in patients with intracranial atherosclerosis, even after surgical revascularization.

Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease

ObjectiveTo directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD. MethodsFrom 2017–2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke). ResultsOf 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively. ConclusionsPatients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.

Association of plaque characteristics with long-term stroke recurrence in patients with intracranial atherosclerotic disease: a 3D high-resolution MRI-based cohort study

ObjectivesTo evaluate the predictive ability of plaque characteristics for long-term stroke recurrence among patients with symptomatic intracranial atherosclerotic disease (ICAD).MethodsThis cohort study included 132 patients with acute ischemic stroke (AIS) attributed to ICAD who were recruited between July 2017 and December 2020 and followed until stroke recurrence or December 2021. Plaque surface irregularity, degree of stenosis, plaque burden, remodeling ratio, enhancement ratio, and intraplaque hemorrhage were assessed with 3-dimensional high-resolution magnetic resonance vessel wall imaging (3D HR-MRI). Data were analyzed using Cox models, receiver operating characteristic (ROC) curves, and Kaplan–Meier survival analysis.ResultsOf the 132 patients, during a median follow-up of 2.8 years, stroke recurrence occurred in 35 patients. The multivariable-adjusted hazard ratio (95% confidence interval) of stroke recurrence was 3.15 (1.34–7.42) per 10% increase in plaque burden and 2.17 (1.27–3.70) for enhancement ratio. The area under the curve (AUC) to predict stroke recurrence was 0.725 (95% CI 0.629–0.822) for plaque burden, 0.692 (95% CI 0.593–0.792) for enhancement ratio, and only 0.595 (95% CI 0.492–0.699) for the Essen stroke risk score. The Kaplan–Meier survival analysis further demonstrated significant differences in survival of free recurrent stroke between patients with plaque burden or enhancement ratio below and above the optimum cut-offs (both p < 0.001).ConclusionHigher plaque burden and enhancement ratio are independent risk factors for long-term stroke recurrence among patients with symptomatic ICAD, and valuable imaging markers for predicting and stratifying risk of stroke recurrence.Clinical relevance statementIn patients with symptomatic ICAD, the results of this high-resolution magnetic resonance vessel wall imaging study have potential implications for optimal management of intracranial plaques and secondary prevention of stroke recurrence based on plaque burden and enhancement ratio.Key Points• Identification of intracranial plaque characteristics responsible for stroke recurrence is essential to preventing stroke recurrence in patients with symptomatic intracranial atherosclerotic disease.• Higher plaque burden and enhancement ratio are independent risk factors for stroke recurrence.• Plaque burden and enhancement ratio are valuable imaging markers in the prediction and stratification of the risk of stroke recurrence.

Use of the neuroform atlas for stenting of intracranial atherosclerotic disease: Clinical and angiographic outcomes.

Intracranial atherosclerotic disease (ICAD) is a potential cause of ischemic stroke. Treatment of ICAD can include intracranial stenting. There are specifically designed stents for this use-case; however, less is known about the off-label use of the Neuroform Atlas stent. In this study, we describe the outcomes of the Neuroform Atlas stent for treatment of ICAD. Adult patients with symptomatic ICAD failing best medical treatment undergoing elective intracranial stenting using the Neuroform Atlas stent between November 2018 and March 2021 were included. Patient demographics, procedure-related details and clinical and imaging outcomes were analyzed. Eighteen patients met the inclusion criteria, with a mean follow-up duration of 9.6 ± 6.8 (standard deviation) months. There were two procedure-related mortalities (one massive intracranial hemorrhage and one groin site complication with sepsis). Fifteen patients were alive at the 6-month follow-up, all with satisfactory stent patency on follow-up imaging without any new ischemic events. Modified Rankin Scale at latest follow-up was 1.9 (interquartile range 5). In this single-center consecutive series, intracranial stenting with the Neuroform Atlas stent was a safe and effective treatment for symptomatic ICAD patients failing best medical management.

Hemodynamic significance of intracranial atherosclerotic disease and ipsilateral imaging markers of cerebral small vessel disease.

Cerebral small vessel disease (CSVD) commonly exists in patients with symptomatic intracranial atherosclerotic disease (sICAD). We aimed to investigate the associations of hemodynamic features of sICAD lesions with imaging markers and overall burden of CSVD. Patients with anterior-circulation sICAD (50%-99% stenosis) were analyzed in this cross-sectional study. Hemodynamic features of a sICAD lesion were quantified by translesional pressure ratio (PR = Pressurepost-stenotic/Pressurepre-stenotic) and wall shear stress ratio (WSSR = WSSstenotic-throat/WSSpre-stenotic) via CT angiography-based computational fluid dynamics modeling. PR ⩽median was defined as low ("abnormal") PR, and WSSR ⩾ fourth quartile as high ("abnormal") WSSR. For primary analyses, white matter hyperintensities (WMHs), lacunes, and cortical microinfarcts (CMIs) were assessed in MRI and summed up as overall CSVD burden, respectively in ipsilateral and contralateral hemispheres to sICAD. Enlarged perivascular spaces (EPVSs) and cerebral microbleeds (CMBs) were assessed for secondary analyses. Among 112 sICAD patients, there were more severe WMHs, more lacunes and CMIs, and more severe overall CSVD burden ipsilaterally than contralaterally (all p < 0.05). Abnormal PR and WSSR (vs normal PR and WSSR) was significantly associated with moderate-to-severe WMHs (adjusted odds ratio = 10.12, p = 0.018), CMI presence (5.25, p = 0.003), and moderate-to-severe CSVD burden (12.55; p = 0.033), ipsilaterally, respectively independent of contralateral WMHs, CMI(s), and CSVD burden. EPVSs and CMBs were comparable between the two hemispheres, with no association found with the hemodynamic metrics. There are more severe WMHs and CMI(s) in the hemisphere ipsilateral than contralateral to sICAD. The hemodynamic significance of sICAD lesions was independently associated with severities of WMHs and CMI(s) ipsilaterally.

Intracranial atherosclerotic disease: current management strategies.

A stroke due to underlying intracranial large artery occlusion, which is atherosclerotic in nature, is known as intracranial atherosclerotic disease (ICAD). It is important to recognize that ischaemic stroke due to ICAD differs from extracranial disease and other stroke aetiologies and requires a nuanced approach. It is a significant cause of stroke worldwide, and severe symptomatic ICAD can present challenges from a therapeutic standpoint, including recurrent ischaemic stroke despite optimal management. Furthermore, exploring the underlying pathophysiological mechanisms responsible for the disease may be necessary while considering treatment options. This narrative review aims to provide an all-encompassing overview of this disease. Epidemiology and clinical pathophysiology will be explored in detail. The findings of large clinical trials will serve as a guide to finding the most optimized management strategies. Another critical question that arises is the treatment of acute ischaemic stroke due to large vessel occlusion with underlying intracranial atherosclerosis, is the treatment and clinical diagnosis the same as for other aetiologies of stroke (i.e. extracranial disease and nonvalvular atrial fibrillation)? Consequently, secondary prevention of patients with ischaemic stroke or transient ischaemic attack will be divided into medical therapy, risk factor control, and endovascular and surgical treatment options.

Predicting acute ischemic stroke using the revised Framingham stroke risk profile and multimodal magnetic resonance imaging.

Patients with transient ischemic attacks (TIA) have a significant risk of developing acute ischemic strokes (AIS), emphasizing the critical need for hierarchical management. This study aims to develop a clinical-imaging model utilizing multimodal magnetic resonance imaging (mMRI) and the revised Framingham Stroke Risk Profile (FSRP) to predict AIS and achieve early secondary prevention. mMRI scans were conducted on patients with symptomatic intracranial atherosclerotic disease (ICAD) to assess vascular wall features and cerebral perfusion parameters. Based on diffusion-weighted imaging (DWI), patients were divided into two groups: TIA and AIS. Clinical data were evaluated to calculate the FSRP score. Differences in clinical and imaging characteristics between the groups were analyzed, and a predictive model for AIS probability in patients with ICAD was established. A total of 112 TIA and AIS patients were included in the study. The results showed that the AIS group had higher proportions of FSRP-high risk, hyperhomocysteinemia, and higher value of low-density lipoprotein (LDL), standardized plaque index (SQI), and enhancement rate (ER) compared to the TIA group (p < 0.05). Mean transit time (MTT) and time to peak (TTP) in the lesion area were significantly longer in the AIS group (p < 0.05). Multivariate analysis identified FSRP-high risk (p = 0.027) and high ER (p = 0.046) as independent risk factors for AIS. The combined clinical and mMRI model produced an area under the curve (AUC) of 0.791 in receiver operating characteristic (ROC) analysis. The constructed nomogram model combining clinical and mMRI features demonstrated favorable clinical net benefits. FSRP-high risk and high ER were confirmed as independent risk factors for AIS. The combined prediction model utilizing clinical and imaging markers effectively predicts stroke risk in symptomatic ICAD patients.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease.

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

Association of the coexistence of intracranial atherosclerotic disease and cerebral small vessel disease with acute ischemic stroke

PurposeWhether the coexistence of intracranial atherosclerotic disease (ICAD) and cerebral small vessel disease (CSVD) is an effective indicator for acute ischemic stroke (AIS) is unclear. This study aimed to investigate the association of coexistence of ICAD and CSVD with AIS. MethodsPatients with symptomatic ICAD were recruited from a multicenter study. All patients underwent intracranial artery vessel wall and brain magnetic resonance (MR) imaging at 3.0 T. The characteristics of T1 hyperintensity, plaque enhancement, and surface irregularity of the ICAD were assessed. The types of CSVD including enlarged perivascular space, white matter hyperintensity and lacune, and AIS were also analyzed. Logistic regressions were used to evaluate the associations of coexistence of ICAD and CSVD with AIS. ResultsOf 122 recruited patients (mean age: 56.69 ± 11.07 years; 70 males), 69 (56.56%) had AIS. Coexistence of ICAD and CSVD was more likely found in patients with AIS compared to those without AIS (all P < 0.05). After full adjustment, coexistences of surface irregularity and EPVS (odds ratio [OR], 12.770; 95% confidence interval [CI], 2.163–75.380; P = 0.005), surface irregularity and lacune (OR, 8.450; 95% CI, 2.028–35.213; P = 0.003), enhancement and lacune (OR, 13.888; 95% CI, 2.888–66.786; P = 0.001), surface irregularity and WMH (OR, 3.692; 95% CI, 1.264–10.786; P = 0.017), and enhancement and WMH (OR, 7.899; 95% CI, 2.357–26.475; P = 0.001) were significantly associated with AIS. ConclusionCoexistence of intracranial atherosclerosis and cerebral small vessel disease might be a stronger indicator for acute ischemic stroke than each alone.

101 30-Day Outcomes of Resolute Onyx Stent for Symptomatic Intracranial Stenosis: A Multicenter Propensity-Score Matched Comparison With SAMMPRIS Trial

Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause over 10% of strokes annually in the US alone. Previous investigations employing stenting, most notably SAMMPRIS trial, have produced unfavorable results in regards to both periprocedural complications and risk of recurrent stroke. However, newer generation balloon-mounted drug-eluting stents (BM-DES) have been hypothesized to harbor several technical advantages that may confer improvements in these critical metrics. Prospectively maintained databases from eight comprehensive stroke centers were reviewed to identify adult patients undergoing RO-ZES for the treatment of sICAD between January,2019 and December,2021. Only patients that presented with either recurrent stroke or TIA, intracranial stenosis 70-99%, with at least one stroke on best medical management were included. The primary outcome was 30-days composite of stroke, ICH, and/or mortality. A propensity-score matched analyses was performed comparing the results of RO-ZES to the intervention arm of SAMMPRIS. A total of 132 patients met the inclusion criteria for analysis (mean age:64.2 years). Mean severity of stenosis (±SD) was 81.4% (±11.4%). Four (3.03%) stroke and/or deaths were reported within 30 days in RO-ZES group. A propensity-score matched analysis based on age, HLD, HTN, DMII, and smoking demonstrated a statistically significant decreased risk of 30-day stroke and/or death rate in RO-ZES in comparison to SAMMPRIS (2.6% vs. 15.6%, respectively; OR 6.88, 95% CI 1.92-37.54, p < 0.001). Patients treated with RO-ZES had a decreased rate of 30-day major complications in comparison to SAMMPRIS. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD.

Cerebral Hemodynamics Underlying Artery-to-Artery Embolism in Symptomatic Intracranial Atherosclerotic Disease.

Artery-to-artery embolism (AAE) is a common stroke mechanism in intracranial atherosclerotic disease (ICAD), associated with a considerable risk of recurrent stroke. We aimed to investigate cerebral hemodynamic features associated with AAE in symptomatic ICAD. Patients with anterior-circulation, symptomatic ICAD confirmed in CT angiography (CTA) were recruited. We classified probable stroke mechanisms as isolated parent artery atherosclerosis occluding penetrating artery, AAE, hypoperfusion, and mixed mechanisms, largely based on infarct topography. CTA-based computational fluid dynamics (CFD) models were built to simulate blood flow across culprit ICAD lesions. Translesional pressure ratio (PR = Pressurepost-stenotic/Pressurepre-stenotic) and wall shear stress ratio (WSSR = WSSstenotic-throat/WSSpre-stenotic) were calculated, to reflect the relative, translesional changes of the two hemodynamic metrics. Low PR (PR ≤ median) and high WSSR (WSSR ≥ 4th quartile) respectively indicated large translesional pressure and elevated WSS upon the lesion. Among 99 symptomatic ICAD patients, 44 had AAE as a probable stroke mechanism, 13 with AAE alone and 31 with coexisting hypoperfusion. High WSSR was independently associated with AAE (adjusted OR = 3.90; P = 0.022) in multivariate logistic regression. There was significant WSSR-PR interaction on the presence of AAE (P for interaction = 0.013): high WSSR was more likely to associate with AAE in those with low PR (P = 0.075), but not in those with normal PR (P = 0.959). Excessively elevated WSS in ICAD might increase the risk of AAE. Such association was more prominent in those with large translesional pressure gradient. Hypoperfusion, commonly coexisting with AAE, might be a therapeutic indicator for secondary stroke prevention in symptomatic ICAD with AAE.

Abstract 138: Hypoperfusion Delay Volume Predicts Early Stroke Recurrence Risk In Symptomatic Anterior Circulation Intracranial Atherosclerotic Disease

Introduction: Data on predictors of early stroke recurrence in patients with symptomatic intracranial atherosclerotic disease (sICAD) is limited. We hypothesized that hypoperfusion delay predicts stroke recurrence within 90-days. Methods: We retrospectively collected all patients hospitalized with anterior circulation sICAD over 3 years (April 2019-April 2022) at a comprehensive stroke center. We collected demographics, clinical risk factors, radiological variables, and treatment strategies. Patients with an indication for anticoagulation such as atrial fibrillation and those with intracranial stenting or angioplasty were excluded. The outcome (verified by two independent reviewers) was recurrent stroke within 90 days in the affected artery. We assessed factors associated with stroke recurrence. We measured the effect of hypoperfusion delay volume on stroke recurrence using Cox-regression models. Results: Out of 131 sICAD hospitalizations during the study period, 66 involved the middle cerebral artery (MCA) M1 segment or intracranial internal carotid artery (ICA) and 44 patients met the inclusion criteria. The mean age was 71 years and 41% were women; 75% were treated with best medical management (dual antiplatelet therapy/high intensity statin therapy); and 75% had baseline perfusion imaging performed. Over 90 days, 11/44 (25%) patients had recurrent stroke. Factors associated with recurrence stroke were no best medical management (15.2% vs. 54.5%, p = 0.02), hypoperfusion Tmax&gt;4 sec mismatch volume (p = 0.003), and hypoperfusion delay Tmax&gt;6 sec mismatch volume (p=0.01). Using Youden’s cutoff for Tmax&gt;4 sec mismatch (13 mL) and for Tmax&gt;6 sec mismatch (5 mL), the risk of recurrent stroke at 90 days in separate models was higher in patients with Tmax&gt;4 sec delay mismatch volume &gt; 13 mL (HR 11.98 95% CI 1.48-96.96 p=0.02) and Tmax&gt;6 sec mismatch volume &gt; 5 mL (HR 4.37 95% CI 1.02-18.82, p=0.048). Effect size of the associations did not meaningfully change after adjusting for best medical management. Conclusion: Hypoperfusion delay is associated with an increased recurrent stroke risk within 90 days in patients with sICAD, despite best medical management. Validation by large prospective studies is warranted.