Symptomatic Intracranial Atherosclerotic Stenosis Research Articles

Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

Drug-coated balloons (DCBs) have exhibited promising results in coronary and peripheral artery diseases, but conclusive evidence is lacking in intracranial vasculature. We assessed the safety and efficacy of DCBs vs stent angioplasty for symptomatic intracranial atherosclerotic stenosis (sICAS) and initially identified patients who might have benefited most from DCB treatment. A single-center, retrospective cohort study was conducted from June 2021 to May 2022 with 154 patients with sICAS divided into 2 treatment groups: a DCB group (with or without remedial stenting, n = 47) and a stent group (n = 107). The treatment outcomes were compared using 1:2 propensity score matching. The primary safety end point was perioperative stroke or mortality, and the primary efficacy end point was the rate of target vessel restenosis at 12 months. The degree of luminal change was analyzed as a subgroup, defined as the difference between the degree of stenosis at follow-up and immediately after intervention. One hundred eighteen patients were enrolled using propensity score matching, with 43 patients in the DCB group and 75 in the stent group. The incidence of perioperative adverse events was 2.3% in the DCB group and 8.0% in the stent group (P = .420). At a median follow-up of 12 months, the incidence of restenosis (11.9% [5/43] vs 28.0% [21/75], P = .045) and the median degree of stenosis (30% [20%, 44%] vs 30% [30%, 70%], P = .009, CI [0-0.01, 0.2]) were significantly lower in the DCB group than in the stent group. DCB angioplasty effectively prevented adverse events in the target vessel area and significantly reduced the degree of luminal change in the M1 segment of the middle cerebral artery (0 [0, 15%] vs 10% [0, 50%], P = .016). DCB angioplasty might be a safe and effective alternative to stent angioplasty to treat sICAS, particularly among patients with M1 segment of the middle cerebral artery stenosis.

Commentary: Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

Commentary: Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

209 Transcriptomic Analysis of the Post-mortem Brain in Intracranial Atherosclerosis Implicates Interferon Signaling

INTRODUCTION: Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke. Stroke patients manifesting symptomatic ICAS often have poor prognoses, including worsened functional outcome, increased morbidity, and mortality. Despite risk factor management, ICAS exhibits a nonlinear rise in incidence with age, with an increase in unstable lipid-rich plaques. Understanding mechanisms of ICAS is crucial to improve clinical outcomes and reduce stroke incidence. Previous studies have demonstrated that intracranial arteries demonstrate different histopathologic profiles compared to extracranial arteries, likely lowering their risk of atherosclerosis. However, these studies are limited to healthy intracranial arteries. Comprehensive multiomic data examining diseased intracranial arteries are limited. METHODS: We performed bulk transcriptomic analysis in 4 tissues in a post-mortem brain dataset (N=304), with 34 patients with cerebral atherosclerosis confirmed via autopsy, 90 patients with peripheral atherosclerosis, and 180 controls. Cell type deconvolution was conducted to identify differential expression signatures in 7 neuronal and glial subtypes. To examine interferon response further in glial cells, we generated human induced pluripotent stem cell (hiPSC)-derived astrocytes treated with 3 doses of interferon and performed transcriptomic analysis. RESULTS: Cerebral atherosclerosis was significantly (pathway enrichment p<10e-9) associated with interferon signaling compared to peripheral atherosclerosis and controls. Glial cells particularly expressed patterns associated with cerebral atherosclerosis. Astrocytes, oligodendrocytes, excitatory neurons, and endothelial cells were most impacted. In hiPSC-derived astrocytes treated with interferon, we identified upregulation of interferon-inducible genes matching those found in intracranial atherosclerosis in the post-mortem brain, implicating glial reactivity to interferon-related stress. CONCLUSIONS: Our study implicates interferon signaling as critical within the development of cerebral atherosclerosis. Protection of the intracranial arteries from atherosclerosis may occur due to reduced expression of interferon-inducible genes. Targeted treatment of cerebral atherosclerosis should consider interferon-signaling modulators.

Hemodynamic Impairments of Evaluating Symptomatic Intracranial Atherosclerotic Stenosis using Quantitative Flow Ratio on Digital Subtraction Angiography : AComparison with Computed Tomography Perfusion, MRI and Fractional Flow Reserve.

Cerebral hemodynamics are important for the management of intracranial atherosclerotic stenosis (ICAS). The quantitative flow ratio (QFR) is anovel angiography-derived index for assessing the functional relevance of ICAS without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to FFR are scarce. In this prospective study 56patients with anterior circulation symptomatic ICAS who received endovascular treatment were included. The new method of computing QFR from asingle angiographic view, i.e., the Murray law-based QFR (μQFR), was applied to the examined vessels. An artificial intelligence algorithm was developed to realize the automatic delineation of vascular contour. Pressure gradients were measured before and after treatment within the lesion vessel using apressure guidewire and the FFR was calculated. There was agood correlation between μQFR and FFR. Preoperative FFR predicted DWI watershed infarction (FFR optimal cut-off level: 0.755). Preoperative μQFR predicted DWI watershed infarction (μQFR optimal cut-off level: 0.51). Preoperative FFR predicted CTP hypoperfusion (FFR best predictive value: 0.62). Preoperative μQFR predicted CTP hypoperfusion (μQFR best predictive value: 0.375). The μQFR based on DSA images can be used as an indicator to assess the functional status of the lesion in patients with ICAS.

Angiography‑based quantitative flow ratio for functional assessment of intracranial atherosclerotic disease.

Intracranial atherosclerotic stenosis (ICAS), an important cause of stroke, is associated with a considerable stroke recurrence rate despite optimal medical treatment. Further assessment of the functional significance of ICAS is urgently needed to enable individualised treatment and, thus, improve patient outcomes. We aimed to evaluate the haemodynamic significance of ICAS using the quantitative flow ratio (QFR) technique and to develop a risk stratification model for ICAS patients. Patients with moderate to severe stenosis of the middle cerebral artery, as shown on angiography, were retrospectively enrolled. For haemodynamic assessment, the Murray law-based QFR (μQFR) was performed on eligible patients. Multivariate logistic regression models composed of μQFR and other risk factors were developed and compared for the identification of symptomatic lesions. Based on the superior model, a nomogram was established and validated by calibration. Among 412 eligible patients, symptomatic lesions were found in 313 (76.0%) patients. The μQFR outperformed the degree of stenosis in discriminating culprit lesions (area under the curve [AUC]: 0.726 vs 0.631; DeLong test p-value=0.001), and the model incorporating μQFR and conventional risk factors also performed better than that containing conventional risk factors only (AUC: 0.850 vs 0.827; DeLong test p-value=0.034; continuous net reclassification index=0.620, integrated discrimination improvement=0.057; both p<0.001). The final nomogram showed good calibration (p for Hosmer-Lemeshow test=0.102) and discrimination (C-statistic 0.850, 95% confidence interval: 0.812-0.883). The μQFR was significantly associated with symptomatic ICAS and outperformed the angiographic stenosis severity. The final nomogram effectively discriminated symptomatic lesions and may provide a useful tool for risk stratification in ICAS patients.

Has collateral blood flow any effect on restenosis rate? Our experience.

Restenosis is one of the important factors affecting the effectiveness of percutaneous transluminal angioplasty and stenting in the treatment of intracranial atherosclerotic stenosis. We aimed to clarify whether recruitable collateral flow could cause restenosis in patients treated with percutaneous transluminal angioplasty and stenting. Our study retrospectively analyzed patients with symptomatic severe intracranial atherosclerotic stenosis (≥70%) who underwent percutaneous transluminal angioplasty and stenting. We enrolled 28 patients with restenosis and 71 patients without restenosis. We analyzed baseline data, perioperative events, and follow-up results of patients in the two groups. Binary logistic regression analysis was used to identify restenosis predictors. For preoperative stroke, the restenosis group had a greater likelihood of having a previous stroke (89.3%), which was less prevalent in the non-restenosis group (66.2%) (P = 0.020). The restenosis group had a higher rate of re-stroke (21.4 vs. 4.2%, P = 0.022). After binary logistic regression analysis, collateral circulation and residual stenosis were independent risk factors of restenosis, with overall risk (95% confidence intervals) of 5.034 (1.484-4.066, P < 0.001) and 1.064 (1.006-1.125, P = 0.030), respectively. Restenosis risk increased 1.456-fold for each collateral circulation grade increase. However, for each 1% increase in residual stenosis, restenosis risk increased by 5.9% (P = 0.03). The chance of restenosis is minimal when the residual stenosis rate after percutaneous transluminal angioplasty and stent implantation is 15.85%. Good collateral circulation was significantly associated with restenosis in patients undergoing intracranial angioplasty, the residual stenosis rate tends to be 15.85% to reduce restenosis risk. Compared to patients with restenosis, those without restenosis have a low stroke risk during follow-up.

Endovascular treatment of symptomatic severe intracranial atherosclerotic stenosis with a novel intracranial dedicated drug-eluting stent: a more effective treatment approach.

Endovascular treatment of severe intracranial atherosclerotic stenosis (ICAS) using coronary drug-eluting stents (DESs) significantly reduces the risk of in-stent restenosis (ISR) and stroke recurrence. However, there are few reports regarding the treatment of ICAS with intracranial dedicated DES. Herein, we present our experience with the feasibility, safety, and medium-term follow-up outcomes of a novel intracranial DES, named NOVA stent, in patients with symptomatic severe ICAS (≥70%). From December 2021 to May 2022, patients with symptomatic severe ICAS who underwent implantation of the NOVA stent in our institution were retrospectively analyzed for procedural results, perioperative complications, imaging and clinical follow-up outcomes. Twenty-four patients, 16 (66.7%) with anterior circulation lesions and 8 (33.3%) with posterior circulation lesions, were enrolled. All patients with intracranial ICA (n = 6), middle cerebral artery (n = 10), basilar artery (n = 3), intracranial vertebral artery (n = 3), and the vertebrobasilar junction (n = 2) stenosis were treated successfully using NOVA stents. The severity of stenosis ranged from 75 to 96% (mean 85.9%) before treatment and this was reduced to 0 to 20% (mean 8.6%) immediately after stent placement. Symptomatic distal embolism occurred in one case; however, there were no other perioperative complications. The mean follow-up duration was 12.2 ± 1.06 months. No symptomatic ischemic events occurred during follow-up. Follow-up cerebral angiography was performed in 22 of 24 patients (91.7%), and significant ISR occurred in one patient (4.2%). Our results demonstrate that implantation of the novel intracranial DES NOVA in severe ICAS is feasible, safe, and effective in selected cases, reducing the incidence of ISR, and showing excellent midterm clinical outcomes, providing a promising option for ICAS treatment.

Optimal Medical Management of Atherosclerotic Intracranial Stenosis.

Reducing the high risk of recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) has proven to be challenging, but aggressive medical management, with intensive risk factor control and antithrombotic therapy, has been shown to be beneficial. High-intensity statins are recommended for patients with atherosclerotic stroke, including sICAS. Ezetimibe and PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors are beneficial for those who fail to reach low-density lipoprotein targets or those with statin intolerance. The treatment target for sICAS is low-density lipoprotein <70 mg/dL. In neurologically stable patients, blood pressure should be treated to goal <140/90 mm Hg with the use of thiazide diuretics, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers preferentially. For those with diabetes, treat to goal hemoglobin A1C ≤7% for most patients through combination of diet, insulin, and hypoglycemic drugs. Some degree of physical activity (eg, walking, stationary biking with arms or legs, etc) should be encouraged in all patients with sICAS who are not severely disabled. A minimum of 10 minutes of moderate-intensity aerobic activity 4 times a week is recommended for patients who are capable of exercise. For all patients with severe sICAS (70%-99% stenosis), dual antiplatelet therapy for up to 90 days followed by single antiplatelet agent is recommended.

Abstract TP299: The Relationship Between Intracranial Arterial Stenosis Rate and Cerebral Perfusion

Background and and Objectives: The pressure ratio (PR) across lesions is a vital indicator for assessing residual blood flow after stenosis, yet the relationship between symptomatic intracranial atherosclerotic stenosis degrees and cross-lesion pressure ratios remains unclear. Methods: Data were derived from the Chinese National Stroke Registry III (CNSR III). Three-dimensional meshes were constructed based on TOF-MRA using the finite element method controlled by the Navier-Stokes equation to obtain pressure values. PR was calculated as the ratio of proximal to distal pressure at the stenosis site, indicating post-stenosis blood flow. PR &gt; 0.76 meant normal pressure ratio, while PR ≤ 0.76 indicated reduced ratio. Arterial stenosis severity was categorized using the WASID Method: 50%-69% for moderate and 70%-99% for severe. Statistical analysis explored the correlation between stenosis severity and low PR. Results: The study included 438 patients with symptomatic intracranial arterial stenosis (50-99%), median age 64, 33.79% female. PR ≤ 0.76 accounted for 30%. Among them, PR ≤ 0.76 was observed in 26% of moderate stenosis (50-69%) patients and 39% of severe stenosis (70-99%) patients (Figure A). The PR ≤ 0.76 frequency was significantly higher in severe compared to moderate stenosis (P=0.01). For anterior (Figure B) and posterior (Figure C) circulation stenosis, PR ≤ 0.76 accounted for 43% and 22% respectively, more prevalent in severe stenosis (P=0.01 and P=0.61, respectively). Conclusion: Most patients with symptomatic intracranial atherosclerotic stenosis exhibit normal PR levels, with a correlation between arterial stenosis and cross-lesion pressure ratio. Further research is needed to determine if PR is a more suitable criterion than arterial stenosis for selecting patients for stent treatment.

Randomized Secondary Prevention Trials in Participants With Symptomatic Intracranial Atherosclerotic Stenosis.

Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts.

Edge-Type Hyperintense Intracranial Artery Plaque: A Potential MRI Biomarker of Stroke Recurrence.

Identifying patients at high risk of stroke recurrence is important for stroke prevention and treatment. To explore the characteristics of T1 hyperintense plaques (HIP) and their relationship with stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). Retrospective. One hundred fifty-seven patients with moderate-to-severe (≥50%) nonocclusive sICAS and MRI studies (42 females and 115 males, mean age 58.69 ± 10.68 years). 3D higher-resolution black-blood T1-weighted fast-spin-echo sequence at 3.0 T. HIP (signal intensity [SI] of plaque-to-adjacent gray matter >1.0 on non-contrast T1-weighted images) and non-HIP plaques were identified. HIP plaques were categorized as edge type (high SI adjacent to lumen) and non-edge type (high SI within plaque). Clinical and imaging features of different plaque types were compared. Stroke recurrence was assessed through telephone or medical records at 3 and 6 months, and then once a year post-MRI. The relationship between edge type and non-edge types HIP with stroke recurrence was analyzed. Student's t test, Mann-Whitney U-test, chi square test and Fisher's exact test to compare features between plaque types. Kaplan-Meier curves (with log-rank tests) and Cox proportional hazards regression to assess relationship between stroke recurrence and different plaque types. A two-tailed P-value of <0.05 was considered statistically significant. Of 157 culprit lesions, 87 (55%) were HIPs (43 edge type, 44 non-edge type) and 70 (45%) were non-HIPs. Plaque thickness, area, and volume were significantly higher for HIPs than for non-HIPs. Among patients with HIPs, edge type was significantly more likely in the posterior circulation (53.5% vs. 27.3%), and had significantly higher plaque thickness, length, area, volume, plaque burden, and remodeling index than non-edge type. Edge-type HIP was significantly more common than non-edge HIP in patients with diabetes mellitus (51.2% vs. 29.5%) and dyslipidemia (79.1% vs. 54.5%). During median follow-up of 27 months, 33 patients experienced stroke recurrence. Recurrence was associated with edge-type HIP (adjusted hazard ratio = 2.83; 95% confidence interval: 1.40-5.69), both in the overall cohort (34.9% vs. 15.8%) and in patients with HIP (34.9% vs. 9.0%). Age ≥60 years and edge-type HIP had a significant interaction. Hyperintense plaque may be categorized as edge type or non-edge type. Edge-type HIP may be a potential MRI biomarker of stroke recurrence. 3 TECHNICAL EFFICACY: Stage 2.

An interpretable machine learning model for stroke recurrence in patients with symptomatic intracranial atherosclerotic arterial stenosis.

Symptomatic intracranial atherosclerotic stenosis (SICAS) is the most common etiology of ischemic stroke and one of the main causes of high stroke recurrence. The recurrence of stroke is closely related to the prognosis of ischemic stroke. This study aims to develop a machine learning model based on high-resolution vessel wall imaging (HR-VWI) to predict the risk of stroke recurrence in SICAS. This study retrospectively collected data from 180 SICAS stroke patients treated at the hospital between 2020.01 and 2022.01. Relevant imaging and clinical data were collected, and follow-up was conducted. The dataset was divided into a training set and a validation set in a ratio of 7:3. We employed the least absolute shrinkage and selection operator (LASSO) regression to perform a selection on the baseline data, laboratory tests, and neuroimaging data generated by HR-VWI scans collected from the training set. Finally, five machine learning techniques, including logistic regression model (LR), support vector machine (SVM), Gaussian naive Bayes (GNB), Complement naive Bayes (CNB), and k-nearest neighbors algorithm (kNN), were employed to develop a predictive model for stroke recurrence. Shapley Additive Explanation (SHAP) was used to provide visualization and interpretation for each patient. The model's effectiveness was evaluated using average accuracy, sensitivity, specificity, precision, f1 score, PR curve, calibration curve, and decision curve analysis. LASSO analysis revealed that "history of hypertension," "homocysteine level," "NWI value," "stenosis rate," "intracranial hemorrhage," "positive remodeling," and "enhancement grade" were independent risk factors for stroke recurrence in SICAS patients. In 10-fold cross-validation, the area under the curve (AUC) ranged from 0.813 to 0.912 in ROC curve analysis. The area under the precision-recall curve (AUPRC) ranged from 0.655 to 0.833, with the Gaussian Naive Bayes (GNB) model exhibiting the best ability to predict stroke recurrence in SICAS. SHAP analysis provided interpretability for the machine learning model and revealed essential factors related to the risk of stroke recurrence in SICAS. A precise machine learning-based prediction model for stroke recurrence in SICAS has been established to assist clinical practitioners in making clinical decisions and implementing personalized treatment measures.

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

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

(Published) Stroke recurrence is associated with unfavorable intracranial venous outflow in patients with symptomatic intracranial atherosclerotic large vessel severe stenosis or occlusion

(Published) Stroke recurrence is associated with unfavorable intracranial venous outflow in patients with symptomatic intracranial atherosclerotic large vessel severe stenosis or occlusion

Comparison of drug-coated balloon angioplasty versus standard medical therapy on recurrent stroke and mortality rates among patients with symptomatic intracranial atherosclerotic stenosis: protocol for a systematic review and meta-analysis

IntroductionStroke remains the second leading cause of death worldwide, a common cause of which is intracranial atherosclerotic stenosis (ICAS). Medical treatment is recommended as first-line therapy for treating ICAS, but...

Cerebral hemodynamics and stroke risks in symptomatic intracranial atherosclerotic stenosis with internal versus cortical borderzone infarcts: A computational fluid dynamics study

There may be different mechanisms underlying internal (IBZ) and cortical (CBZ) borderzone infarcts in intracranial atherosclerotic stenosis. In 84 patients with symptomatic, 50-99% atherosclerotic stenosis of M1 middle cerebral artery (MCA-M1) with acute borderzone infarcts in diffusion-weighted imaging, we classified the infarct patterns as isolated IBZ (n = 37), isolated CBZ (n = 31), and IBZ+CBZ (n = 16) infarcts. CT angiography-based computational fluid dynamics models were constructed to quantify translesional, post-stenotic to pre-stenotic pressure ratio (PR) in the MCA-M1 lesion. Those with IBZ infarcts were more likely to have a low PR (indicating impaired antegrade flow across the lesion) than those without (p = 0.012), and those with CBZ infarcts were more likely to have coexisting small cortical infarcts (indicating possible embolism) than those without (p = 0.004). In those with isolated IBZ or CBZ infarcts, low PR was independently associated with isolated IBZ infarcts (adjusted odds ratio = 4.223; p = 0.026). These two groups may also have different trajectories in the stroke risks under current medical treatment regimen, with a higher risk of same-territory ischemic stroke recurrence within 3 months in patients with isolated IBZ infarcts than isolated CBZ infarcts (17.9% versus 0.0%; log-rank p = 0.023), but similar risks later in 1 year.

A novel cerebrovascular drug-coated balloon catheter for treating symptomatic intracranial atherosclerotic stenosis lesions: Study protocol for a prospective, multicenter, single-arm, target-value clinical trial

BackgroundPrevious single-center studies have demonstrated that drug-coated balloons (DCBs) may reduce restenosis rates, which is an important factor affecting the prognosis for intracranial interventional therapy. However, currently available cardiac DCBs are not always suitable for the treatment of intracranial atherosclerotic stenosis (ICAS). This study aimed to evaluate the safety and efficacy of a novel DCB catheter designed for patients with severely symptomatic ICAS. MethodsThis prospective, multicenter, single-arm, target-value clinical trial was conducted in 9 Chinese stroke centers to evaluate the safety and efficacy of a novel DCB catheter for treating symptomatic severe ICAS. Primary metrics and other indicators were collected and analyzed using SAS version 9.4 (SAS Institute, Cary, NC, USA). ResultsA total of 155 patients were enrolled in this study. The preliminary collection of follow-up data has been completed, while data quality control is ongoing. ConclusionResults of this study demonstrated the patency rate, safety, and effectiveness of a novel on-label paclitaxel DCB designed for the treatment of ICAS. Trial registrationChiCTR, ChiCTR2100047223. Registered June 11, 2021-Prospective registration, https://www.chictr.org.cn/ChiCTR2100047223.

Intracranial stenting versus aggressive medical therapy for symptomatic intracranial stenosis: A meta-analysis of multicenter randomized controlled trials and an expert assessment of the current data.

Intracranial atherosclerotic stenosis (ICAS) is associated with high risk of recurrent strokes despite best medical management (MM). We aimed to synthesize the evidence from randomized studies comparing intracranial stenting plus MM versus MM alone. Comprehensive search of MEDLINE database was performed until May 2023. The data were extracted and pooled as risk ratio (RR) with 95% confidence interval (95% CI). We included three multicenter RCTs totaling 919 patients. As compared to MM alone, intracranial stenting was associated with statistically significant higher risks of any stroke or death (RR = 2.93, 95%CI [1.80-4.78], p < 0.0001), stroke in the same territory of qualifying artery (RR = 3.56, 95%CI [1.97-6.44], p < 0.0001), any ischemic stroke (RR = 2.22, 95%CI [1.27-3.87], p = 0.005), hemorrhagic stroke (RR = 13.49, 95%CI [2.59-70.15], p = 0.0002), and death (RR = 5.43, 95%CI [1.21-24.40], p = 0.003) within 30 days of randomization. There was a persistent lack of benefit and signals of harm at the last follow up within 1-3 years: any stroke or death (RR = 1.57, 95%CI [0.92-2.67], p = 0.1), stroke in the same territory of qualifying artery (RR = 1.84, 95%CI [0.97-3.50], p = 0.06), any ischemic stroke (RR = 1.56, 95%CI [1.11-2.20], p = 0.01), death (RR = 1.61, 95%CI [0.77-3.38], p = 0.2). The cumulative rate of stroke in the same territory of qualified artery with MM alone within the 1-3-year follow up was lower than expected, with only 47 out of the 450 (10.4%) MM alone patients suffering such events. The findings from this meta-analysis do not recommend stenting as a routine care option for the broader symptomatic ICAS patient population. The rates of recurrent strokes in ICAS patients managed with aggressive MM do not seem to be as high as anticipated. Additional multicenter RCTs including safer devices, larger sample sizes, and patients at higher risk of recurrent events are warranted.

Hemodynamics combined with inflammatory indicators exploring relationships between ischemic stroke and symptomatic middle cerebral artery atherosclerotic stenosis

Background and purposeIntracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke, and high-resolution vessel wall imaging (HR-VWI) can be used to assess the plaque characteristics of ICAS. This study combined HR-VWI, hemodynamics, and peripheral blood inflammatory indicators to investigate the role of these factors in symptomatic intracranial atherosclerotic stenosis (sICAS) and their inter-relationships.MethodsPatients diagnosed with atherosclerotic middle cerebral artery stenosis were recruited retrospectively from June 2018 to July 2022. Plaque enhancement was qualitatively and quantitatively analyzed, and the degree of plaque enhancement was graded according to the plaque-to-pituitary stalk contrast ratio (CR). Computational fluid dynamics models were constructed, and then hemodynamic parameters, including wall shear stress (WSS) and pressure ratio (PR), were measured and recorded. Univariate and multivariable analyses were performed to identify factors that can predict sICAS. In addition, the correlation analysis between the plaque characteristics on HR-VWI, hemodynamic parameters, and peripheral blood inflammatory indicators was performed to investigate the interrelationships between these factors.ResultsThirty-two patients were included. A higher proportion of plaque enhancement, maximum WSS, and WSS ratio (WSSR) were significantly associated with sICAS. The multiple logistic regression analysis showed that only the WSSR was an independent risk factor for sICAS. The correlation analysis revealed that both the CR and plaque burden showed linear positive correlation with the WSSR (R = 0.411, P = 0.022; R = 0.474, P = 0.007, respectively), and showed linear negative correlation with the lymphocyte to monocyte ratio (R = 0.382, P = 0.031; R = 0.716, P < 0.001, respectively).ConclusionsThe plaque enhancement and WSSR were significantly associated with sICAS, WSSR was an independent risk factor for sICAS. Plaque enhancement and plaque burden showed linear correlation with the WSSR and lymphocyte-to-monocyte ratio (LMR). Hemodynamics and inflammation combined to promote plaque progression.

Complications and long-term in-stent restenosis of endovascular treatment of severe symptomatic intracranial atherosclerotic stenosis and relevant risk factors.

To investigate the complications and in-stent restenosis of endovascular treatment of severe symptomatic intracranial atherosclerotic stenosis and relevant risk factors. Three hundred and fifty-four consecutive patients with intracranial atherosclerotic stenosis (70%-99%) were retrospectively enrolled. The clinical data, treatment outcomes, complications and in-stent restenosis at follow-up were analyzed. The endovascular treatment was composed of balloon dilatation only in 21 (5.93%) patients, and deployment of self-expandable stents in 232 (65.54%), balloon-expandable stents in 75 (21.19%), and both balloon- and self-expandable stents in 26 (7.34%), with a total of 359 stents being successfully deployed at the stenotic location. After treatment, the residual stenosis ranged 9.2%±1.5% (range 7%-19%), which was significantly (P < .05) smaller than that before treatment. Periprocedural complications occurred in 43 patients with a complication rate of 12.15% including arterial dissection in 4 (1.13%) patients, new cerebral infarction in 21 (5.93%), cerebral hemorrhage in 12 (3.3%), and subarachnoid hemorrhage in 6 (1.69%). Hyperlipidemia [odds ratio (OR) 10.35, 95% confidence interval (CI) 4.42-24.28, and P < .0001] and location at the middle cerebral artery (MCA) (OR 4.15, 95% CI 1.92-8.97, and P < .001) were significant (P < .05) risk factors for periprocedural complications, whereas hyperlipidemia (OR 11.28, 95% CI 4.65-30.60, and P < .0001), location at the MCA (or 5.26, 95% CI 2.03-15.08, and P < .001), and angulation (OR 1.02, 95% CI 1.00-1.04, and P = .02) were significant (P < .05) independent risk factors for periprocedural complications. Follow-up was performed in 287 (81.07%) patients at 6 to 36 (28 ± 6.7) months. In-stent restenosis was present in 36 (12.54%), and female sex (OR 2.53, and 95% CI 1.27-5.06) and periprocedural complications (OR 9.18, and 95% CI 3.52-23.96) were significant (P < .05) risk factors for in-stent restenosis, with periprocedural complication (OR 9.61, and 95% CI 3.48-27.23) as the only significant (P < .0001) independent risk factor for in-stent restenosis. A certain rate of periprocedural complications and in-stent stenosis may occur in endovascular treatment of severe intracranial stenosis, and the relevant risk factors may include hyperlipidemia, MCA location, angulation at the stenosis and female sex.