Infarct Patterns, Collaterals and Likely Causative Mechanisms of Stroke in Symptomatic Intracranial Atherosclerosis (original) (raw)
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Six-month follow-up study in patients with symptomatic intracranial arterial stenosis
Journal of Clinical Neuroscience, 2006
Ischaemic stroke due to intracranial atherosclerosis is estimated to comprise 8-12% of all ischaemic strokes. It is known that the risk of recurrence is extremely high in patients with ischaemic stroke caused by intracranial stenosis. In the present study we aimed to evaluate the clinical and radiological findings over a 6-month follow-up period in patients with intracranial atherosclerosis. Prospective data for the ischaemic stroke patients admitted to our clinic between 2001 and 2004 were collected. The localization of stenosis/occlusion detected by magnetic resonance angiography (MRA) was recorded and patients were divided into two groups according to the presence of one or more arterial stenoses on MRA. The patients were followed up for 6 months at regular intervals and stroke recurrence and deaths were noted. Of the 47 patients, 11 had posterior circulation stenosis and 36 had anterior circulation stenosis. Thirty-three patients had only one intracranial artery stenosis, whereas 14 had more than one intracranial artery stenosis. Of the 38 patients who completed the 6month follow-up period, 13 had recurrent stroke, and 10 died. The rate of stroke recurrence in patients with intracranial artery stenosis may be higher than in patients with stroke due to other aetiologies, and stenosis of multiple intracranial arteries increases the rate of recurrence.
Autopsy Prevalence of Intracranial Atherosclerosis in Patients With Fatal Stroke
Stroke, 2008
Background and Purpose-The objective of this study was to determine the prevalence of intracranial plaques and stenoses and their causal role in patients with fatal stroke. Intracranial atherosclerosis is considered to be a rare condition with a severe prognosis. However, disease prevalence may be underestimated due to lack of appropriate diagnostic procedures. Methods-We performed a systematic analysis of intra-and extracranial arteries, the aortic arch, and the heart in 339 consecutive autopsies of patients with stroke. Clinical history, risk factors, imaging data, and general autopsy reports were analyzed. Patients with brain hemorrhage (nϭ80) were used as control subjects. Results-Intracranial plaques and stenoses occurred in 62.2% (95% CI, 56.3 to 68.1) and 43.2% (95% CI, 37.2 to 49.3) of patients with brain infarction, respectively, compared with 48.8% (PϽ0.05) and 17.5% (PϽ0.001) of patients with brain hemorrhage, respectively. In the 43% of patients with brain infarction with at least one intracranial plaqueinducing luminal stenosis graded Ͼ30%, the stenosis was considered to be causal in 5.8% of cases (nϭ15) because of superimposed clot on ulcerated plaques; 27% of these patients had stenoses graded 30% to 75%. In multivariate analyses, diabetes and male sex were significantly associated with intracranial plaques and stenosis. History of myocardial infarction was significantly associated with intracranial plaques and previous stroke was associated with intracranial stenosis. Conclusions-Intracranial plaques and stenoses are highly prevalent in fatal stroke, and stenoses graded 30% to 75% may be causal. New arterial wall imaging techniques should be used to reevaluate the frequency and role of intracranial artery plaques in living patients with stroke. (Stroke. 2008;39:1142-1147.)
Consensus Conference on Intracranial Atherosclerotic Disease: Rationale, Methodology, and Results
Journal of Neuroimaging, 2009
The consensus conference on intracranial atherosclerotic disease (ICAD) identifies principles of management, and research priorities in various aspects upon which leading experts can agree (using "Delphi" method). ICAD is more prevalent in Asian, Hispanic, and African-American populations. Patients who have had a stroke or transient ischemic attack (TIA) attributed to stenosis (50-99%) of a major intracranial artery face a 12-14% risk of subsequent stroke during the 2-year period after the initial ischemic event, despite treatment with antithrombotic medications. The annual risk of subsequent stroke may exceed 20% in high-risk groups. The medical treatment of patients with symptomatic ICAD is directed toward: 1. Prevention of intraluminal thrombo-embolism, 2. plaque stabilization and regression, and 3. management of atherogenic risk factors. In patients with ICAD, short-term and long-term anticoagulation (compared with aspirin) have not shown to be beneficial. The current guidelines recommend that aspirin monotherapy, the combination of aspirin and extended release dipyridamole, and clopidogrel monotherapy (rather than oral anticoagulants) are all acceptable options in patients with non-cardioembolic ischemic stroke and TIA. Overall, the subgroup analysis from randomized trials provides evidence about benefit of aggressive atherogenic risk factor management among patients with ICAD. Intracranial angioplasty with or without stent placement has evolved as a therapeutic option for patients with symptomatic ICAD, particularly those with highgrade stenosis with recurrent ischemic symptoms and/or medication failure. A matched comparison between medical-treated patients in the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) study and stent-treated patients in the National Institutes of Health intracranial stent registry concluded that stent placement may offer benefit in patients with 70-99% stenosis. The 5-year, multicenter, prospective, randomized Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis study supported by the National Institutes of Health is currently comparing stent placement with intense medical management with intense medical management alone in patients with high-grade symptomatic intracranial stenosis. The proceedings of the consensus conference provide a template for standardizing management of patients with ICAD and determining research priorities.
Infarct Pattern in Patients with Varying Degrees of Internal Carotid Artery Stenosis
Bangladesh Journal of Neuroscience, 2019
Background: Internal carotid artery (ICA) is one of the commonest site stenosis in patients with ischemic stroke. There is difference in the distribution of stenosis among different sites of cerebral infarct.Volume and severity of cerebral infarct may also depend on the degree of stenosis. To plan efficient evaluation and treatment of individual patient of ischemic stroke, the responsible clinician must be familiar with the relative probability of finding occlusive lesions at various sites within the vascular tree. Objective: The objective of this study was to evaluate the angiographic pattern of ICA stenosis among different types of cerebral infarct. Materials and Methods: We evaluated 53 ischemic stroke patients from indoor, outdoor, stroke and neuro intervention clinic, BSMMU. CT scan and/ or MRI of brain were done to each patient to confirm the diagnosis. After vascular imaging, the degree of stenosis was measured by the NASCET formula. Results: Cervical segment of ICA was most ...
Recurrent stroke risk in intracranial atherosclerotic disease
Frontiers in Neurology
Recurrent stroke risk secondary to intracranial atherosclerotic disease remains high despite aggressive medical treatment. This risk is further amplified in subgroups possessing biomarkers of hemodynamic insufficiency and potential for embolization, which have been shown to be independently and synergistically predictive of recurrent stroke. Luminal stenosis was predominantly used as entry criteria in major treatment trials, discounting the potential role of hemodynamics from primary analyses, limiting the strength of evidence and conclusions of these biomarkers to post-hoc analyses and other natural history studies. Future treatment trials should consider stratifying patients using a combination of these high-risk biomarkers. In the absence of trials, risk stratifying patients based on the presence of these markers may lend to more individualized clinical decisions. We aimed to summarize the studies that have investigated the relationship between biomarkers and their role in predic...
Neurological Sciences, 2014
Intracranial large artery stenosis and occlusion disease has been considered to be the cause of 8-10 % of ischaemic strokes in North America, and 30-50 % of strokes and more than 50 % of transient ischaemic attacks in Chinese population. So far we do not know the real prevalence of intracranial disease (ID) and the distribution of its risk factors in European population. We aimed to determine the prevalence and risk factors of ID in a European stroke population with computed tomography angiography (CTA). A retrospective study of consecutive ischaemic patients at the Stroke Unit of Utrecht, The Netherlands, from September 2006 to August 2008 was conducted. We assessed the presence of occlusion and/or stenosis of intracranial Internal Carotid Artery (ICA) and Middle Cerebral Artery on post-contrast 30-mm reconstruction axial CTA images. We analyzed the proportion of patients with ID, and the association of ID with risk factors and stroke subtype. In 220 patients (187 with stroke, 33 with TIA; mean age was 65 years, 57.3 % were male), intracranial stenosis was found in 6.4 % (95 % CI 3.9-10.4), intracranial occlusion in 34.5 % (95 % CI 28.6-41.0), and both occlusion and stenosis in 2.3 % (95 % CI 1.0-5.2). Multivariate analysis showed that the variables independently associated with ID were: extracranial ICA atherosclerosis (OR, 24.64;) and stroke subtypes TACS-PACS (OR, 7.61; 95 % CI 3.31-17.49). In conclusion, prevalence of intracranial stenosis in our study may well be consistent with previous observations in European and non-European population. ID may have been an underestimated condition in ischaemic Caucasian population.
International Journal of Medical Arts, 2020
Background: Atherosclerotic infarction accounts for a sizable proportion of cerebral infarcts whether occurs from extracranial or intracranial atherosclerotic disease. Despite recent studies on stroke risk factors; it is still unclear whether or not single risk factor specifically affect extracranial or intracranial arteries in stroke patients. Aim of the work: To determine the difference between intracranial and extracranial steno-occlusive atherosclerosis and its correlation with risk factors of acute ischemic stroke using Magnetic Resonance Angiogram (MRA) and/or Computed Tomography Angiography (CTA) with Duplex. Patients and methods: All cases diagnosed as acute ischemic stroke were subjected to detailed history, full neurological examination, routine laboratory tests, extracranial vessels assessed by duplex, intracranial vessels assessed by MRA and/or CTA. Results: 61 patients included in the study (38 males and 23 females), with mean age (64.5 ± 11.4). Extracranial stenosis was (57 patients, 93.4%), while intracranial stenosis was (49 patients, 80.3%). But the intracranial significant stenosis was (45 patients, 73.77%), while the extracranial significant stenosis (26 patients, 42.62%). Hypertension (72.1%), obesity (62.3%), diabetes (57.4%), dyslipidemia (54.1%) and smoking (39.3%), were risk factors equally affecting the extracranial and the intracranial systems in the same descending order. There was a higher prevalence of hypertension among patients with intracranial significant stenosis showing a significant P-value of 0.048. Conclusion: Extracranial stenosis was more common than the intracranial stenosis, but the intracranial significant stenosis is more prevalent than the extracranial. Hypertension is a significant risk factor for intracranial significant stenosis.
Prospective study of symptomatic atherothrombotic intracranial stenoses The GESICA Study
—Background: Symptomatic intracranial atherothrombotic stenoses (ICAS) are associated with high rates of cerebrovascular ischemic events. Objective: To conduct a prospective multicenter study to evaluate the natural history of ICAS and, in those patients refractory to medical treatment, the outcomes associated with intracranial angioplasty. Methods: Patients aged 18 to 80 were enrolled with symptoms attributed to a single ICAS of 50%. Optimal medical therapy of vascular risk factors and preventive antithrombotic therapy were at the discretion of the local investigator. Patients were eligible for intracranial angioplasty after experiencing recurrent stroke despite medical therapy. Neurologic and ultrasonographic examinations were performed at study inclusion, 3 months after enrollment, and every 6 months of follow-up thereafter, for 36 months. Results: One hundred two patients were included, with a mean age of 63.3 10.4 years. Intracranial artery stenoses involved the vertebral artery in 22.5%, the basilar artery in 25.5%, the middle cerebral artery in 26.5%, and the internal carotid artery in 25.5%. In 27.4% of the patients, the stenoses had clinical hemodynamic characteristics. During a mean follow-up of 23.4 months, 38.2% of the patients had a cerebrovascular event: ischemic stroke in 13.7% and TIA in 24.5%. Among patients with a hemodynamically significant stenosis, 60.7% had a recurrent stroke or TIA in the territory of the stenotic artery; this association was significant in univariate analysis. Twenty-eight patients underwent an endovascular procedure with a neurologic periprocedural complication rate of 14.2%. The overall vascular death rate was 8.8%. Conclusions: Despite medical treatment, the 2-year recurrence rate of ischemic events in the territory of the stenotic artery was 38.2%. Cardiovascular events occurred in 18.6% of patients. Clinically significant hemodynamic stenoses were associated with stroke recurrence and may help identify a high risk subset of patients.