Management Strategies in Posterior Circulation Intracranial Atherosclerotic Disease

Introduction: Prior studies have evaluated risks factors for recurrent stroke in patients with symptomatic intracranial atherosclerotic disease (ICAD). However, few reports have assessed risk factors for early infarct recurrence in the territory distal to the symptomatic artery. Methods: We analyzed data from patients who underwent study-paid brain MRI at 6-8 weeks after enrollment in the ongoing MyRIAD study, an NIH/NINDS funded prospective multicenter observational study of patients with recent ( < 21 days) stroke or TIA (recurrent or with DWI) caused by ICAD 50-99% without planned angioplasty/stenting. The outcome of interest was new infarcts on brain MRI (on DWI or FLAIR) at 6-8 weeks compared to qualifying brain MRI at time of index stroke or TIA. Qualifying events and clinical and radiographic outcomes are centrally ascertained by 2 independent reviewers. We used logistic regression to identify independent clinical predictors of new infarct in the territory of the symptomatic artery. Results: Among 84 (80%) of 105 enrolled patients in MyRIAD with 6-8 week MRI, the mean age was 63.6 + 12.4 years, 83.1% have stenosis 70-99%, and 51.2% had history of diabetes; those who underwent MRI did not differ from those who did not undergo MRI. A new DWI/FLAIR infarct in the territory of the symptomatic artery was noted in 26.2%. Those with recurrent infarcts were younger (57.7 vs. 65.7 years, p=0.009), more likely to have diabetes (71.4% vs. 44.3%, p=0.043), have greater degree of stenosis (82.5% vs. 76.0%, p=0.099), and have greater decline in systolic blood pressure (SBP) from enrollment to 6-8 week follow-up (+5 vs. -6.2 mm Hg, p=0.074). In adjusted analyses, age (aOR 0.922, 95% CI 0.869-0.979) and change in SBP (aOR 0.967, 95% CI 0.937-0.997) were related to new infarct in the territory. Conclusions: Early recurrent infarcts occur in more than one-quarter of patients with symptomatic ICAD, may be a suitable biomarker of disease activity, and add to the subclinical burden of this high-risk disease. Given the association between SBP lowering and infarct recurrence, studies of early blood pressure management strategies, including extended permissive hypertension, may be warranted in this population.

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Submaximal Angioplasty for Symptomatic Intracranial Atherosclerotic Disease: A Meta-Analysis of Peri-Procedural and Long-Term Risk

Neurosurgery ◽

10.1093/neuros/nyz337 ◽

2019 ◽

Vol 86 (6) ◽

pp. 755-762

Author(s):

Christopher J Stapleton ◽

Yi-Fan Chen ◽

Hussain Shallwani ◽

Kunal Vakharia ◽

Tanya N Turan ◽

...

Keyword(s):

English Language ◽

Meta Analysis ◽

Rank Correlation ◽

Posterior Circulation ◽

Atherosclerotic Disease ◽

Inclusion Criteria ◽

Intracranial Atherosclerotic Disease ◽

Language Studies ◽

Event Rates

Abstract BACKGROUND Symptomatic intracranial atherosclerotic disease (ICAD) is an important cause of stroke. 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. OBJECTIVE To examine the periprocedural and long-term risks associated with submaximal angioplasty for ICAD based on the available literature. METHODS All English language studies of intracranial angioplasty for ICAD were screened. Inclusion criteria were as follows: ≥ 5 patients, intervention with submaximal angioplasty alone, and identifiable periprocedural (30-d) outcomes. Analysis was co-nducted to identify the following: 1) periprocedural risk of any stroke (ischemic or hemorrh-agic) or death, and 2) stroke in the territory of the target vessel and fatal stroke beyond 30 d. Mixed effects logistic regression was used to summarize event rates. Funnel plot and rank correlation tests were employed to detect publication bias. The relative risk of periprocedural events from anterior vs posterior circulation disease intervention was also examined. RESULTS A total of 9 studies with 408 interventions in 395 patients met inclusion criteria. Six of these studies included 113 posterior circulation interventions. The estimated pooled rate for 30-d stroke or death following submaximal angioplasty was 4.9% (95% CI: 3.2%-7.5%), whereas the estimated pooled rate beyond 30 d was 3.7% (95% CI: 2.2%-6.0%). There was no statistical difference in estimated pooled rate for 30-d stroke or death between patients with anterior (4.8%, 95% CI: 2.8%-7.9%) vs posterior (5.3%, 95% CI: 2.4%-11.3%) circulation disease (P > .99). CONCLUSION Submaximal angioplasty represents a potentially promising intervention for symptomatic ICAD.

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E-049 Dwi infarction patterns and perfusion parameters in anterior versus posterior circulation stroke secondary to intracranial atherosclerotic disease

10.1136/neurintsurg-2019-snis.124 ◽

2019 ◽

Author(s):

R Abdalla ◽

O Ansari ◽

M Pan ◽

D Cantrell ◽

A Shaibani ◽

...

Keyword(s):

Posterior Circulation ◽

Atherosclerotic Disease ◽

Posterior Circulation Stroke ◽

Intracranial Atherosclerotic Disease

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De novo pseudoaneurysm formation after angioplasty and stenting of posterior circulation intracranial atherosclerotic disease: mechanism, characterization with intravascular ultrasound and management considerations

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2012-010443 ◽

2012 ◽

Vol 5 (5) ◽

pp. 447-451

Author(s):

Guilherme Dabus ◽

Italo Linfante ◽

Edgar A Samaniego

Keyword(s):

Intravascular Ultrasound ◽

De Novo ◽

Posterior Circulation ◽

Atherosclerotic Disease ◽

Disease Mechanism ◽

Pseudoaneurysm Formation ◽

Intracranial Atherosclerotic Disease ◽

Angioplasty And Stenting

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Intraplaque Hemorrhage in Symptomatic Intracranial Atherosclerotic Disease

Journal of Neuroimaging ◽

10.1111/j.1552-6569.2009.00442.x ◽

2011 ◽

Vol 21 (2) ◽

pp. e159-e161 ◽

Cited By ~ 48

Author(s):

Tanya N. Turan ◽

Leonardo Bonilha ◽

Paul S. Morgan ◽

Robert J. Adams ◽

Marc I. Chimowitz

Keyword(s):

Atherosclerotic Disease ◽

Intraplaque Hemorrhage ◽

Intracranial Atherosclerotic Disease

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Abstract P476: Safety and Efficacy of Balloon Mounted Drug-Eluting Stent in the Treatment of Symptomatic Intracranial Atherosclerotic Disease Multicenter International Experience

Stroke ◽

10.1161/str.52.suppl_1.p476 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Mahmoud Mohammaden ◽

Raul G Nogueira ◽

WONDWOSSEN TEKLE ◽

farhan siddiq ◽

Diogo C Haussen ◽

...

Keyword(s):

Clinical Trials ◽

Endovascular Treatment ◽

Medical Management ◽

Randomized Clinical Trials ◽

Atherosclerotic Disease ◽

Drug Eluting Stent ◽

Safety And Efficacy ◽

Intracranial Atherosclerotic Disease ◽

Drug Eluting

Introduction: Intracranial atherosclerotic disease (ICAD) is a common cause of refractory stroke. Randomized clinical trials failed to prove the safety and efficacy of the endovascular treatment options of symptomatic ICAD (sICAD). However, there are many concerns regarding inclusion criteria in these trials which made them less effective than standard medical management. Herein, we aim to study the safety and efficacy of drug-eluting balloon mounted stents (DES) in the treatment of sICAD. Methods: A retrospective review of endovascular database from 10 comprehensive stroke centers inside and outside the USA from January 2017 to January 2020 was reviewed. Patients were included if they had symptomatic intracranial stenosis ≥70% in the target vessel, failed best medical management, and underwent intracranial stenting with DES. The primary outcome was the occurrence of ischemic stroke, hemorrhage, or mortality within 72 hours of the procedure. Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure. Results: There was a total of 129 patients, the median age was 65 [58-72] years, 40 (31%) were females. The intracranial stenotic lesions were located in anterior circulation in 74 (57.4%) of cases [24 (18.6%) supraclinoid ICA, 5 (3.9%) cavernous ICA, 17 (13.2%) petrous ICA, 5 (19.4%) MCA-M1, and 3 (2.3%) M2] and in posterior circulation in 55 (42.6%) of cases [36 (27.9) vertebral artery V4 segment, 18 (14%) basilar and 1 (0.7%) PCA]. Recurrent stroke was the qualifying event in 101 (78.3%) while transient ischemic attacks (TIA) were identified in 28 (21.7%) of cases. The median time from the qualifying event to stenting was 6 [2-24] days. Strokes were reported within 72 hours of the procedure; 2 (1.6%) ischemic, 2 (1.6%) hemorrhagic strokes and 2 (1.6%) patients suffered inpatient mortality. The median follow-up time was 6 [3-6.75] months. Among 99 patients who had clinical follow up 2 (2%) had TIA and 6 (6.1%) had strokes. Fifty-one patients had follow-up imaging of whom symptomatic ISR was reported in 8 (15.7%). Conclusion: Our study has shown that in appropriately selected patients with sICAD, endovascular treatment using DES is safe and effective. Prospective randomized clinical trials are warranted.

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