Challenges in the Medical Management of Symptomatic Intracranial Stenosis in an Urban Setting

Sangha, Rajbeer Singh; Naidech, Andrew M.; Corado, Carlos; Ansari, Sameer A.; Prabhakaran, Shyam

doi:10.1161/strokeaha.116.016254

Cited by 51 publications

(36 citation statements)

References 29 publications

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“…DAPT in ICAD stroke patients resulted in significant MES reduction as recorded on TCD within days of treatment [ 209 ]. However, the low recurrence rates for patients on DAPT have not been replicated in a prospective registry [ 210 ] or in a post hoc analysis of a RCT with ICAD patients [ 211 ].…”

Section: Intracranial Atherosclerotic Diseasementioning

confidence: 99%

Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke

et al. 2018

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Atherosclerosis is a major cause of ischemic stroke that can be effectively prevented with appropriate lifestyle modifications and control of cardiovascular risk factors. Medical advances in recent years along with aggressive cardiovascular risk factor modifications have resulted in decreased recurrence rates of atherosclerotic stroke. Non-statin lipid-lowering molecules have recently shown clinical benefit and are recommended for very high-risk patients to reduce their risk of stroke. Aggressive hypertension treatment is crucial to reduce atherosclerotic stroke risk. Advances in antithrombotic treatments include combinations of antiplatelets and new antiplatelet agents in the acute phase post-stroke, which carries a high risk of recurrence. Intensive medical treatment has also limited the indications for carotid interventions, especially for asymptomatic disease. Intracranial atherosclerotic disease may provoke stroke through various mechanisms; it is increasingly recognized as a cause of ischemic stroke with advanced imaging and is best managed with lifestyle modifications and medical therapy. The diagnostic search for the vulnerable culprit atherosclerotic plaque is an area of intense research, from the level of the intracranial arteries to that of the aortic arch. Ultrasonography and novel magnetic resonance imaging techniques (high-resolution vessel-wall imaging) may assist in the identification of vulnerable atherosclerotic plaques as the underlying cause in cryptogenic or misdiagnosed non-atherosclerotic ischemic stroke. Vertebrobasilar atherosclerotic disease is less common than carotid artery disease; thus, high-quality data on effective prevention strategies are scarcer. However, aggressive medical treatment is also the gold standard to reduce cerebrovascular disease located in posterior circulation.

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Section: Intracranial Atherosclerotic Diseasementioning

confidence: 99%

Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke

et al. 2018

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“…In addition, the effect of early drug treatment was not good in our study. Although antiplatelet drugs and statins were prescribed and risk factor intervention was emphasized upon after admission, there were no Aggressive Medical Measures like in the SAMMPRIS trial in real life (16), which has been proved in follow-up, medication and lifestyle control is not qualified as requested. Based on a large sample of Chinese ICAS patients, the CICAS registration study pointed out that the risk of stroke recurrence increases with the increase of the number of risk factors (4).…”

Section: Discussionmentioning

confidence: 99%

Risk of Recurrence of Symptomatic Intracranial Atherosclerosis in Posterior Circulation Seen to Be Higher Than That in Anterior Circulation in Long-Term Follow-Up

Zhang

Jia

et al. 2020

Front. Neurol.

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Background: Intracranial atherosclerotic stenosis (ICAS) is an important cause of ischemic stroke. In Asians, intracranial atherosclerotic disease leads to 33-50% of ischemic events. At present, treatment with medication vs. endovascular therapy (EVT) for symptomatic ICAS (sICAS) patients is still debatable. The clinical prognosis of patients who are not completely free of stroke symptoms despite regular medication and are not eligible for EVT for various reasons, is not yet investigated. Aim: To report the long-term recurrence rate of stroke in a cohort of symptomatic ICAS patients who intended to undergo EVT upon admission but could not for various reasons after digital subtraction angiography (DSA) evaluation. Method: This is a retrospective analysis of consecutive sICAS patients in a single center from January 1, 2016 to August 31, 2017 who underwent DSA assessment alone and were not eligible for further EVT. Demographic information, risk factors related to cerebrovascular disease, clinical comorbidities, medication, imaging data, and long-term outcomes were reported. Results: A total of 218 patients were included in the study; 42 (19.2%) patients had recurrence of stroke/transient ischemic attack (TIA) at the 1-year follow up. Patients were divided into two groups according to lesions in anterior circulation (n = 120) or posterior circulation (n = 98). There was a higher stroke/TIA recurrence rate in the posterior circulation than anterior circulation group (25.5 vs. 14.2%, p = 0.035). Given the advanced age, higher prevalence of coronary heart disease, larger stenosis length, and poorer collateral circulation, the posterior circulation group showed a higher risk of recurrent stroke/TIA and death than the anterior circulation group [HR = 3.092, 95% CI (1.335-7.164), p = 0.0084], after adjusting for all confounding factors in the COX regression model. Kaplan-Meier analysis showed that sICAS recurrence and mortality risk in the posterior circulation group was consistently higher than that in the anterior circulation group (log-rank-test, p = 0.033). Zhang et al. Recurrent Risk of sICAS Conclusions: Patients with posterior circulation sICAS have higher recurrence risk than those with anterior circulation managed with medication alone. Further, posterior circulation lesion is an independent risk factor for recurrence in sICAS patients.

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“…Moreover, the efficacy of extracranial–intracranial arterial bypass has yet to be conclusively demonstrated in large studies even for hemodynamic compromised patients (4). Considering that the event rate of recurrent stroke in refractory patients may be higher than what was previously reported in the randomized trial, endovascular therapy may still remain an option (15).…”

Section: Discussionmentioning

confidence: 99%

Endovascular Recanalization of Non-acute Symptomatic Middle Cerebral Artery Total Occlusion and Its Short-Term Outcomes

et al. 2019

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Background and Purpose: The optimal treatment for patients with non-acute symptomatic middle cerebral artery (MCA) total occlusion and a high risk of recurrent ischemic stroke despite medical management is not well-established. We aimed to assess the feasibility, safety, and short-term outcomes of angioplasty and stenting for these patients. Methods: Data of 22 patients with non-acute symptomatic MCA total occlusion who have failed medical management and undergone endovascular recanalization were retrospectively collected in our prospective database. All occlusive lesions were predilated with conventional balloons, followed by paclitaxel-coated coronary balloon inflation or not, and then a remedial stenting was performed or not, depending on the discretion of the operator. The rate of successful recanalization, perioperative outcomes, and short-term outcomes, such as restenosis and stroke recurrence, was analyzed. Results: Successful recanalization was achieved in 95.5% of patients, with 14 patients undergoing balloon angioplasty and 7 patients undergoing remedial stenting. Seven patients developed perioperative complications, including one patient with persistent neurological deficit. Over a median clinical follow-up duration of 5.0 months, only one patient had recurrent ischemic symptoms attributed to the cessation of antiplatelet treatment owing to postoperative intracranial hemorrhage. The proportion of patients who achieved favorable clinical outcome (modified ranking scale score of 0–2) was 85.7%. Post-procedural repeat vascular imaging was performed at 4.5 ± 1.84 months, with nine and one patient undergoing cerebral angiography and magnetic resonance angiography, respectively. One (10%) artery presented with asymptomatic reocclusion. Conclusions: Angioplasty and stenting may be feasible for the patients with non-acute symptomatic atherosclerotic MCA total occlusive disease who have failed medical management.

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Challenges in the Medical Management of Symptomatic Intracranial Stenosis in an Urban Setting

Cited by 51 publications

References 29 publications

Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke

Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke

Risk of Recurrence of Symptomatic Intracranial Atherosclerosis in Posterior Circulation Seen to Be Higher Than That in Anterior Circulation in Long-Term Follow-Up

Endovascular Recanalization of Non-acute Symptomatic Middle Cerebral Artery Total Occlusion and Its Short-Term Outcomes

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