Infarct Recurrence in Intracranial Atherosclerosis: Results from the MyRIAD Study

Romano, Jose G.; Nizam, Azhar; Feldmann, Edward; Sangha, Rajbeer Singh; Cotsonis, George; Campo‐Bustillo, Iszet; Koch, Sebastian; Rundek, Tatjana; Chimowitz, Marc I.; Liebeskind, David S

doi:10.1016/j.jstrokecerebrovasdis.2020.105504

Cited by 38 publications

(46 citation statements)

References 33 publications

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“… 8 In contrast, a more recent study examined patients with anterior and posterior circulation intracranial atherosclerotic stenosis, using several measures of hemodynamics, and potential for artery‐to‐artery embolism and showed that none of the techniques reliably predicted an increased risk of subsequent stroke. 23 This suggests that some of our current techniques for measuring hemodynamics may not be predictive of stroke risk or may have different predictive value depending on the population being studied.…”

Section: Discussionmentioning

confidence: 99%

Vertebrobasilar Stroke: Association Between Infarction Patterns and Quantitative Magnetic Resonance Angiography Flow State

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Libman

Schneider

et al. 2022

JAHA

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Background Treatment and prognosis of vertebrobasilar atherosclerotic disease differs depending on stroke mechanism, such as artery‐to‐artery embolism, branch atheromatous disease, and hemodynamic ischemia. Our aim was to investigate the relationship between infarction pattern and flow status using quantitative magnetic resonance angiography (QMRA), to determine the validity of using infarction patterns to infer stroke mechanism. Methods and Results This is a retrospective study of patients with ischemic stroke with intra‐ or extracranial vertebrobasilar atherosclerotic stenosis, who underwent magnetic resonance imaging of the brain, neurovascular imaging, and QMRA, between 2009 and 2021. Patients with cerebral infarction predating or following QMRA by ≥1 year, or QMRA studies performed for basilar thrombosis, vertebral dissection, or only postangioplasty/stenting, were excluded. Poststenotic flow (basilar and posterior cerebral arteries) was dichotomized as low‐flow or normal‐flow based on published criteria. Of 1211 consecutive patients who underwent QMRA noninvasive optimal analysis, 69 met inclusion. Mixed patterns were most common (46.4%), followed by perforator (23.2%), borderzone (14.5%), and territorial (15.9%). Patients with low‐flow had a significantly higher rate of borderzone+ patterns (borderzone alone or in mixed pattern) compared with patients with normal‐flow (77.4% low‐flow versus 39.5% normal‐flow, P =0.002). Borderzone+ patterns were associated with 61.5% probability of low‐flow state, while no borderzone (perforator/territorial) patterns were associated with 76.7% probability of normal‐flow state. Conclusions Borderzone infarction pattern (alone or mixed) was associated with low poststenotic posterior circulation flow by QMRA. However, borderzone pattern only moderately predicted low‐flow state, and may be an unreliable flow marker. Therefore, infarct topography may complement, but should not replace hemodynamic studies to establish flow status.

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Section: Discussionmentioning

confidence: 99%

Vertebrobasilar Stroke: Association Between Infarction Patterns and Quantitative Magnetic Resonance Angiography Flow State

Ballout

Libman

Schneider

et al. 2022

JAHA

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“…Romano et al recently used the same 2D PCMRI technique in The Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease study in patients with symptomatic intracranial stenoses in both the anterior and posterior circulation. Low flow across the stenosis could not predict stroke/TIA recurrence with this more inclusive approach ( Romano et al, 2021 ). It is not entirely straightforward to compare our data to these studies, as we present a more heterogeneous sample including any patient with VB stroke.…”

Section: Discussionmentioning

confidence: 99%

Hemodynamic Disturbances in Posterior Circulation Stroke: 4D Flow Magnetic Resonance Imaging Added to Computed Tomography Angiography

et al. 2021

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Objective: A clinically feasible, non-invasive method to quantify blood flow, hemodynamics, and collateral flow in the vertebrobasilar arterial tree is missing. The objective of this study was to evaluate the feasibility of quantifying blood flow and blood flow patterns using 4D flow magnetic resonance imaging (MRI) in consecutive patients after an ischemic stroke in the posterior circulation. We also explore if 4D-flow, analyzed in conjunction with computed tomography angiography (CTA), has potential as a diagnostic tool in posterior circulation stroke.Methods: Twenty-five patients (mean age 62 years; eight women) with acute ischemic stroke in the posterior circulation were investigated. At admission, all patients were examined with CTA followed by MRI (4D flow MRI and diffusion-weighted sequences) at median 4 days after the presenting event. Based on the classification of Caplan, patients were divided into proximal/middle (n = 16) and distal territory infarcts (n = 9). Absolute and relative blood flow rates were calculated for internal carotid arteries (ICA), vertebral arteries (VA), basilar artery (BA), posterior cerebral arteries (P1 and P2), and the posterior communicating arteries (Pcom). In a control group consisting of healthy elderly, the 90th and 10th percentiles of flow were calculated in order to define normal, increased, or decreased blood flow in each artery. “Major hemodynamic disturbance” was defined as low BA flow and either low P2 flow or high Pcom flow. Various minor hemodynamic disturbances were also defined. Blood flow rates were compared between groups. In addition, a comprehensive analysis of each patient’s blood flow profile was performed by assessing relative blood flow rates in each artery in conjunction with findings from CTA.Results: There was no difference in total cerebral blood flow between patients and controls [604 ± 117 ml/min vs. 587 ± 169 ml/min (mean ± SD), p = 0.39] or in total inflow to the posterior circulation (i.e., the sum of total VA and Pcom flows, 159 ± 63 ml/min vs. 164 ± 52 ml/min, p = 0.98). In individual arteries, there were no significant differences between patients and controls in absolute or relative flow. However, patients had larger interindividual relative flow variance in BA, P1, and P2 (p = 0.01, <0.01, and 0.02, respectively). Out of the 16 patients that had proximal/middle territory infarcts, nine had CTA findings in VA and/or BA generating five with major hemodynamic disturbance identified with 4D flow MRI. For those without CTA findings, seven had no or minor 4D flow MRI hemodynamic disturbance. Among nine patients with distal territory infarcts, one had major hemodynamic disturbances, while the remaining had minor disturbances.Conclusion: 4D flow MRI contributed to the identification of the patients who had major hemodynamic disturbances from the vascular pathologies revealed on CTA. We thus conclude that 4D flow MRI could add valuable hemodynamic information when used in conjunction with CTA.

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“…The National Institutes of Health‐funded MYRIAD study was a prospective observational study designed to evaluate the causes of stroke in ICAD by using imaging biomarkers for specific pathophysiological processes 10 . MYRIAD included 105 participants across 10 recruiting sites in the United States 11 . To be eligible, individuals had to be ≥50 years of age (or 30–49 years if ≥2 vascular risk factor or established atherosclerotic disease) and present within 21 days of a stroke or transient ischemic attack caused by moderate‐to‐severe ICAD (50–99%) of the intracranial internal carotid artery (ICA), middle cerebral artery M1‐segment (MCA‐M1), vertebral artery V4‐segment (VA‐V4), or basilar artery (BA).…”

Section: Methodsmentioning

confidence: 99%

Intracranial dolichoectasia in patients with symptomatic intracranial atherosclerotic disease: Results from the MYRIAD study

Brutto

Liebeskind

Campo‐Bustillo

et al. 2021

Journal of Neuroimaging

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Background and Purpose It is unknown whether intracranial atherosclerotic disease (ICAD), in addition to causing stenosis, also associates with abnormal arterial enlargement, a condition known as intracranial dolichoectasia (IDE). Across symptomatic ICAD patients, we aim to determine IDE prevalence and IDE impact on cerebral hemodynamics and recurrent cerebral ischemia. Methods We analyzed 98 participants (mean age 63.8 ± 11.9 years, 56.1% men) of the prospective observational study MYRIAD. Participants were enrolled within 21 days of an ischemic stroke or transient ischemic attack caused by moderate‐to‐severe ICAD. Semi‐automatic vessel segmentation was used to determine diameters, length, and tortuosity‐index of proximal intracranial arteries. Either ectasia (increased diameter) or dolichosis (increased length or TI) defined IDE. We assessed IDE association with new infarcts during 12‐month follow‐up, and IDE correlation with cerebral hemodynamics determined by quantitative MR‐angiography (QMRA), MR‐perfusion weighted‐imaging, and transcranial Doppler breath‐holding index. Results IDE was present in 35.7% of patients and 10.2% of symptomatic arteries. Basilar stenosis was associated with higher IDE prevalence (27.8% vs. 8.8%, p = 0.04), whereas other symptomatic arteries showed no association with IDE. Symptomatic arteries with IDE had lower hypoperfusion prevalence on MR‐PWI (11.1% vs. 28.4%, p = 0.03). Increased diameter (r = 0.33, p<0.01) and tortuosity‐index (r = 0.29, p = 0.01) showed positive correlation with QMRA flow rate. IDE was not associated with new infarcts during follow‐up. Conclusions IDE was common among symptomatic ICAD patients. IDE was not associated with stroke recurrence. Instead, increased diameter and tortuosity correlated with improved blood flow across the stenotic artery, suggesting that IDE may originate as an adaptive mechanism in ICAD.

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Infarct Recurrence in Intracranial Atherosclerosis: Results from the MyRIAD Study

Cited by 38 publications

References 33 publications

Vertebrobasilar Stroke: Association Between Infarction Patterns and Quantitative Magnetic Resonance Angiography Flow State

Vertebrobasilar Stroke: Association Between Infarction Patterns and Quantitative Magnetic Resonance Angiography Flow State

Hemodynamic Disturbances in Posterior Circulation Stroke: 4D Flow Magnetic Resonance Imaging Added to Computed Tomography Angiography

Intracranial dolichoectasia in patients with symptomatic intracranial atherosclerotic disease: Results from the MYRIAD study

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