Hemodynamic Markers in the Anterior Circulation as Predictors of Recurrent Stroke in Patients With Intracranial
Ashley M Wabnitz1,2, Colin P Derdeyn3, David J Fiorella4
1From the Department of Neurology, Medical University of South Carolina, Charleston (A.M.W., T.N.T., M.I.C.).
Insights
Patients with borderzone infarcts and poor collateral flow face a higher risk of recurrent stroke, even with aggressive medical therapy for intracranial stenosis. Identifying these hemodynamic markers is crucial for stroke prevention strategies.
Area of Science:
- Neurology
- Vascular Neurology
- Neuroimaging
Background:
- Aggressive medical therapy in the SAMMPRIS trial was superior to stenting for intracranial stenosis but still had a high stroke rate.
- Identifying patients at high risk for recurrent stroke on medical management is critical.
Purpose of the Study:
- To investigate the association between hemodynamic markers and recurrent stroke rates in medically treated patients from the SAMMPRIS trial.
- To determine if infarct patterns (borderzone, core, perforator) and collateral flow status predict stroke recurrence.
Main Methods:
- Post hoc analysis of SAMMPRIS trial participants with middle cerebral artery or intracranial carotid artery infarcts.
- Infarct territories were classified as borderzone, core middle cerebral artery, or perforator.
- Collateral flow was assessed using a standardized scale; statistical analyses included log-rank and chi-squared tests.
Main Results:
- Borderzone infarcts were associated with a higher, though not statistically significant, rate of recurrent stroke compared to core or perforator infarcts (26.4% vs. 8.3-12.5%).
- Impaired collateral flow was significantly more common in patients with borderzone infarcts (70%).
- Patients with both borderzone infarcts and impaired collateral flow exhibited the highest recurrent stroke risk (37%).
Conclusions:
- Borderzone infarct patterns and impaired collateral flow are key indicators of high recurrent stroke risk in patients with intracranial stenosis treated medically.
- These hemodynamic factors can help identify a high-risk subgroup requiring closer monitoring and potentially intensified preventive strategies.
Abstract:
Background and Purpose- Although aggressive medical therapy was superior to stenting in the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis), the stroke rate in the medical arm was still high. The aim of this study was to determine the association between hemodynamic markers (borderzone infarct pattern and impaired collateral flow on baseline imaging) and rates of recurrent stroke in patients treated medically in SAMMPRIS. Methods- This was a post hoc analysis of patients whose qualifying event for SAMMPRIS was an infarct in the territory of a stenotic middle cerebral artery or intracranial carotid artery. Infarcts were adjudicated as involving primarily internal or cortical borderzone territories, the core middle cerebral artery territory, or perforator territories, and collateral flow was assessed according to a standard scale (American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology). Log-rank tests and χ2 tests were performed to assess associations of infarct patterns and collateral flow with rates of recurrent stroke. Results- Of 101 patients who qualified, 14 of 53 (26.4%) with borderzone infarcts, 2 of 24 (8.3%) with core middle cerebral artery infarcts, and 3 of 24 (12.5%) with perforator infarcts had a recurrent stroke in the territory (P=0.14 for comparing the 3 groups, P=0.052 for borderzone versus nonborderzone). Of 82 patients with collateral flow assessment, 30 of 43 (70%) with borderzone infarcts, 7 of 19 (37%) with core middle cerebral artery infarcts, and 11 of 20 (55%) with perforator infarcts had impaired collateral flow distal to the stenosis (P=0.049). Patients with borderzone infarcts and impaired collateral flow had the highest risk of recurrent stroke (37%). Conclusions- Borderzone infarcts and impaired collateral flow identify a subgroup of patients with intracranial stenosis who are at particularly high risk of recurrent stroke on medical treatment. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00576693.
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