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Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Disease: Classification and Clinical Implications
Xueyan Feng1, Ka Lung Chan1, Linfang Lan1,2
1From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., Y.S., X.L., T.W.L.), the Chinese University of Hong Kong, Prince of Wales Hospital.
Insights
Identifying stroke mechanisms in intracranial atherosclerotic stenosis is key for prevention. Mixed artery-to-artery embolism and hypoperfusion mechanisms increase stroke relapse risk.
Area of Science:
- Neurology
- Vascular Neurology
- Stroke Medicine
Background:
- Symptomatic intracranial atherosclerotic stenosis (ICAS) poses a risk for recurrent ischemic events.
- Understanding the precise stroke mechanism in ICAS is crucial for effective secondary prevention strategies.
- Current classification of stroke mechanisms in ICAS may lack reproducibility.
Purpose of the Study:
- To develop and validate reproducible classification criteria for stroke mechanisms in patients with symptomatic ICAS using routine neuroimaging.
- To explore the clinical implications and prognostic value of these classified stroke mechanisms.
Main Methods:
- A cohort of 153 patients with acute ischemic stroke due to 50%-99% stenosis in the anterior circulation ICAS was recruited.
- Two independent investigators classified stroke mechanisms (parent artery atherosclerosis, artery-to-artery embolism, hypoperfusion, mixed) based on infarct topography and angiography.
- Reproducibility of the classification criteria was assessed using intraclass correlation coefficients (κ).
Main Results:
- The most frequent mechanisms were isolated hypoperfusion (35.3%) and mixed artery-to-artery embolism and hypoperfusion (37.3%).
- The mixed mechanism group showed higher rates of dyslipidemia and hypertension.
- The proposed classification criteria demonstrated substantial to excellent intrarater and interrater reproducibility (κ = 0.791–0.908).
- A mixed mechanism of artery-to-artery embolism and hypoperfusion was associated with a significantly higher risk of recurrent ischemic stroke within 1 year (24.4% vs. 7.8%).
Conclusions:
- Artery-to-artery embolism and hypoperfusion frequently coexist in ICAS-related ischemic stroke.
- These combined mechanisms are associated with an increased risk of stroke recurrence.
- The developed classification criteria are reproducible and aid in stratifying stroke risk in ICAS patients.
Abstract:
Background and Purpose- In patients with symptomatic intracranial atherosclerotic stenosis, identifying the underlying stroke mechanisms may inform secondary prevention. We aimed to propose reproducible classification criteria for stroke mechanisms based on routine neuroimaging in symptomatic intracranial atherosclerotic stenosis and explore their clinical implications. Methods- We recruited patients with acute ischemic stroke attributed to 50% to 99% intracranial atherosclerotic stenosis in anterior circulation from 2 centers. Two investigators independently classified probable stroke mechanisms as parent artery atherosclerosis occluding penetrating artery, artery-to-artery embolism, hypoperfusion, and mixed mechanisms, with prespecified criteria based on infarct topography and magnetic resonance/computed tomography angiography. These stroke mechanisms were correlated with features of the patients at baseline and recurrent ischemic stroke in the same territory or relevant transient ischemic attack within 1 year. Results- Among 153 patients recruited, the most common stroke mechanisms were isolated hypoperfusion (35.3%) and mixed mechanism of artery-to-artery embolism and hypoperfusion (37.3%) that was associated with higher incidence of dyslipidemia (P=0.045) and hypertension (P=0.033) than patients with other stroke mechanisms. The proposed criteria showed substantial to excellent intrarater and interrater reproducibilities (κ, 0.791-0.908). Overall, 31 patients received interventional treatment of the diseased intracranial artery; 122 received medical treatment, among whom a mixed mechanism of artery-to-artery embolism and hypoperfusion at baseline was associated with higher risk of ischemic stroke in the same territory within 1 year (24.4% versus 7.8%; hazard ratio, 3.40; 95% CI, 1.25-9.20; log-rank P=0.010) than other mechanisms combined. Conclusions- Artery-to-artery embolism and hypoperfusion commonly coexist in ischemic stroke attributed to intracranial atherosclerotic stenosis, which may be associated with higher risk of stroke relapse.
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