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Published on: April 23, 2021
Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and
Xuan Tian1, Hui Fang2, Linfang Lan1,3
1Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China.
Insights
A new D2H2A nomogram effectively predicts recurrent stroke risk in symptomatic intracranial atherosclerotic stenosis (sICAS) patients. It integrates vascular risk factors with hemodynamic significance from computational fluid dynamics (CFD) models for better risk stratification.
Area of Science:
- Neurology
- Cardiovascular Research
- Medical Imaging and Diagnostics
Background:
- Symptomatic intracranial atherosclerotic stenosis (sICAS) carries a high risk of recurrent stroke, even with optimal medical treatment.
- Both luminal stenosis severity and hemodynamic significance, assessed via computational fluid dynamics (CFD), are linked to stroke recurrence.
- Predictive tools are needed to stratify sICAS patients for stroke risk.
Purpose of the Study:
- To develop and compare stroke risk prediction nomograms for sICAS patients.
- To evaluate nomograms based on conventional vascular risk factors, stenosis severity, and hemodynamic metrics derived from CFD.
Main Methods:
- Patients with 50%-99% sICAS underwent CT angiography (CTA).
- Conventional vascular risk factors were collected; stenosis was dichotomized (moderate/severe).
- CTA-based CFD modeling quantified translesional pressure ratio (PR) and wall shear stress ratio (WSSR) to classify hemodynamic status (normal/intermediate/abnormal).
Main Results:
- The D2H2A nomogram (diabetes, dyslipidemia, hemodynamic status, hypertension, age ≥50) demonstrated good calibration and discrimination (C-statistic 0.73).
- The D2H2A nomogram outperformed models using only vascular risk factors or vascular risk factors plus stenosis severity.
- It showed superior risk reclassification and net benefits in decision curve analysis.
Conclusions:
- The D2H2A nomogram, integrating vascular risk factors and CFD-derived hemodynamic significance, is a valuable tool for sICAS patient risk stratification.
- This nomogram aids in predicting the risk of recurrent stroke in sICAS patients receiving optimal medical treatment.
Background And Purpose:
Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics.
Methods:
Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year.
Results:
Among 245 sICAS patients, 20 (8.2%) had SIT. The D2H2A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results.
Conclusions:
The D2H2A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment.
