Does flow status predict risk of recurrent stroke in patients with intracranial stenoocclusive disease?
Griffin Hornung, 1Donald
1 B.S. ,
2 M.D. ,
Timothy White, Brendan Ryu, 2 Woo, M.D.
1 B.S. , and
Henry
and Barbara Zucker School of Medicine at Hofstra/Northwell 2North Shore University Hospital
Results
Background Research concerning the optimal treatment of patients with intracranial arterial stenosis has focused on comparing the efficacy of various drugs used in medical management and, more recently, on the advantages of intervention over medication-based regimens.1-5 Intracranial arterial stenosis patients assigned warfarin and those assigned aspirin in the WASID trial saw no difference in rates ischemic stroke or cranial hemorrhage, but patients taking warfarin saw an increased risk of bleeding and of death from non-vascular causes.1 However, medical management displayed comparatively reduced effectiveness in patients with “misery perfusion” (defined by poor blood flow, blood volume, and oxygen consumption parameters) than in those without.2 The COSS and SAMMPRIS trials compared the efficacy of medical management to that of interventions, and both were stopped after attempts to show the effectiveness of their respective interventions proved futile.3,4 The SAMMPRIS trial concluded that a regimen of aspirin, clopidogrel, and risk factor mitigation was superior to intervention with the Wingspan stent.3 The WEAVE trial redefined high volume sites and implemented a longer time from event to intervention, which helped display periprocedural safety for the Wingspan stent system, contradicting the results of the SAMMPRIS trial.3,5
Figure 5: 3-D visualization of blood flow. The yellow marker indicates the location of measurement for flow in the LMCA. This image is also from the patient’s first NOVA scan.
Figure 1: Circle of Willis. Reprinted from Wikimedia Commons, 2021. The VERiTAS trial suggested that stroke risk in posterior cranial circulation depended less on level of steno-occlusion and more on flow distal to the atherosclerosis.6 Quantitative magnetic resonance angiography (QMRA) using the noninvasive optimal vessel analysis (NOVA) protocol was used in the VERiTAS trial to assess flow parameters and ultimately risk of stroke.6 Together, the data from these trials suggest that QMRA and NOVA data could be used to identify patients with anterior circulation stenosis who are at risk for recurrent stroke so that they may be treated with angioplasty and stenting.
Hypothesis Data from QMRA with NOVA can be used to identify stenotic vessels in the anterior cranial circulation that put patients at increased risk of recurrent stroke.
Figure 2: NOVA report from a patient following LMCA infarct. Direction and magnitude of blood flow are overlaid on a schematic of the Circle of Willis.
Future Directions Figure 3: Second NOVA report from the same patient following a recurrent infarct.
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database. •
Figure 4: LMCA flow in mL/min. This graph corresponds with the LMCA flow from the patient’s first QMRA with NOVA scan.
Examine clinical follow-up records to identify instances of stroke, along with location and residual symptoms.
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Correlate recurrent stroke risk with flow in distinct cranial arteries using NOVA reports.
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Translate findings to best-practices for treatment of patients with stenoocclusive disease.
Methods All Northwell Health patients who underwent QMRA with NOVA scans were identified using AllScripts EEHR, Sunrise, and CARESTREAMS PACS software and were screened to confirm steno-occlusive disease. A REDCap database was designed for consolidation of patient demographics, clinical follow-ups, imaging data from CT, MRI, and SPECT scans, and for the flow data from the QMRA with NOVA scans.
Transfer QMRA with NOVA data for Northwell Health patients into a
Resources 1
Chimowitz, M. I., Lynn, M. J., Howlett-Smith, H., Stern, B. J., Hertzberg, V. S., Frankel, M. R., Levine, S. R., Chaturvedi, S., Kasner, S. E., Benesch, C. G., Sila, C. A., Jovin, T. G., & Romano, J.G. (2015). Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis. The New England Journal of Medicine, 352(13), 1305-1316. https://www.nejm.org/doi/full/10.1056/NEJMoa043033 2Yamauchi, H., Higashi, T., Kagawa, S., Nishii, R., Kudo, T., Sugimoto, K., Okazawa, H., & Fukuyama, H. (2012). Is misery perfusion still a predictor of stroke in symptomatic major cerebral artery disease? Brain, 135(8), 2515-2526. https://doi.org/10.1093/brain/aws131 3Chimowitz, M. I., Lynn, M. J., Derdeyn, C. P., Turan, T. N., Fiorella, D., Lane, B. F., Janis, L. S., Lutsep, H. L., Barnwell, S. L., Waters, M. F., Hoh, B. L., Hourihane, J. M., Levy, E. I., Alexandrov, A. V., Harrigan, M. R., Chiu, D., Klucznik, R. P., Clark, J. M., McDougall, C.G., …Cloft, H. J. (2011). Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis. The New England Journal of Medicine, 365(11), 993-1003. https://www.nejm.org/doi/metrics/10.1056/NEJMoa1105335 4Powers, W. J., Clarke, W. R., Grubb, R. L., Jr. Videen, T. O., Adams, H. P., Jr, & Derdeyn, C. P. (2011). Extracranial-Intracranial Bypass Surgery for Stroke Prevention in Hemodynamic Cerebral Ischemia: The Carotid Occlusion Surgery Study Randomized Trial. JAMA, 306(18), 1983-1992. https://jamanetwork.com/journals/jama/fullarticle/1104607 5Alexander, M. J., Alois Zauner, A., John C. Chaloupka, J. C., Baxter, B., Callison, R. C., Gupta, R., Song, S. S., & Yu, W. (2019). WEAVE Trial: Final Results in 152 On-Label Patients. Stroke, 50(4), 889-894. https://doi.org/10.1161/STROKEAHA.118.023996 6 Amin-Hanjani, S., Du, X., Rose-Finnell, L., Pandey, D. K., Richardson, D., Thulborn, K. R., Elkind, M. S. V., Zipfel, G. J., Liebeskind, D. S., Silver, F. L., Kasner, S. E., Aletich, V. A., Caplan, L. R., Derdeyn, C. P., Gorelick, P. B., & Charbel, F. T. (2015). Hemodynamic Features of Symptomatic Vertebrobasilar Disease. (2015). Stroke, 46(7), 1850-1856. https://doi.org/10.1161/STROKEAHA.115.009215 Figure 1: Circle of Willis [Online image]. (2007). Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Circle_of_Willis_en.svg#filelinks. Published 2021. Accessed September 29, 2021.