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Background: The influence of burden of atherosclerosis in the brain supplying arteries on mortality in patients with acute ischemic stroke or transient ischemic attack is poorly known. We assessed whether total burden of atherosclerosis within cervicocerebral arteries is associated with long-term mortality., Methods and Results: A total of 406 patients (median age, 71.8 years; 57.9% male) with acute ischemic stroke or transient ischemic attack were included and their cervicocerebral arteries imaged with computed tomography angiography. The presence of atherosclerotic findings was scored for 25 artery segments and points were summed as a Cervicocerebral Atherosclerosis Burden (CAB) score, analyzed as quartiles. Data on all-cause mortality came from Statistics Finland. After a median follow-up of 7.3 years, 147 (33.5%) patients had died. Compared with surviving patients, those who died had a higher median CAB score (5, interquartile range 2-10 versus 11, 7-16; P <0.001). Cumulative mortality increased from 8.9% (95% CI, 7.0-10.8) in the lowest to 61.4% (95% CI, 55.4-67.4) in the highest quartile of CAB score. Adjusted for demographics, cardiovascular risk factors, secondary preventive medication, and admission National Institute of Health Stroke Scale score, every CAB score point increased probability of death by 3%. Analyzed in quartiles, the highest CAB quartile was associated with a 2.5-fold likelihood of all-cause mortality., Conclusions: The main findings of our study were the increasing mortality with the total burden of computed tomography angiography-defined atherosclerosis in the brain supplying arteries after ischemic stroke or transient ischemic attack and that the CAB score-integrating this pathology-independently increased all-cause mortality.

Importance: Prior randomized trials have generally shown harm or no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis, but it remains uncertain as to whether refined patient selection and more experienced surgeons might result in improved outcomes., Objective: To compare stenting plus medical therapy vs medical therapy alone in patients with symptomatic severe intracranial atherosclerotic stenosis., Design, Setting, and Participants: Multicenter, open-label, randomized, outcome assessor-blinded trial conducted at 8 centers in China. A total of 380 patients with transient ischemic attack or nondisabling, nonperforator (defined as nonbrainstem or non-basal ganglia end artery) territory ischemic stroke attributed to severe intracranial stenosis (70%-99%) and beyond a duration of 3 weeks from the latest ischemic symptom onset were recruited between March 5, 2014, and November 10, 2016, and followed up for 3 years (final follow-up: November 10, 2019)., Interventions: Medical therapy plus stenting (n = 176) or medical therapy alone (n = 182). Medical therapy included dual-antiplatelet therapy for 90 days (single antiplatelet therapy thereafter) and stroke risk factor control., Main Outcomes and Measures: The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. There were 5 secondary outcomes, including stroke in the qualifying artery territory at 2 years and 3 years as well as mortality at 3 years., Results: Among 380 patients who were randomized, 358 were confirmed eligible (mean age, 56.3 years; 263 male [73.5%]) and 343 (95.8%) completed the trial. For the stenting plus medical therapy group vs medical therapy alone, no significant difference was found for the primary outcome of risk of stroke or death (8.0% [14/176] vs 7.2% [13/181]; difference, 0.4% [95% CI, -5.0% to 5.9%]; hazard ratio, 1.10 [95% CI, 0.52-2.35]; P = .82). Of the 5 prespecified secondary end points, none showed a significant difference including stroke in the qualifying artery territory at 2 years (9.9% [17/171] vs 9.0% [16/178]; difference, 0.7% [95% CI, -5.4% to 6.7%]; hazard ratio, 1.10 [95% CI, 0.56-2.16]; P = .80) and 3 years (11.3% [19/168] vs 11.2% [19/170]; difference, -0.2% [95% CI, -7.0% to 6.5%]; hazard ratio, 1.00 [95% CI, 0.53-1.90]; P > .99). Mortality at 3 years was 4.4% (7/160) in the stenting plus medical therapy group vs 1.3% (2/159) in the medical therapy alone group (difference, 3.2% [95% CI, -0.5% to 6.9%]; hazard ratio, 3.75 [95% CI, 0.77-18.13]; P = .08)., Conclusions and Relevance: Among patients with transient ischemic attack or ischemic stroke due to symptomatic severe intracranial atherosclerotic stenosis, the addition of percutaneous transluminal angioplasty and stenting to medical therapy, compared with medical therapy alone, resulted in no significant difference in the risk of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The findings do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis., Trial Registration: ClinicalTrials.gov Identifier: NCT01763320.

Background: Patients with symptomatic intracranial atherosclerotic disease (sICAD) have an increased risk of stroke and vascular death. The aim of the study was to evaluate the natural history and outcome of patients with sICAD treated medically., Methods: The study population was first-ever transient ischemic attack (TIA) or stroke patients presenting to our institute who on vascular imaging had isolated intracranial atherosclerosis as cause of their symptoms and have a follow-up of 90 days. Unfavorable outcome was defined as occurrence of TIA, stroke, acute coronary event, and/or vascular death., Results: Fifty-three (11.8%) of the 449 ischemic stroke patients had sICAD. The risk of stroke in sICAD was 8.9%, 11.1%, 13.3%, and 15.6% in first 7 days, 30 days, 90 days, and 1 year, respectively. Five (11.1%) had cardiovascular events and accounted for 50% of mortality. The predictors of unfavorable outcome were presented as limb weakness (85.7% versus 58.8%, hazard ratio 1.5; 95% confidence interval [CI], .05-.9; P = .04), National Institutes of Health Stroke Scale (NIHSS) score 8 at admission (50% versus 5.9%, hazard ratio 8.5; 95% CI, .007-.5; P = .02), magnetic resonance imaging (MRI) with multiple diffusion-weighted imaging (DWI) lesions (65.4% versus 26.7%; 95% CI, .04-.7; P = .01), and angiography suggestive of diffuse atherosclerosis (50% versus 11.8%; 95% CI, odds ratio .02-.7; P = .009). On stepwise multiple regression, variables for unfavorable outcome were NIHSS score of 8 or more at admission (P = .001), multiple DWI lesion on MRI (P = .04), and diffuse atherosclerosis on angiography (P = .006)., Conclusion: The patients with sICAD have a high risk of stroke and cardiac events even on aggressive medical treatment. Clinical and imaging features can identify this high-risk group., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: In Caucasian patients with acute stroke or transient ischemic attack (TIA) due to symptomatic intracranial atherosclerotic stenoses (ICAS), only limited data on the recurrent stroke rate and its associated risk factors have been reported. In view of the increasing options for endovascular interventions, we sought to investigate the prevalence, risk for recurrent stroke and mortality in these patients., Methods: A total of 304 consecutive patients with acute ischemic stroke or TIA due to 50-99% ICAS were prospectively documented in 19 German stroke centers. In 201 patients (68.1% of the survivors), a central biannual telephone follow-up could assess recurrent stroke and mortality up to a median of 2 years after the index event., Results: An ischemic cerebrovascular event attributable to symptomatic ICAS was found in 2.24% of the consecutively admitted patients. The overall cumulative recurrent stroke rate after admission was 17.9% (95% CI = 13.4-23.5) for the first year and 23.3% (95% CI = 17.8-29.8) over 3 years. After correction for age and sex, only previous stroke (HR = 2.11, 95% CI = 1.14-3.91) and diabetes (HR = 2.41, 95% CI = 1.33-4.37) were significantly associated with recurrent stroke., Conclusion: Although the prevalence of this etiology seems very low in patients admitted to German stroke centers, we found a high risk of recurrent stroke in patients with symptomatic ICAS. Whether endovascular interventions can reduce this high risk needs to be determined in a randomized trial., (Copyright (c) 2010 S. Karger AG, Basel.)

Background: We aimed to evaluate the prognostic value of myocardial perfusion gated SPECT in patients with symptomatic intracranial large-artery atherosclerosis (ILA)., Methods: Seventy-two consecutive first-ever symptomatic ILA patients without known heart disease underwent a stress myocardial perfusion gated SPECT, and long-term follow-up was conducted thereafter., Results: During an average follow-up of 15.2 +/- 9 months, 9 patients (13.8%) presented major coronary events (CEs). Survival analyses (Kaplan-Meier and Cox regression) identified presence of moderate-to-severe myocardial perfusion defects (log rank p = 0.004) and ejection fraction <50% (p = 0.014) as predictors of future CEs. Neurovascular ischemic events were not predicted by SPECT variables., Conclusion: Myocardial perfusion scintigraphy predicts future CEs in patients with symptomatic ILA and may be helpful to guide therapeutic strategies in this subgroup of stroke patients.

The data of 825 consecutive patients with ischemic stroke or TIA were retrospectively reviewed for ultrasound findings of stenoses or occlusions of the middle cerebral artery (MCA). Using survival statistics,we studied the influence of various factors on the prognosis of MCA findings. We identified 90 subjects with MCA stenosis or occlusion. Microembolic signals were demonstrated in 33% and spontaneous flow variations in 7%. Symptomatic MCA findings normalized more quickly than asymptomatic findings. Microembolic signals occurred only in symptomatic stenoses. Spontaneous flow variations strongly predicted the disappearance of a stenosis. Atherogenic risk factors were associated with stable ultrasound findings. These data suggest that different types of MCA findings exist: (1) dynamic, emboligenic stenoses or occlusions with early normalization and a high risk for ischemic events and (2) static, nonemboligenic stenoses with rare normalization and a low risk of ischemic events. A high percentage of the former may be of embolic origin, and the latter may be atherosclerotic plaques.

Between the years 1964 and 1973, 225 patients with transient ischemic attacks (TIAs) due primarily to atherosclerosis were evaluated and treated. They have now been followed for from 3 to 14 years (average 5.5 years). As of 1976, 82 of the 225 patients were dead, 21 from cerebral infarction, 52 from heart disease and nine from other causes. Of the 56 untreated patients, 11 (19 percent) had cerebral infarctions, four (7 percent) of which were fatal; six (11 percent) were still having TIAs. Of the 45 patients medically treated, 10 (24 percent) had cerebral infarctions, three (7 percent) of which were fatal; 11(25 percent) still experienced TIAs. In the surgical group of 124, 27 (21 percent) had postoperative cerebral infarctions, seven (6 percent) of which were fatal; 23 (18 percent) had cerebral infarctions during follow-up, of which seven (6 percent) were fatal; and 15 (12 percent) were still having TIAs. No statistically significant differences (p less than 0.05) related to cerebral infarction or TIAs developed among the three groups. The majority (23 percent) eventually succumbed to myocardial infarction, leading us to conclude that great emphasis must be placed upon TIAs as a warning for cardiac as well as cerebrovascular disease.

A randomised controlled trial of endarterectomy in patients with carotid artery disease showed that operation significantly reduced the frequency of transient ischaemic attacks (TIA) in the relevant vascular territory. Because of the high post-operative morbidity in the surgical group, the trial was abandoned before conclusions could be drawn as to the influence of endarterectomy on long-term survival or on the incidence of subsequent strokes.