Access the full text.
Sign up today, get DeepDyve free for 14 days.
Ya-bing Wang, Tao Wang, A. Dmytriw, Kun Yang, L. Jiao, Huaizhang Shi, Jie Lu, Tianxiao Li, Yujie Huang, Zhenwei Zhao, Wei Wu, J. Wan, Qin-jian Sun, B. Hong, Yongli Li, Li-yong Zhang, J. Chu, Qiong Cheng, Yiling Cai, Pengfei Wang, Q. Luo, Hua Yang, Baijing Dong, Yang-pei Zhang, Jun Zhao, Zuoquan Chen, Wei Li, Xiaoxin Bai, Weiwen He, Xueli Cai, Maimai Ti, O. Zaidat (2021)Safety of endovascular therapy for symptomatic intracranial artery stenosis: a national prospective registry
Stroke and Vascular Neurology, 7
Jichang Luo, Tao Wang, P. Gao, T. Krings, L. Jiao (2018)Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects
Frontiers in Neurology, 9
R. Agha, M. Borrelli, M. Vella-Baldacchino, R. Thavayogan, D. Orgill (2017)A protocol for the development of the STROCSS guideline: Strengthening the Reporting of Cohort Studies in Surgery
International Journal of Surgery Protocols, 5
D. Fiorella, C. Derdeyn, M. Lynn, S. Barnwell, B. Hoh, E. Levy, M. Harrigan, P. Richard, Klucznik, C. McDougall, G. Pride, O. Zaidat, H. Lutsep, M. Waters, J. Hourihane, A. Alexandrov, D. Chiu, Joni Clark, Mark Johnson, M. Torbey, Z. Rumboldt, H. Cloft, T. Turan, Bethany Lane, L. Janis, M. Chimowitz (2012)Detailed Analysis of Periprocedural Strokes in Patients Undergoing Intracranial Stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)
A. Abou‐Chebl, H. Steinmetz (2012)Critique of "Stenting versus aggressive medical therapy for intracranial arterial stenosis" by Chimowitz et al in the new England Journal of Medicine.
Stroke, 43 2
M. Beausang-Linder, A. Bill (1981)Cerebral circulation in acute arterial hypertension--protective effects of sympathetic nervous activity.
Acta physiologica Scandinavica, 111 2
M. Chow, T. Masaryk, H. Woo, M. Mayberg, P. Rasmussen (2005)Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: midterm analysis of clinical and radiologic predictors of neurological morbidity and mortality.
AJNR. American journal of neuroradiology, 26 4
Jin Yu, Ming-Li Li, Yu-yuan Xu, Shi-wen Wu, M. Lou, Xuetao Mu, F. Feng, Shan Gao, Weihai Xu (2017)Plaque distribution of low-grade basilar artery atherosclerosis and its clinical relevance
BMC Neurology, 17
Biao Huang, Wanqun Yang, Xintong Liu, Hong-jun Liu, Pei-jun Li, Hai-ke Lu (2013)Basilar artery atherosclerotic plaques distribution in symptomatic patients: a 3.0T high-resolution MRI study.
European journal of radiology, 82 4
W. Bai, B. Gao, Tian-Xiao Li, Zi-liang Wang, D. Cai, Liang-fu Zhu, Jiang-yu Xue, Zhao-shuo Li (2016)Wingspan stenting can effectively prevent long-term strokes for patients with severe symptomatic atherosclerotic basilar stenosis
Interventional Neuroradiology, 22
B. Kim, Kyung Lee, Hyun Kim, Young Kim, S. Koh, S. Heo, D. Chang (2018)Basilar Artery Plaque and Pontine Infarction Location and Vascular Geometry
Journal of Stroke, 20
C. Derdeyn, M. Chimowitz, M. Lynn, D. Fiorella, T. Turan, L. Janis, Jean Montgomery, A. Nizam, Bethany Lane, H. Lutsep, S. Barnwell, M. Waters, B. Hoh, J. Hourihane, E. Levy, A. Alexandrov, M. Harrigan, D. Chiu, R. Klucznik, Joni Clark, C. McDougall, Mark Johnson, G. Pride, J. Lynch, O. Zaidat, Z. Rumboldt, H. Cloft (2014)Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial
The Lancet, 383
(1998)Prognosis of patients with symptomatic vertebral or basilar artery stenosis. The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study Group.
Stroke, 29 7
R. Agha, Ali Abdall-Razak, E. Crossley, Naeem Dowlut, Christos Iosifidis, Ginimol Mathew, Beamishaj, M. Bashashati, F. Millham, D. Orgill, A. Noureldin, I. Nixon, A. Alsawadi, P. Bradley, S. Giordano, D. Laskin, S. Basu, M. Johnston, O. Muensterer, I. Mukherjee, J. Ngu, M. Valmasoni, D. Pagano, Baskaran Vasudevan, R. Rosin, J. McCaul, Jörg Albrecht, J. Hoffman, M. Thorat, S. Massarut, A. Thoma, B. Kirshtein, R. Afifi, N. Farooq, B. Challacombe, P. Pai, B. Perakath, H. Kadioglu, J. Aronson, K. Raveendran, D. Machado-Aranda, Roberto Klappenbach, D. Healy, D. Miguel, C. Leles, M. Ather (2019)STROCSS 2019 Guideline: Strengthening the Reporting of Cohort Studies in Surgery.
International journal of surgery
An updated definition of
Máximo Torche, A. Mahmood, R. Araújo, M. Dujovny, Ljubsia Dragovic, J. Ausman (1992)Microsurgical anatomy of the lower basilar artery.
Neurological research, 14 3
Sean Savitz, Heinrich Mattle (2012)Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis
Yearbook of Critical Care Medicine, 2012
Fei Li, Q. Chen, Zhibiao Chen, Daofeng Tian, Q. Cai (2016)Magnetic Resonance Imaging of Plaque Burden in Vascular Walls of the Middle Cerebral Artery Correlates with Cerebral Infarction.
Current neurovascular research, 13 4
Yuncai Ran, Yuting Wang, Ming Zhu, Xiao Wu, A. Malhotra, Xiaowen Lei, Feifei Zhang, Xiao Wang, S. Xie, Jian Zhou, Jinxia Zhu, Jingliang Cheng, Chengcheng Zhu (2019)Higher Plaque Burden of Middle Cerebral Artery Is Associated With Recurrent Ischemic Stroke
B. Kim, Hyun Kim, Wonho Jho, Young Kim, S. Koh, S. Heo, D. Chang, Young-Jun Lee (2019)Asymptomatic Basilar Artery Plaque Distribution and Vascular Geometry
Journal of Atherosclerosis and Thrombosis, 26
Ye Cao, Yi Sun, Bin Zhou, Huilin Zhao, Ying Zhu, Jianrong Xu, Xiaosheng Liu (2017)Atherosclerotic plaque burden of middle cerebral artery and extracranial carotid artery characterized by MRI in patients with acute ischemic stroke in China: association and clinical relevance
Neurological Research, 39
Weihai Xu, Ming-Li Li, Shan Gao, J. Ni, Li-xin Zhou, M. Yao, B. Peng, F. Feng, Zheng-yu Jin, L. Cui (2011)Plaque Distribution of Stenotic Middle Cerebral Artery and Its Clinical Relevance
F. Li, QX. Chen, ZB. Chen (2016)Magnetic resonance imaging of plaque burden in vascular walls of the middle cerebral artery correlates with cerebral infarction
Curr Neurovasc Res, 13
N. Saeki, A. Rhoton (1977)Microsurgical anatomy of the upper basilar artery and the posterior circle of Willis.
Journal of neurosurgery, 46 5
Shasha Deng, Jinmei Zheng, Yuxin Wu, Dandan Yang, Huajun Chen, Bin Sun, Yunjing Xue, Xihai Zhao (2021)Geometrical characteristics associated with atherosclerotic disease in the basilar artery: a magnetic resonance vessel wall imaging study.
Quantitative imaging in medicine and surgery, 11 6
N. Ma, W. Jiang, X. Lou, L. Ma, B. Du, Jiong Cai, T. Zhao (2010)Arterial remodeling of advanced basilar atherosclerosis
Sung-hwan Lim, Hojin Choi, H. Kim, Juhan Kim, S. Heo, D. Chang, J. Lee, Young-Jun Lee, Ji Kim, Hyun Kim, Young Kim (2015)Basilar plaque on high-resolution MRI predicts progressive motor deficits after pontine infarction.
Atherosclerosis, 240 1
(2013)for the 21 st century : a statement for healthcare professionals from the American Heart Association / American Stroke Association
H. Nordmeyer, R. Chapot, Ayhan Aycil, C. Stracke, M. Wallocha, M. Hadisurya, M. Heddier, P. Haage, R. Weber (2018)Angioplasty and Stenting of Intracranial Arterial Stenosis in Perforator-Bearing Segments: A Comparison Between the Anterior and the Posterior Circulation
Frontiers in Neurology, 9
D. Mandell, M. Mossa-Basha, Y. Qiao, C. Hess, F. Hui, C. Matouk, M. Johnson, M. Daemen, A. Vossough, M. Edjlali, D. Saloner, S. Ansari, B. Wasserman, D. Mikulis (2017)Intracranial Vessel Wall MRI: Principles and Expert Consensus Recommendations of the American Society of Neuroradiology
American Journal of Neuroradiology, 38
P. Buijs, M. Krabbe-Hartkamp, C Bakker, E Lange, L Ramos, M. Breteler, W Mali (1998)Effect of age on cerebral blood flow: measurement with ungated two-dimensional phase-contrast MR angiography in 250 adults.
Radiology, 209 3
Y. Nishijima (1994)[Anatomical analysis of the basilar artery and its branches with special reference to the arterial anastomosis, and its course and distribution on the pontine ventral surface].
Nihon Ika Daigaku zasshi, 61 6
(2013)An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association
Mengnan Wang, Fang Wu, Yujiao Yang, Huijuan Miao, Z. Fan, X. Ji, Debiao Li, Xiuhai Guo, Qi Yang (2018)Quantitative assessment of symptomatic intracranial atherosclerosis and lenticulostriate arteries in recent stroke patients using whole-brain high-resolution cardiovascular magnetic resonance imaging
Journal of Cardiovascular Magnetic Resonance, 20
Jichang Luo, Long Li, Tao Wang, Kun Yang, Yao Feng, R. Yang, Yan Ma, P. Gao, Bin Yang, L. Jiao (2021)Risk Factors of New Cerebral Infarctions After Endovascular Treatment for Basilar Artery Stenosis Based on High-Resolution Magnetic Resonance Imaging
Frontiers in Neurology, 11
Zhensen Chen, Ao-fei Liu, Huijun Chen, C. Yuan, Le He, Yandong Zhu, M. Guan, Wei-jian Jiang, Xihai Zhao (2016)Evaluation of basilar artery atherosclerotic plaque distribution by 3D MR vessel wall imaging
Journal of Magnetic Resonance Imaging, 44
W. Roth, S. Morgello, J. Goldman, J. Mohr, Mitchell Elkind, R. Marshall, J. Gutierrez (2017)Histopathological Differences Between the Anterior and Posterior Brain Arteries as a Function of Aging
Baixue Jia, D. Liebeskind, N. Ma, F. Gao, D. Mo, G. Luo, Xiaobing Li, Xiaojie Sui, G. Peng, Z. Miao (2016)Factors associated with perforator stroke after selective basilar artery angioplasty or stenting
Journal of NeuroInterventional Surgery, 9
Beibei Sun, Lingling Wang, Xiao Li, Jin Zhang, Jianjian Zhang, Xiaosheng Liu, Hengqu Wu, M. Mossa-Basha, Jianrong Xu, Bing Zhao, Huilin Zhao, Yan Zhou, Chengcheng Zhu (2021)Intracranial Atherosclerotic Plaque Characteristics and Burden Associated With Recurrent Acute Stroke: A 3D Quantitative Vessel Wall MRI Study
Frontiers in Aging Neuroscience, 13
E. Almallouhi, S. kasab, Lidia Yamada, Renee' Martin, T. Turan, M. Chimowitz (2020)Relationship Between Vascular Risk Factors and Location of Intracranial Atherosclerosis in the SAMMPRIS Trial.
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
O. Samuels, G. Joseph, M. Lynn, Harriet Smith, M. Chimowitz (2000)A standardized method for measuring intracranial arterial stenosis.
AJNR. American journal of neuroradiology, 21 4
K. Gröschel, S. Schnaudigel, S. Pilgram, K. Wasser, A. Kastrup (2009)A systematic review on outcome after stenting for intracranial atherosclerosis.
Stroke, 40 5
C. Ryu, H. Kwak, G. Jahng, H. Lee (2014)High-Resolution MRI of Intracranial Atherosclerotic Disease
S. Marinković, H. Gibo (1993)The Surgical Anatomy of the Perforating Branches of the Basilar Artery
R. Guo, Xue-Bin Zhang, Xianjin Zhu, Zunjin Liu, S. Xie (2018)Morphologic characteristics of severe basilar artery atherosclerotic stenosis on 3D high-resolution MRI
BMC Neurology, 18
Clinical Relevance of Plaque Distribution for Basilar Artery Stenosis J. Luo, X. Bai, K. Huang, T. Wang, R. Yang, L. Li, Q. Tian, R. Xu, T. Li, Y. Wang, Y. Chen, P. Gao, J. Chen, B. Yang, Y. Ma and L. Jiao AJNR Am J Neuroradiol 2023, 44 (5) 530-535 This information is current as doi: https://doi.org/10.3174/ajnr.A7839 of June 3, 2023. http://www.ajnr.org/content/44/5/530 ORIGINAL RESEARCH ADULT BRAIN Clinical Relevance of Plaque Distribution for Basilar Artery Stenosis J. Luo, X. Bai, K. Huang, T. Wang, R. Yang, L. Li, Q. Tian, R. Xu, T. Li, Y. Wang, Y. Chen, P. Gao, J. Chen, B. Yang, Y. Ma, and L. Jiao ABSTRACT BACKGROUND AND PURPOSE: There is no clear association between plaque distribution and postoperative complications in patients with basilar artery atherosclerotic stenosis. The aim of this study was to determine whether plaque distribution and post- operative complications after endovascular treatment for basilar artery stenosis are related. MATERIALS AND METHODS: Our study enrolled patients with severe basilar artery stenosis who were scanned with high-resolution MR imaging and followed by DSA before the intervention. According to high-resolution MR imaging, plaques can be classiﬁed as ven- tral, lateral, dorsal, or involved in 2 quadrants. Plaques affecting the proximal, distal, or junctional segments of the basilar artery were classiﬁed according to DSA. An experienced independent team assessed ischemic events after the intervention using MR imaging. Further analysis was conducted to determine the relationship between plaque distribution and postoperative complications. RESULTS: A total of 140 eligible patients were included in the study, with a postoperative complication rate of 11.4%. These patients were an average age of 61.9 (SD, 7.7) years. Dorsal wall plaques accounted for 34.3% of all plaques, and plaques distal to the ante- rior-inferior cerebellar artery accounted for 60.7%. Postoperative complications of endovascular treatment were associated with plaques located at the lateral wall (OR ¼ 4.00; 95% CI, 1.21–13.23; P ¼ .023), junctional segment (OR ¼ 8.75; 95% CI, 1.16–66.22; P ¼ .036), and plaque burden (OR ¼ 1.03; 95% CI, 1.01–1.06; P ¼ .042). CONCLUSIONS: Plaques with a large burden located at the junctional segment and lateral wall of the basilar artery may increase the likelihood of postoperative complications following endovascular therapy. A larger sample size is needed for future studies. ABBREVIATIONS: HR-MR imaging ¼ high-resolution MR imaging; LA ¼ lumen area; MLN ¼ maximal lumen narrowing; VA ¼ vessel area; WA ¼ wall area he basilar artery is the main artery for the posterior intracra- Patients with symptomatic and severe basilar artery stenosis Tnial circulation, where atherosclerotic stenosis is frequently ($70%) may benefit from endovascular treatment, including discovered in patients with ischemic events, such as stroke and primary angiography, balloon-mounted stent placement, and 1 2 TIA, which are responsible for 10.7% of strokes annually. self-expanding stent placement. Compared with the those in the anterior circulation, postoperative complications are higher in the posterior circulation with a reported risk of 21.6% in the Received November 20, 2022; accepted after revision March 1, 2023. 3,4 basilar artery. Therefore, it is crucial to understand and pre- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China; Department of Neurosurgery vent a high risk of complications occurring during endovascular (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Xuanwu treatment in patients with basilar artery stenosis. Hospital, Beijing Key Laboratory of Clinical Epidemiology (Q.T.), School of Public Health, and Department of Interventional Radiology (P.G., L.J.), Xuanwu Hospital, The distribution of atherosclerotic plaques is associated with Capital Medical University, Beijing, China; and The Eighth Afﬁliated Hospital (K.H.), 5-7 the risk of ischemic events. For example, it is more likely that SUN YAT-SEN University, Shenzhen, Guangdong Province, China. atherosclerotic plaques located near perforating orifices are symp- This study was funded by the National Key Research and Development Program of China (2016YFC1301703), Beijing Science and Technology Planning Project tomatic during stent placement and may have a “snow plowing” (Z201100005520019), and Beijing Hospitals Authority's Ascent Plan (DFL20220702). effect. Several postmortem studies have demonstrated that basilar Please address correspondence to Liqun Jiao, MD, PhD, Departments of artery perforators typically originate from the lateral and dorsal Neurosurgery and Interventional Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St, Xicheng District, 100053, Beijing, China; walls of the segment, distal from the anterior-inferior cerebellar e-mail: email@example.com artery, possibly explaining the high rate of postoperative compli- Indicates open access to non-subscribers at www.ajnr.org 9,10 cations. However, the relationship between the distribution of basilar artery plaque and postoperative complications has not yet Indicates article with online supplemental data. http://dx.doi.org/10.3174/ajnr.A7839 been reported . 530 Luo May 2023 www.ajnr.org weakness; 3) treatment using endovascular therapy; 4) HR-MR imaging performed before the intervention; and 5) MR imaging performed before and within 72 hours after the intervention. The exclusion criteria were as follows: 1) stroke caused by occlu- sion of the basilar artery, 2) concurrent endovascular treatment of another intracranial or extracranial vessel, 3) basilar artery ste- nosis accompanied by moderate-to-severe vertebral artery stenosis, and 4) nonatherosclerotic causes (eg, Moyamoya disease, vasculitis, or dissection). Imaging Protocols and Evaluation FIG 1. A, The basilar artery is divided into 4 quadrants at the axial Before the intervention, all eligible patients were examined position based on high-resolution MR imaging. B, The basilar artery is using a 3T MR imaging scanner (Magnetom Spectra; Siemens) divided into 2 segments referring to the AICA on the basis of DSA, equipped with a standard 8-channel head coil. The scans were the proximal and distal segments. The junctional segment is deﬁned when the plaque involves both segments across the anterior-inferior obtained using multiple sequences, including fast spin-echo T1- cerebellar artery. weighted imaging, TOF-MR angiography, and T1-weighted enhanced imaging. The parameters of the sequences are Understanding the distribution of basilar artery plaques can described in the Online Supplemental Data. HR-MR imaging help in reducing the incidence of postoperative complications. was acquired in the sagittal plane covering the basilar artery ves- Evidence from studies since the Stenting versus Aggressive Medical sel. Reconstruction of the axial, coronal, and sagittal views was Management for Preventing Recurrent Stroke in Intracranial required to analyze all the images. DSA examinations were also Stenosis (SAMMPRIS) trial has shown that the postoperative risk of performed for all the eligible patients. endovascular treatment for intracranial stenosis can be reduced An image core lab (http://imagecorelabcn.com/)was used to from 14.7% to 9.4% by excluding symptomatic patients with perfo- review all the images. The clinical data of patients were undisclosed rating infarction. The postoperative risk could be reduced exclud- and not included in the statistical analyses. Before the formal ing perforating infarction actually infers the plaque location, assessment, 5% of data from the analyzed cohort was used to train whether it is near perforating orifices, according to the phenotype of raters. Whenever the agreement was excellent (reliability, .0.75) cerebral infarction. Presently, plaque distribution in axial and coro- between 2 raters, the imaging data were formally evaluated. The nal positions can be precisely evaluated using high-resolution MR maximal lumen narrowing (MLN) or reference site, lumen diame- 12,13 imaging (HR-MR imaging) and DSA. However, very few stud- ter, vessel area (VA), and lumen area (LA) at the MLN or reference ies have explored the direct relationship between plaque distribution site were manually evaluated. Reference sites were defined accord- and postoperative complications after endovascular treatment from ing to Warfarin versus Aspirin for Symptomatic Intracranial the axial and coronal positions for basilar artery stenosis. The cur- Disease (WASID) trial as normal segments proximal to the steno- rent study investigated the distribution of basilar artery atheroscler- sis or distal vessels if the proximal segment was diseased. otic plaques and their clinical relevance using HR-MR imaging and On the basis of HR-MR imaging and DSA, we observed the DSA. Our findings can help neurointerventionalists with better following vessel parameters: patient selection and, thus, lower the procedural risk. � Wall area (WA): difference between VA and LA (VA – LA). � Plaque burden: [(WA – WA )/ VA ] 100%. MLN reference MLN MATERIALS AND METHODS � Remodeling index: VA MLN/VA reference. Subjects This study was based on the Clinical Registration Trial of Intracranial Stenosis degree is (1-Luminal Diameter at MLN/Luminal Stenting for Patients with Symptomatic Intracranial Artery Stenosis Diameter at the Reference Site) 100% from DSA. (CRTICAS) data base (ClinicalTrials.gov identifier: NCT01994161). Using 2 perpendicular lines, we divided the cross-sectional pla- The protocol complies with ethics principles of the Declaration of que into 4 quadrants at the MLN: ventral, dorsal, left, and right. Helsinki and good clinical practice and has been approved by the The left and right sites were classified as lateral sites. If the plaque the review board and ethic committee of Xuanwu Hospital, Capital was large and its thickest aspect spanned more than 2 quadrants, it Medical University ( 004). Written informed consent was was considered distributed between .2quadrants (Fig 1A). In the obtained from all the patients. The results of this study have been coronal position, DSA was used to divide the basilar artery into 2 reported in accordance with the Strengthening The Reporting Of segments on the basis of the branches of the anterior-inferior cere- 15 18 Cohort Studies in Surgery (STROCSS) criteria. bellar artery. Lesions crossing the anterior-inferior cerebellar ar- The study included patients with basilar artery stenosis who tery were categorized as junctional segment lesions (Fig 1B). were enrolled between December 2013 and December 2015 in several high-volume tertiary centers in China. The inclusion cri- Interventional Procedure and Assessment of Outcome teria were as follows: 1) degree of stenosis of .70% as confirmed All patients were treated by a team of neurosurgeons and neuro- by DSA; 2) patients with basilar artery atherosclerotic stenosis radiologists with extensive experience in endovascular treatment. who experienced ischemic symptoms, such as dizziness, vertigo, Experienced operators determined the therapeutic strategy headache, double vision, slurred speech, and numbness or according to the lesion characteristics. Aspirin, 100 mg daily, was AJNR Am J Neuroradiol 44:530–35 May 2023 www.ajnr.org 531 Table 1: Clinical and lesion characteristics Variables All Patients (n = 140) Ischemic Events (n = 16) Nonischemic Events (n = 124) P Value Sex, male 106 (75.7%) 12 (75.0%) 87 (70.2%) .914 Age (mean) (yr) 61.9 (SD, 7.7) 62.5 (SD, 6.6) 61.8 (SD, 7.9) .728 BMI (mean) (kg/m ) 26.2 (SD, 3.0) 25.8 (SD, 2.2) 26.3 (SD, 3.1) .522 Qualifying event .419 TIA 23 (16.4%) 1 (6.3%) 22 (17.7%) Stroke 117 (83.6%) 15 (93.7%) 102 (82.3%) Hypertension 117 (83.6%) 14 (87.5%) 103 (83.1%) .927 Diabetes mellitus 58 (41.4%) 7 (43.8%) 51 (41.1%) .841 Hyperlipidemia 36 (25.7%) 4 (25.0%) 32 (25.8%) 1.000 CAD 14 (10.0%) 2 (12.5%) 12 (9.7%) 1.000 Smoking history 58 (41.4%) 6 (37.5%) 52 (41.9%) .735 Drinking history 38 (27.1%) 3 (18.8%) 35 (28.2%) .615 Preoperative mRS .218 ,2 125 (89.3%) 16 (100%) 109 (87.9%) $2 15 (10.7%) 0 15 (12.1%) Stenosis degree (mean) (%) 77.7 (SD, 9.3) 76.2 (SD, 14.2) 77.9 (SD, 9.2) .826 Plaque length (mean) (mm) 5.9 (SD, 3.8) 4.9 (SD, 3.2) 5.9 (SD, 3.9) .212 Plaque burden (mean) (%) 5.5 (SD, 23.6) 19.3 (SD, 18.3) 3.7 (SD, 23.6) .047 Remodeling index (mean) 0.8 (SD, 0.4) 0.9 (SD, 0.4) 0.8 (SD, 0.4) .430 Treatment type .323 PA 26 (18.6%) 5 (31.3%) 21 (16.9%) BMS 30 (21.4%) 2 (12.5%) 28 (22.6%) SES 84 (60.0%) 9 (56.2%) 75 (60.5%) Note:—BMI indicates body mass index; CAD, coronary artery disease; PA, primary angioplasty; BMS, balloon-mounted stent; SES, self-expansion stent. combined with clopidogrel, 75 mg daily for 5 days before, or a The average age of these patients was 61.9 (SD, 7.7) years. loading dose of aspirin and clopidogrel, 300 mg each, was used 1 Twenty-six (18.5%) patients underwent primary angioplasty, and 114 (81.5%) underwent stent placement, which included 30 bal- day before endovascular treatment. Standard protocols for the loon-mounted stents and 84 self-expansion stents. Furthermore, procedure were followed as described previously. Three-month 16 patients with postoperative ischemic events, including 3 TIAs, dual-antiplatelet therapy, comprising aspirin, 100 mg daily, and 4 perforating infarctions, 7 artery-to-artery embolisms, and 2 clopidogrel, 75 mg daily, was initiated following the intervention. mixed mechanisms were regarded as the ischemic events group, An experienced team of neurosurgeons and neuroradiologists and 124 patients without postoperative ischemic events, as the investigated the postoperative ischemic events, including TIA nonischemic events group (Online Supplemental Data). Table 1 and ischemic stroke. Ischemic stroke was defined as a neurologic summarizes the clinical and lesion characteristics, with the excep- deficit lasting .24 hours. TIA was defined as a neurologic deficit tion of plaque burden (mean, 19.3% [SD, 18.3%] versus 3.7% [SD, lasting ,24 hours. Depending on whether postoperative out- 23.6%]; P ¼ .047) between the ischemic events group and the non- come events occurred after endovascular treatment, patients were ischemic events group. classified into an either ischemic or nonischemic events group. A total of 140 basilar artery plaques were reviewed from the axial and coronal positions. In the axial view at the MLN site, Statistical Analysis 12.9% of plaques were distributed ventral to the basilar artery Data were analyzed using the SAS software (Version 9.4; SAS wall, and 22.1% in the lateral, 34.3% in the dorsal, and 30.7% in Institute). Quantitative variables are presented as means. Qualitative $2 quadrants. The plaques distributed in the lateral wall were variables are presented as numbers and percentages. Descriptive more common in the ischemic events group than in the nonis- analyses were performed for participants in the postoperative ische- chemic events group (43.8% versus 19.3%, P ¼ .049). In the coro- mic and nonischemic events group. The x test or Fisher exact test nal view, plaque distribution was most common at the segment was used to compare the categoric variables, as appropriate. The distal to the anterior-inferior cerebellar artery (60.7%), followed Student t test or Wilcoxon test was used to compare the quantitative by the segment proximal to the anterior-inferior cerebellar artery variables. Univariate and multivariate regression analyses were per- (35.0%), and least in the junctional segment (4.3%). Plaques dis- formed to investigate the factors influencing the postoperative ische- tributed at the junctional segment in the ischemic events group mic events. Variables with P, .1, along with sex, age, and treatment were more frequent compared with the nonischemic events type, were included in the multivariate regression analysis. P, .05 group (18.8% versus 2.4%, P ¼ .020). The additional details of was considered as statistically significant. plaque distribution are presented in Table 2. The risk of ischemic events was the highest in patients with plaques located at the lat- RESULTS eral wall (22.5%) and junctional segment (50.0%) of the basilar In total, 281 consecutive patients with severe symptomatic basilar artery (Online Supplemental Data). Additionally, the high risk of artery stenosis underwent endovascular treatment. Among them, ischemic events in patients with plaques located at the junctional 140 patients having complete HR-MR imaging and DSA data segment of the basilar artery was associated with a large remodel- were finally included in the analysis (Online Supplemental Data). ing index compared with that in the nonischemic events group 532 Luo May 2023 www.ajnr.org Table 2: Plaque distribution of the basilar artery explain the high risk associated with All Patients Ischemic Events Nonischemic Events endovascular treatment. Previous stud- Plaque Distribution (n = 140) (n = 16) (n = 124) P Value ies have suggested that SAMMPRIS, Axial position strict patient selection, technical devel- Ventral 18 (12.9%) 2 (12.5%) 16 (12.9%) 1.000 opment, and incremental experience of Lateral 31 (22.1%) 7 (43.8%) 24 (19.3%) .049 the operators reduces the risk of post- Dorsal 48 (34.3%) 3 (18.7%) 45 (36.3%) .262 operative complications for endovascu- $2 quadrants 43 (30.7%) 4 (25.0%) 39 (31.5%) .776 Coronal position lar treatment. Our study showed a Proximal segment 49 (35.0%) 6 (37.5%) 43 (34.7%) 1.000 relatively lower risk compared with Distal segment 85 (60.7%) 7 (43.8%) 78 (62.9%) .176 SAMMPRIS (21.6%) and is comparable Junctional segment 6 (4.3%) 3 (18.8%) 3 (2.4%) .020 27,28 with several studies (11.2%–14.2%). However, the prevention of postopera- tive complications is necessary to maxi- Table 3: Relationship between plaque distribution and ischemic mize the benefits of endovascular treatment. events by multivariate analysis It is highly likely that postoperative complications can be OR (95% CI) P Value reduced by assessing the plaque distribution and features. Plaque Age 1.00 (0.92–1.08) .997 distribution has been abundantly indicated to be a significant indi- Treatment type 0.99 (0.50–1.99) .994 cator of postoperative complications, thus revealing that postoper- Plaque burden 1.03 (1.01–1.06) .042 ative complications of intracranial atherosclerotic plaques located Plaque distribution in the posterior circulation were higher than those in the anterior Lateral 4.00 (1.21–13.23) .023 29-31 Junctional segment 8.75 (1.16–66.22) .036 circulation (12.1% versus 6.6, P, .01). However, the associa- tion of local distribution of basilar artery atherosclerotic plaques with postoperative complications is unclear. Several researchers (mean, 1.38 [SD, 0.20] versus 0.82 [SD, 0.29]; 95% CI, 0.05–1.13; have hypothesized that plaques near the perforating orifices might P ¼ .049) (Online Supplemental Data). be a determinant of postoperative complications through narrative The multivariate logistic regression analysis showed that pla- 6,18,32,33 analysis in plaque microanatomy studies. ques distributed at the lateral wall (OR ¼ 4.00; 95% CI, 1.21– In this study, plaques present in the lateral wall were associated 13.23; P ¼ .023) and junctional segments (OR ¼ 8.75; 95% CI, with a higher risk of postoperative complications. Penetrating 1.16–66.22; P ¼ .036) aswell asplaque burden (OR ¼ 1.03; 95% arteries from the lateral and dorsal sides of the basilar artery have CI, 1.01–1.06; P ¼ .042) were associated with a higher risk of been observed in previous studies. According to the anatomic postoperative ischemic events (Table 3, Fig 2). studies, 65.3% of penetrating arteries originate from the lateral side of the basilar artery, whereas 34.7% originate from the dorsal DISCUSSION side. Additionally, the anastomosis rate of penetrating arteries In this study, symptomatic patients with severe basilar artery ste- emerging from the basilar artery is high (range, 41.6%–66.6%). nosis were enrolled to investigate the correlation of atherosclerotic From an axial perspective, the anastomosis rate of penetrations plaque distribution with postoperative complications. The risk of emerging from the dorsal side was higher than that on the lateral postoperative ischemic events in patients with severe symptomatic side. Moreover, 99% of the anastomoses of penetrating arteries basilar artery stenosis was 11.4% (16/140). Although plaque distri- from thedorsal sideof basilar artery arelocated on theventral sur- bution of the basilar artery was most commonly observed at the face of the pontocerebrum surface, 57.5% of the anastomoses occur dorsal wall of the basilar artery in the axial (34.3%) and distal seg- between the penetrating arteries of the pontocerebrum, and 21.3%, ments in the coronal view (60.7%), the risk of postoperative com- between penetrations originating from the basilar artery and ante- plications was highest when the plaques were situated in the rior-inferior cerebellar artery. As a result, plaques involving the lateral wall and junctional segment of the basilar artery. In addi- lateral side of the basilar artery may be a risk factor for endovascu- tion to the large plaque burden, plaques located at the lateral wall lar treatment for patients with severe basilar artery stenosis. and junctional segment of the basilar artery were independent risk In addition, a large plaque burden is associated with postopera- factors for postoperative ischemic events. tive complications, which may be due to a large plaque burden The high risk of postoperative complications is a substantial being more vulnerable during the expansion process of the balloon limitation for endovascular treatment of intracranial atheroscler- or stent. Furthermore, a large plaque burden has a high risk of 4,20 otic stenosis, especially in the posterior circulation. The basilar initial and recurrent ischemic symptoms in patients with intracra- 38-40 artery is the main artery for the posterior circulation, which has nial stenosis. Thus, anevaluationof bothplaque burden and the highest risk of postoperative complications for endovascular distribution characteristics may be helpful in excluding high-risk treatment among the intracranial arteries. The posterior circula- patients from endovascular treatment of basilar artery stenosis. tion appears to be more capable of plaque burden because it has a This study has some limitations. First, although the study cohort lower blood flow and less sympathetic innervation compared had a larger sample size compared with other HR-MR imaging 21-24 with the anterior circulation. Additionally, the number of studies, the incidence of postoperative complications was low, com- 17, 41 perforating arteries in the basilar artery is significantly higher prising only 16 cases. Therefore, the impact of plaque location than that of the other intracranial arteries. These reasons on different stroke mechanisms (eg, artery-to-artery and perforating AJNR Am J Neuroradiol 44:530–35 May 2023 www.ajnr.org 533 Disclosure forms provided by the authors are available with the full text and PDF of this article at www.ajnr.org. REFERENCES 1. Prognosis of patients with symptomatic vertebral or basilar artery stenosis: the Warfarin-Aspirin Symptomatic Intra- cranial Disease (WASID) Study Group. Stroke 1998;29:1389–92 CrossRef Medline 2. Chow MM, Masaryk TJ, Woo HH, et al. Stent-assisted angioplasty of intra- cranial vertebrobasilar atherosclero- sis: midterm analysis of clinical and radiologic predictors of neurological morbidity and mortality. AJNR Am J Neuroradiol 2005;26:869–74 Medline 3. Fiorella D, Derdeyn CP, Lynn MJ; et al. SAMMPRIS Trial Investigators. Detailed analysis of periprocedural strokes in patients undergoing intracranial stent- ing in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS). Stroke 2012;43:2682–88 CrossRef Medline FIG 2. An adult patient presented with recurrent stroke for 1 month. A, Preoperative DSA 4. Almallouhi E, Al Kasab S, Yamada L, et revealed 79.3% stenosis at the distal segment of the basilar artery. The middle column shows al. Relationship between vascular risk cross-sectional T1-weighted basilar artery images at the MLN (B) and reference (REF) (E) sites. The factors and location of intracranial ath- 2 2 2 VA and LA at the MLN (B,VA ¼ 0.157 cm ,LA ¼ 0.014 cm )and REF (E,VA ¼ 0.237 cm ,LA ¼ erosclerosis in the SAMMPRIS Trial. J 0.075 cm ) sites were manually traced for measuring after zooming in 400. The plaque burden Stroke Cerebrovasc Dis 2020;29:104713 was calculated as 16.6% using [(WA -WA )/ VA ] 100%. D, A 2.5 8mm Apollo balloon- CrossRef Medline MLN REF MLN mounted stent (MicroPort NeuroTech) was positioned at the stenotic segment. DWI (C) and ADC 5. Ryu CW, Kwak HS, Jahng GH, et al. imaging (F)conﬁrmed a new mixed type of infarction (white arrows) after the intervention. High-resolution MRI of intracranial atherosclerotic disease. Neurointervention 2014;9:9–20 CrossRef Medline 6. Deng S,Zheng J,Wu Y,et al. Geometrical characteristics associated stroke) in symptomatic basilar artery stenosis is currently unavail- with atherosclerotic disease in the basilar artery: a magnetic resonance able and warrants further analysis. Second, plaque characteristics vessel wall imaging study. Quant Imaging Med Surg 2021;11:2711–20 from the axial position based on HR-MR imaging were assessed at CrossRef Medline the site of the MLN and not in other planes of plaque. The site of 7. Jia B, Liebeskind DS, Ma N, et al. Factors associated with perfora- MLN was considered as the evaluation level because stress is most tor stroke after selective basilar artery angioplasty or stenting. J pronounced during endovascular therapy and may be associated Neurointerv Surg 2017;9:738–42 CrossRef Medline 8. Xu WH, Li ML, Gao S, et al. Plaque distribution of stenotic middle with postoperative complications. Third, plaque burden was not an- cerebral artery and its clinical relevance. Stroke 2011;42:2957–59 alyzed separately at various plaque distributions from the axial and CrossRef Medline coronal positions to determine the potential mechanism of plaque 9. Marinković SV, Gibo H. The surgical anatomy of the perforating distribution, which was constrained by the small number of cases branches of the basilar artery. Neurosurgery 1993;33:80–87 CrossRef Medline of postoperative complications. This issue warrants further anal- 10. Saeki N, Rhoton AL Jr. Microsurgical anatomy of the upper basilar ysis with a larger sample size. artery and the posterior circle of Willis. JNeurosurg 1977;46:563–78 CrossRef Medline 11. Abou-Chebl A, Steinmetz H. Critique of “Stenting versus aggressive CONCLUSIONS medical therapy for intracranial arterial stenosis” by Chimowitz et The current study showed that a large burden of plaques located al in the New England Journal of Medicine. Stroke 2012;43:616–20 CrossRef Medline at the lateral wall and junctional segment of the basilar artery may 12. Wang M, Wu F, Yang Y, et al. Quantitative assessment of sympto- serve as predictive factors for postoperative complications during matic intracranial atherosclerosis and lenticulostriate arteries endovascular treatment. This finding may be helpful in selecting in recent stroke patients using whole-brain high-resolution car- appropriate patients for endovascular treatment among sympto- diovascular magnetic resonance imaging. J Cardiovasc Magn matic patients with basilar artery stenosis. Reson 2018;20:35 CrossRef Medline 13. Mandell DM, Mossa-Basha M, Qiao Y, et al; Vessel Wall Imaging Study Group of the American Society of Neuroradiology. Intracranial ACKNOWLEDGMENTS vessel wall MRI: principles and expert consensus recommendations We would like to thank Editage (www.editage.com)for English lan- of the American Society of Neuroradiology. AJNR Am J Neuroradiol guage editing. 2017;38:218–29 CrossRef Medline 534 Luo May 2023 www.ajnr.org 14. Wang Y,Wang T,Dmytriw AA,et al. Safety of endovascular therapy 28. Luo J, Li L, Wang T, et al. Risk factors of new cerebral infarctions af- for symptomatic intracranial artery stenosis: a national prospective ter endovascular treatment for basilar artery stenosis based on high- registry. Stroke Vasc Neurol 2022;7:166–71 CrossRef Medline resolution magnetic resonance imaging. Front Neurol 2020;11:620031 15. Agha R, Abdall-Razak A, Crossley E, et al; Group S. STROCSS 2019 CrossRef Medline Guideline. Strengthening the reporting of cohort studies in sur- 29. Nordmeyer H, Chapot R, Aycil A, et al. Angioplasty and stenting of gery. Int J Surg 2019;72:156–65 CrossRef Medline intracranial arterial stenosis in perforator-bearing segments: a 16. Samuels OB, Joseph GJ, Lynn MJ, et al. A standardized method for comparison between the anterior and the posterior circulation. measuring intracranial arterial stenosis. AJNR Am J Neuroradiol Front Neurol 2018;9:533 CrossRef Medline 2000;21:643–46 Medline 30. Gröschel K, Schnaudigel S, Pilgram SM, et al. A systematic review on 17. Yu J, Li ML, Xu YY, et al. Plaque distribution of low-grade basilar outcome after stenting for intracranial atherosclerosis. Stroke artery atherosclerosis and its clinical relevance. BMC Neurol 2009;40:e340–47 CrossRef Medline 2017;17:8 CrossRef Medline 31. Nordmeyer H, Chapot R, Aycil A, et al. Angioplasty and stenting of 18. Chen Z, Liu AF, Chen H, et al. Evaluation of basilar artery athero- intracranial arterial stenosis in perforator-bearing segments: a sclerotic plaque distribution by 3D MR vessel wall imaging. JMagn comparison between the anterior and the posterior circulation. Reson Imaging 2016;44:1592–99 CrossRef Medline Front Neurol 2018;9:533 CrossRef Medline 19. Sacco RL, Kasner SE, Broderick JP, et al; Council on Nutrition, 32. Guo R, Zhang X, Zhu X, et al. Morphologic characteristics of severe Physical Activity and Metabolism. An updated definition of stroke basilar artery atherosclerotic stenosis on 3D high-resolution MRI. for the 21st century: a statement for healthcare professionals from BMC Neurol 2018;18:206 CrossRef Medline the American Heart Association/American Stroke Association. 33. Lim SH, Choi H, Kim HT, et al. Basilar plaque on high-resolution Stroke 2013;44:2064–89 CrossRef Medline MRI predicts progressive motor deficits after pontine infarction. 20. Derdeyn CP, Chimowitz MI, Lynn MJ, et al; Stenting and Aggressive Atherosclerosis 2015;240:278–83 CrossRef Medline Medical Management for Preventing Recurrent Stroke in Intracranial 34. Huang B, Yang WQ, Liu XT, et al. Basilar artery atherosclerotic pla- Stenosis Trial Investigators. Aggressive medical treatment with or ques distribution in symptomatic patients: a 3.0T high-resolution without stenting in high-risk patients with intracranial artery ste- MRI study. Eur J Radiol 2013;82:e199–203 CrossRef Medline nosis (SAMMPRIS): the final results of a randomised trial. Lancet 35. Torche M, Mahmood A, Araujo R, et al. Microsurgical anatomy of 2014;383:333–41 CrossRef Medline the lower basilar artery. Neurol Res 1992;14:259–62 CrossRef Medline 21. Buijs PC,Krabbe-Hartkamp MJ,Bakker C,et al. Effect of age on cere- 36. Nishijima Y. Anatomical analysis of the basilar artery and its bral blood flow: measurement with ungated two-dimensional phase- branches with special reference to the arterial anastomosis, and its contrast MR angiography in 250 adults. Radiology 1998;209:667–74 course and distribution on the pontine ventral surface [in Japanese]. CrossRef Medline Nihon Ika Daigaku Zasshi 1994;61:529–47 CrossRef Medline 22. Beausang-Linder M, Bill A. Cerebral circulation in acute arterial 37. Sun B, Wang L, Li X, et al. Intracranial atherosclerotic plaque hypertension: protective effects of sympathetic nervous activity. characteristics and burden associated with recurrent acute stroke: Acta Physiol Scand 1981;111:193–99 Medline a 3D quantitative vessel wall MRI study. Front Aging Neurosci 23. Roth W, Morgello S, Goldman J, et al. Histopathological differences 2021;13:706544 CrossRef Medline between the anterior and posterior brain arteries as a function of 38. Li F, Chen QX, Chen ZB, et al. Magnetic resonance imaging of pla- aging. Stroke 2017;48:638–44 CrossRef Medline que burden in vascular walls of the middle cerebral artery corre- 24. Ma N, Jiang WJ, Lou X, et al. Arterial remodeling of advanced basi- lates with cerebral infarction. Curr Neurovasc Res 2016;13:263–70 lar atherosclerosis: a 3-Tesla MRI study. Neurology 2010;75:253–58 CrossRef Medline CrossRef Medline 39. Cao Y, Sun Y, Zhou B, et al. Atherosclerotic plaque burden of mid- 25. Kim BJ, Lee KM, Kim HY, et al. Basilar artery plaque and pontine dle cerebral artery and extracranial carotid artery characterized by infarction location and vascular geometry. J Stroke 2018;20:92–98 MRI in patients with acute ischemic stroke in China: association CrossRef Medline and clinical relevance. Neurol Res 2017;39:344–50 CrossRef Medline 26. Luo J, Wang T, Gao P, et al. Endovascular treatment of intracranial 40. Ran Y, Wang Y, Zhu M, et al. Higher plaque burden of middle cere- atherosclerotic stenosis: current debates and future prospects. bral artery is associated with recurrent ischemic stroke: a quantita- Front Neurol 2018;9:666 CrossRef Medline tive magnetic resonance imaging study. Stroke 2020;51:659–62 27. Bai WX, Gao BL, Li TX, et al. Wingspan stenting can effectively pre- CrossRef Medline vent long-term strokes for patients with severe symptomatic athero- 41. Kim BJ, Kim HY, Jho W, et al. Asymptomatic basilar artery plaque dis- sclerotic basilar stenosis. Interv Neuroradiol 2016;22:318–24 CrossRef tribution and vascular geometry. J Atheroscler Thromb 2019;26:1007– Medline 14 CrossRef Medline AJNR Am J Neuroradiol 44:530–35 May 2023 www.ajnr.org 535
American Journal of Neuroradiology – American Journal of Neuroradiology
Published: May 1, 2023
Access the full text.
Sign up today, get DeepDyve free for 14 days.