Abstract
Introduction:
Despite aggressive medical management, patients with symptomatic intracranial atherosclerotic disease (ICAD) remain at high risk for recurrent stroke. There are no reliable biomarkers to identify those at highest risk and in whom flow restorative procedures may be warranted. We hypothesized that a borderzone infarct pattern would predict 90-day recurrent stroke in the territory of symptomatic ICAD.
Methods:
Using the prospective registry at a single center, we identified consecutive patients admitted between 2012 and 2017 with confirmed ischemic stroke or transient ischemic attack (TIA) and independently adjudicated symptomatic ICAD with stenosis of >50%. We ascertained clinical events within 3 months of index stroke through telephone interview. Ischemic stroke in the territory of the symptomatic stenotic artery was the primary outcome. A blinded rater assessed infarct pattern: single perforator, territorial, borderzone, or mixed. We evaluated whether infarct pattern was a predictor of recurrent stroke using logistic regression adjusting for age, sex, prior stroke, initial NIHSS score, location of stenosis, degree of stenosis, and use of dual antiplatelet therapy at discharge.
Results:
Among 212 patients who met study criteria, the mean age was 68.2 (±12.2) years and median initial NIHSS score was 3 (interquartile range 1-6). Symptomatic ICAD was localized to the anterior circulation in 132 (64.2%) patients and 171 (80.7%) had stenosis >70%. Isolated borderzone infarcts were noted in 18 patients (8.5%) while they were present in 34 (16.0%) other patients with mixed pattern. At 3 months, 51 (24.1%) patients experienced recurrent stroke in the territory. Among patients with any borderzone infarct, 20 (38.7%) had recurrent stroke versus 31 (19.4%) in patients with other patterns (p=0.005). In adjusted analysis, presence of any borderzone infarct was independently associated with recurrent stroke (aOR 2.59, 95% CI 1.23-5.48, p=0.012).
Conclusions:
In a single-center observational cohort study, we found that a borderzone infarct pattern was a strong predictor of recurrent stroke at 3 months in patients with symptomatic ICAD. Our data suggest that hypoperfusion may be an important mechanism of recurrent stroke in this population.