Systemic atherosclerosis linked with intracranial atherosclerotic disease-related stroke and worse prognosis

1. In patients with stroke who had intracranial atherosclerotic disease (ICAD), atherosclerotic disease in other vascular beds was more common including the aortic arch and coronary artery disease.

2. Patients who presented with stroke and ICAD were at greater risk of subsequent major adverse cardiovascular event (MACE) if they had concurrent extracranial carotid disease, or cardiac disease.

Evidence Rating Level: 2 (Good)

Study Rundown: Intracranial atherosclerotic disease is a common cause of ischemic stroke. Many cardiovascular conditions share similar pathogenesis, predispositions, and risk factors. How these comorbid conditions may influence prognosis in patients with ICAD related stroke is unknown, as patients with other possible etiologies for ischemic stroke are commonly excluded from prior studies. This study investigated consecutive stroke patients for ICAD, and those with ICAD were systematically screened for vascular disease elsewhere in the body. The study found that comorbid atherosclerotic disease is common in the aortic arch and coronary arteries. Cardiac disease and extracranial carotid disease were also linked to greater risk for recurrent MACE in this group of patients.

The study demonstrates the importance of considering comorbidities with shared pathogenesis and risk factors as they may influence prognosis after ICAD related stroke. Clinicians should consider investigations for vascular disease in other anatomic sites, as patients may benefit from interventions directed towards these conditions. The study includes a sizable population with systematic investigations for atherosclerotic disease. The main limitations of the study include its single center design, and use of non-invasive measures of ICAD.

Click to read the study, published in JAMA Neurology

Relevant Reading: Impact of SAMMPRIS on the future of intracranial atherosclerotic disease management: polling results from the ICAD symposium at the International Stroke Conference

In-Depth [prospective cohort]: This study recruited 785 consecutive stroke patients from 2005 to 2008 who presented to a single tertiary stroke center. Patients were excluded if they had severe stroke (Rankin score >5), refused consent, or did not have confirmed stroke on neuroimaging. A total of 403 patients underwent vascular imaging with contrast magnetic resonance angiography, computed tomography angiography, or transcranial Doppler. Systemic vascular disease was evaluated with ultrasonography, coronary catheter angiogram, and echocardiography.

Significant ICAD was found in 146 (36.2%) of patients, and was linked to atherosclerosis in the aortic arch (70 [60.9%] vs 99 [49.0%]; p = 0.04) and coronary arteries (103 [76.9%] vs 153 [63.2%]; p = 0.007). Presence of ICAD concurrent with extracranial carotid (24 [23.4%] vs 3 [9.0%]; p = 0.08; adjusted hazard ratio [aHR] = 2.12) and coronary (19 [29.9%] vs 8 [12.8%]; p = 0.01; aHR = 1.90) artery disease were at greater risk for subsequent MACE as were patients with any cardiac pathology (20 [28.2%] vs 7 [11.4%]; p = 0.01; aHR = 2.24).

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