From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., Y.S., X.L., T.W.L.), the Chinese University of Hong Kong, Prince of Wales Hospital.
Department of Neurology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (L.L.).
Stroke. 2019 Oct;50(10):2692-2699. doi: 10.1161/STROKEAHA.119.025732. Epub 2019 Aug 14.
Background and Purpose- In patients with symptomatic intracranial atherosclerotic stenosis, identifying the underlying stroke mechanisms may inform secondary prevention. We aimed to propose reproducible classification criteria for stroke mechanisms based on routine neuroimaging in symptomatic intracranial atherosclerotic stenosis and explore their clinical implications. Methods- We recruited patients with acute ischemic stroke attributed to 50% to 99% intracranial atherosclerotic stenosis in anterior circulation from 2 centers. Two investigators independently classified probable stroke mechanisms as parent artery atherosclerosis occluding penetrating artery, artery-to-artery embolism, hypoperfusion, and mixed mechanisms, with prespecified criteria based on infarct topography and magnetic resonance/computed tomography angiography. These stroke mechanisms were correlated with features of the patients at baseline and recurrent ischemic stroke in the same territory or relevant transient ischemic attack within 1 year. Results- Among 153 patients recruited, the most common stroke mechanisms were isolated hypoperfusion (35.3%) and mixed mechanism of artery-to-artery embolism and hypoperfusion (37.3%) that was associated with higher incidence of dyslipidemia (=0.045) and hypertension (=0.033) than patients with other stroke mechanisms. The proposed criteria showed substantial to excellent intrarater and interrater reproducibilities (κ, 0.791-0.908). Overall, 31 patients received interventional treatment of the diseased intracranial artery; 122 received medical treatment, among whom a mixed mechanism of artery-to-artery embolism and hypoperfusion at baseline was associated with higher risk of ischemic stroke in the same territory within 1 year (24.4% versus 7.8%; hazard ratio, 3.40; 95% CI, 1.25-9.20; log-rank =0.010) than other mechanisms combined. Conclusions- Artery-to-artery embolism and hypoperfusion commonly coexist in ischemic stroke attributed to intracranial atherosclerotic stenosis, which may be associated with higher risk of stroke relapse.
背景与目的- 在有症状性颅内动脉粥样硬化狭窄的患者中，确定潜在的卒中机制可能有助于二级预防。我们旨在基于有症状性颅内动脉粥样硬化狭窄患者的常规神经影像学提出卒中机制的可重复分类标准，并探讨其临床意义。
方法- 我们从 2 个中心招募了归因于前循环 50%至 99%颅内动脉粥样硬化狭窄的急性缺血性卒中患者。2 位研究者独立根据梗死部位和磁共振/计算机断层血管造影将可能的卒中机制分类为：母动脉粥样硬化闭塞穿支动脉、动脉到动脉栓塞、低灌注和混合机制，并根据预先设定的标准进行分类。这些卒中机制与患者的基线特征以及同一部位的复发性缺血性卒中和 1 年内相关短暂性脑缺血发作相关。
结果- 在纳入的 153 例患者中，最常见的卒中机制是孤立性低灌注（35.3%）和动脉到动脉栓塞和低灌注的混合机制（37.3%），与其他卒中机制相比，这类患者的血脂异常（=0.045）和高血压（=0.033）发生率更高。所提出的标准显示出观察者内和观察者间的高度至极好的可重复性（κ，0.791-0.908）。总体而言，31 例患者接受了病变颅内动脉的介入治疗；122 例患者接受了药物治疗，其中基线时的动脉到动脉栓塞和低灌注的混合机制与 1 年内同一部位的缺血性卒中风险较高相关（24.4%比 7.8%；风险比，3.40；95%置信区间，1.25-9.20；对数秩检验=0.010），高于其他机制的组合。
结论- 颅内动脉粥样硬化狭窄引起的缺血性卒中中，动脉到动脉栓塞和低灌注通常共同存在，这可能与卒中复发风险增加相关。
