" 33$ Atherosclerosis: pathologic process that causes disease of the arteries. Most common cause of in situ local disease within the supraaortic arteries and intracranial arteries. Chronic disease: childhood: fatty streaks fibrous plaques fibrous caps advanced atheromatous lesions Multiple pathogenic factors: endothelial dysfunction inflammatory and immunologic factors plaque rupture traditional risk factors PATHOPHYSIOLOGY In-situ thromboembolism: local thrombosis, embolism (multiple cortical infarcts) Progression of luminal stenosis: hemodynamic insufficiency (watershed infarct) Branch atheromatous disease: small vessel occlusion (single deep infarct) 63(4+, $0' $2.$0 $0&(5 PATHOPHYSIOLOGY: STROKE MECHANISMS EPIDEMIOLOGY Common cause of ischemic stroke 50% in Asia, most common worldwide? Whites: 5 - 10%. Higher in hispanics (x4), blacks (x5), Asians (x6) Underdiagnosis of non-stenosing plaques ,59 (5 $. ,3&6.$5,10 $44 (5 $. !+,5( (5 $. ,3&6.$5,10 13(.,&- (5 $. (631.1*8 3(0,..$4 (5 $. (631.1*8 Genetic susceptibility Vs. Differences in lifestyle and risk factors Hypertension Dyslipidemia *severe stenosis Diabetes *carotid Age *basilar Metabolic syndrome Sedentarism Smoking *MCA: women, blacks RISK FACTORS 63(4+, $2.$0 $0&(5 ,59 (5 $. ,3&6.$5,10 1./45('5 (5 $. $0&(5 (631. 63$0 (5 $. 531-( Risk factors more prevalent than in other stroke subtypes Noninvasive neurovascular imaging CTA, MRA, TCD Better NPV than PPV Limitations: occlusion vs. pseudo-occlusion overestimate severity of stenosis Catheter angiography (1% complications) Advantages: accurate measurement of the degree of stenosis differentiation of occlusion vs. pseudo-occlusion assessment of collateral flow patterns Indications: The added information is unlikely to alter management. I ti t lt ti ti l i di ti liti DIAGNOSIS (.'/$00 (5 $. (631.1*8
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ESNR Stenosis-Urra.pdf · Multiple pathogenic factors: endothelial dysfunction inflammatory and immunologic factors plaque rupture traditional risk factors PATHOPHYSIOLOGY In-situ
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Atherosclerosis: pathologic process thatcauses disease of the arteries.
Most common cause of in situ local diseasewithin the supraaortic arteries and intracranialarteries.
Fibromuscular displasia: most frequently involves the renal and internal carotid and vertebral arteries.
Moyamoya: bilateral stenoses affecting the distal internal carotid arteries and prominent collateralvessels.
DIFFERENTIAL DIAGNOSISHigh risk of stroke, especially in symptomatic cases (up to 25% anual risk in WASID)
Lower with intensive medical therapy (SAMMPRIS 12%)
Subgroups with high risk of stroke:Degree stenosis: severe (≥70%) HR 2Hypoperfusion (“hemodynamic stenosis”) Recent ischemic symptomsPresentation with stroke (vs. TIA)Old infarct in the territory of the stenosisWomenAbsence of statin at trial entry
PROGNOSIS
TREATMENTMaximal medical therapy: association between good control of risk factors and lower risk of events
smoking cessationweight reductionhealthy diet: mediterranean diet (Estruch et al NEJM 2013)
Interventions:EC-IC bypassStenting
SAMMPRISVISSIT
y
Atherosclerotic stenosis of the major intracranial arteries is a commoncause of ischemic stroke, especially in blacks, Asians, and Hispanics
Diagnosis usually made with noninvasive imaging
Differential diagnosis includes other less common types of intracranialvasculopathies
The anual risk of stroke is high, especially in patients with severe stenosis
Despite this, the primary treatment is based in MAXIMAL medical therapy that includes antiplatelet and antihypertensive agents, statins, and lifestyle modifications