Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics

Xuan Tian; Hui Fang; Linfang Lan; Hing Lung Ip; Jill Abrigo; Haipeng Liu; Lina Zheng; Florence S.Y. Fan; Sze Ho Ma; Bonaventure Ip; Bo Song; Yuming Xu; Jingwei Li; Bing Zhang; Yun Xu; Yannie O.Y. Soo; Vincent Mok; Ka Sing Wong; Thomas W. Leung; Xinyi Leng

doi:10.1136/svn-2022-001606

Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics

Xuan Tian, Hui Fang, Linfang Lan, Hing Lung Ip, Jill Abrigo, Haipeng Liu, Lina Zheng, Florence S.Y. Fan, Sze Ho Ma, Bonaventure Ip, Bo Song, Yuming Xu, Jingwei Li, Bing Zhang, Yun Xu, Yannie O.Y. Soo, Vincent Mok, Ka Sing Wong, Thomas W. Leung, Xinyi Leng

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Abstract

Background and purpose: Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics. Methods: Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year. Results: Among 245 sICAS patients, 20 (8.2%) had SIT. The D2H2A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results. Conclusions: The D2H2A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment.

Original language	English
Article number	e22001606
Pages (from-to)	77-85
Number of pages	9
Journal	Stroke and Vascular Neurology
Volume	8
Issue number	1
Early online date	14 Sept 2022
DOIs	https://doi.org/10.1136/svn-2022-001606
Publication status	Published - Feb 2023

Bibliographical note

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Funder

This work was supported by the Direct Grant for Research, The Chinese University of Hong Kong (Reference No. 2019.033), and General Research Fund, Research Grants Council of Hong Kong (Reference number 14106019).

Keywords

atherosclerosis
prospective studies
risk factors
stroke

ASJC Scopus subject areas

Clinical Neurology
Cardiology and Cardiovascular Medicine

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This output contributes to the following UN Sustainable Development Goals (SDGs)

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Tian, X., Fang, H., Lan, L., Ip, H. L., Abrigo, J., Liu, H., Zheng, L., Fan, F. S. Y., Ma, S. H., Ip, B., Song, B., Xu, Y., Li, J., Zhang, B., Xu, Y., Soo, Y. O. Y., Mok, V., Wong, K. S., Leung, T. W., & Leng, X. (2023). Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics. Stroke and Vascular Neurology, 8(1), 77-85. [e22001606]. https://doi.org/10.1136/svn-2022-001606

Tian, X, Fang, H, Lan, L, Ip, HL, Abrigo, J, Liu, H, Zheng, L, Fan, FSY, Ma, SH, Ip, B, Song, B, Xu, Y, Li, J, Zhang, B, Xu, Y, Soo, YOY, Mok, V, Wong, KS, Leung, TW & Leng, X 2023, 'Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics', Stroke and Vascular Neurology, vol. 8, no. 1, e22001606, pp. 77-85. https://doi.org/10.1136/svn-2022-001606

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title = "Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics",

abstract = "Background and purpose: Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics. Methods: Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year. Results: Among 245 sICAS patients, 20 (8.2%) had SIT. The D2H2A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results. Conclusions: The D2H2A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment. ",

keywords = "atherosclerosis, prospective studies, risk factors, stroke",

author = "Xuan Tian and Hui Fang and Linfang Lan and Ip, {Hing Lung} and Jill Abrigo and Haipeng Liu and Lina Zheng and Fan, {Florence S.Y.} and Ma, {Sze Ho} and Bonaventure Ip and Bo Song and Yuming Xu and Jingwei Li and Bing Zhang and Yun Xu and Soo, {Yannie O.Y.} and Vincent Mok and Wong, {Ka Sing} and Leung, {Thomas W.} and Xinyi Leng",

note = "{\textcopyright} Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. ",

year = "2023",

month = feb,

doi = "10.1136/svn-2022-001606",

language = "English",

volume = "8",

pages = "77--85",

journal = "Stroke and Vascular Neurology",

issn = "2059-8688",

publisher = "BMJ Publishing Group",

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TY - JOUR

T1 - Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics

AU - Tian, Xuan

AU - Fang, Hui

AU - Lan, Linfang

AU - Ip, Hing Lung

AU - Abrigo, Jill

AU - Liu, Haipeng

AU - Zheng, Lina

AU - Fan, Florence S.Y.

AU - Ma, Sze Ho

AU - Ip, Bonaventure

AU - Song, Bo

AU - Xu, Yuming

AU - Li, Jingwei

AU - Zhang, Bing

AU - Xu, Yun

AU - Soo, Yannie O.Y.

AU - Mok, Vincent

AU - Wong, Ka Sing

AU - Leung, Thomas W.

AU - Leng, Xinyi

N1 - © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

PY - 2023/2

Y1 - 2023/2

N2 - Background and purpose: Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics. Methods: Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year. Results: Among 245 sICAS patients, 20 (8.2%) had SIT. The D2H2A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results. Conclusions: The D2H2A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment.

AB - Background and purpose: Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics. Methods: Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year. Results: Among 245 sICAS patients, 20 (8.2%) had SIT. The D2H2A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results. Conclusions: The D2H2A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment.

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KW - prospective studies

KW - risk factors

KW - stroke

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JO - Stroke and Vascular Neurology

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Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics

Abstract

Bibliographical note

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Keywords

ASJC Scopus subject areas

UN SDGs

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