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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    2 Citations (Scopus)
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    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 languageEnglish
    Article numbere22001606
    Pages (from-to)77-85
    Number of pages9
    JournalStroke and Vascular Neurology
    Issue number1
    Early online date14 Sept 2022
    Publication statusPublished - 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/.


    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).


    • atherosclerosis
    • prospective studies
    • risk factors
    • stroke

    ASJC Scopus subject areas

    • Clinical Neurology
    • Cardiology and Cardiovascular Medicine


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