Incidence and Risk Factors for Diffusion-Weighted Imaging
(+) Lesions After Intracranial Stenting and Its Relationship
With Symptomatic Ischemic Complications
Keun Young Park, MD; Byung Moon Kim, MD; Dong Joon Kim, MD; Dong Ik Kim, MD;
Ji Hoe Heo, MD; Hyo Suk Nam, MD; Young Dae Kim, MD; Dongbeom Song, MD
Background and Purpose
—Little is known about high-signal lesions in magnetic resonance diffusion-weighted imaging
(DWI [+]) after stenting for intracranial atherosclerotic stenosis. This study aimed to evaluate the incidence, distribution, risk factors, and clinical implications of DWI (+) after intracranial stenting.
—A total of 123 patients (male:female=88:35, mean age, 64.1 years) with symptomatic intracranial atherosclerotic
stenosis (mean stenosis, 76.1±7.7%) underwent both stenting and poststenting DWI. The incidence, distribution (embolic-alone versus stenosis-associated perforator/mixed), and risk factors of DWI (+) and its relationship with symptomatic ischemic complications (SIC, including stroke or transient ischemic attack) were retrospectively evaluated.
—Forty-three patients (35.0%) had DWI (+). Middle cerebral artery, smaller distal parent artery, and treatment-
related dissection were independent risk factors for DWI (+) (P
<0.05). SIC occurred in 4 patients (3.3%), all of whom had DWI (+). Of the patients with DWI (+), neither the number nor the volume of DWI (+) differed significantly between SIC and asymptomatic patients: median number/patient, 3.5 (range, 2–11) versus 2.0 (range, 1–11) and median volume/patient, 329.8 mm3 (range, 76–883.5 mm3) versus 119.5 mm3 (range, 32.5–873.0 mm3). However, SIC occurred more frequently in the stenosis-associated perforator/mixed type (3/11, 27.3%) than in the embolic-alone type (1/32, 3.1%; P
—The incidence of DWI (+) after intracranial stenting for intracranial atherosclerotic stenosis was 35.0%.
Middle cerebral artery, smaller distal parent artery, and treatment-related dissection were independent risk factors for
DWI (+). SIC occurred more frequently in the stenosis-associated perforator/mixed type than in the embolic-alone
type. (Stroke. 2014;45:3298-3303.)
diffusion magnetic resonance imaging ◼ intracranial atherosclerosis ◼ stents ◼ stroke
Diffusion-weighted MRI (MR-DWI) is sensitive to clini- factors of DWI (+) after intracranial stenting and its relation-
cally silent infarctions and overt ischemia because it can
ship to symptomatic ischemic complications (SIC).
accurately detect small ischemic lesions within 40 minutes, and for ≥5 days after the onset of ischemic stroke.1,2 Therefore,
Patients and Methods
MR-DWI positive lesions (DWI [+]) could be used for proce-
Patients who underwent both intracranial stenting for symptomatic
dure outcome monitoring in cerebral angiography, revascular-
ICAS and poststenting MR-DWI between May 2001 and June 2013
ization of cervical internal carotid artery stenosis, coiling for
were identified from a prospectively maintained neurointerventional
intracranial aneurysm, coronary angiography and intervention,
database. Inclusion criteria for intracranial stenting were symptomatic ICAS ≥70%, symptomatic ICAS ≥60% and refractory to antiplatelet
and cardiac surgery.3–14 Intracranial atherosclerotic stenosis
medication, or asymptomatic with progressive worsening of stenosis
(ICAS) is responsible for 9% to 37% of ischemic stroke, with
>80% on follow-up angiography despite dual antiplatelet medication.
even higher rates seen in Asian populations.15,16 Intracranial
Exclusion criteria were suspicion of vasculitis or Moyamoya disease
stenting has been suggested as an adjuvant or a rescue treat-
and parent artery anatomy that made it too dangerous to navigate to a
ment modality for patients who are refractory to medical man-
more distal arterial branch or to deliver the stent to the target lesion. For each patient, the need for and feasibility of intracranial stenting
agement.17–19 Nonetheless, there has been only one small case
were determined after discussion between interventional neuroradiol-
series investigating DWI (+) after intracranial stenting.4 In
ogists and stroke neurologists. For this study, additional exclusion cri-
this study, we evaluated the incidence, distribution, and risk
teria were as follows: (1) patients who underwent balloon angioplasty
Received May 26, 2014; final revision received August 30, 2014; accepted September 4, 2014.
From the Departments of Neurosurgery (K.Y.P.), Radiology (B.M.K., D.J.K., D.I.K.), and Neurology (J.H.H., H.S.N., Y.D.K., D.S.), Severance Hospital,
Yonsei University College of Medicine, Seoul, South Korea.
The online-only Data Supplement is av
Correspondence to Byung Moon Kim, MD, PhD, Department of Radiology, Severance Hospital, Yonsei University College of Medicine, 50–1 Yonsei-ro,
Seodaemun-gu, 120–752, Seoul, South K
2014 American Heart Association, Inc.Stroke is available at http://stroke.ahajournals.org
Park et al DWI (+) Lesion After Intracranial Stenting 3299
alone, (2) patients who underwent emergent stenting as part of intra-
at least twice: within 30 days before and within 24 hours after intra-
arterial recanalization therapy for acute stroke, and (3) patients who
cranial stenting. MR-DWI was also performed if any new neurological
did not have pre- or poststenting MR-DWI.
symptom developed. Pre- and poststenting MR-DWI were analyzed by independent neuroradiologists who had not participated in the treatment.
DWI (+) was defined as any newly developed high-signal intensity le-sion in the relevant brain region after intracranial stenting. The relevant
All patients received dual antiplatelet premedication (aspirin 100 mg
brain region was defined as brain parenchyma downstream of the guid-
and clopidogrel 75 mg daily) for ≥5 days before the procedure. All
ing catheter, as previously reported.9 First, DWI (+) was assessed in each
intracranial stenting was performed under local anesthesia. A bolus
patient. If present, then respective DWI (+) size, number, and volume
of heparin 3000 IU was administered intravenously immediately after
were analyzed for each patient. The total volume of DWI (+) was calcu-
placement of a 6F shuttle guiding sheath (Cook, Bloomington, IN)
lated as the sum of the area of DWI (+) on each slice multiplied by slice
or a 6F Envoy guiding catheter (Cordis, Miami Lakes, FL) into the
thickness. In addition, the distribution of DWI (+) was stratified into
cervical internal carotid artery or vertebral artery. Thereafter, 1000
2 types: embolic-alone and stenosis-associated perforator/mixed type.
IU/h was administered. After completion of the procedure, heparin
Embolic-alone type was defined as DWI (+) distributed in the cortical
was stopped, but not reversed.
and subcortical region distal to the target stenosis (Figure 1). Stenosis-
Balloon-expandable coronary stents (Driver, Medtronic,
associated perforator/mixed type was defined as ≥1 DWI (+) located
Minneapolis, MN; FlexMaster, JOMED, Rangendingen, Germany;
in the territory of the perforator which was closely related to the target
Vision, Guidant, St. Paul, MN) were used before the introduction of
stenosis regardless of the presence of distal embolic lesions (Figure 2).
the Wingspan stent in March 2010. However, the Wingspan stent has
Each patient's neurological status was assessed by board-certified
been used exclusively since its introduction. Wingspan stenting was
neurologists immediately after stenting and daily during admission
performed using a previously reported procedure.18 Prestenting balloon
for the development of any new or worsening neurological deficits.
angioplasty always preceded Wingspan stenting using the Gateway
Clinical outcomes were evaluated at discharge, at 1 month, and at
balloon. Whether or not to perform prestenting balloon angioplasty
3-month intervals thereafter. Periprocedural SIC was defined as the
during balloon-expandable stent (BES) insertion was decided based on
occurrence of any type of stroke or transient ischemic attack during
operator discretion. When performing prestenting balloon angioplasty
admission. All technical and clinical periprocedural complications
before BES insertion, the smallest balloon (1.5–2.0 mm) available was
were prospectively registered into the neurointerventional and neuro-
used for the purpose of allowing the stent to pass through the lesion
logical database and were retrospectively evaluated.
easily. Otherwise, there were no remarkable differences between BES and Wingspan stent procedure and postprocedural management.
MRI and Clinical Assessment
Statistical analysis was performed using IBM SPSS statistics version 20.0 (IBM Corp, Armonk, NY). Continuous variables with a normal
Except for patients with symptomatic intracranial hemorrhage, MR-DWI (field of view, 23 cm×23 cm; matrix, 128×128; b-factor, 0 and 1000; slice thickness, 3–5 mm with no gap) was obtained in all patients
Figure 2. A 68-year-old woman presenting with perforator/mixed
type infarctions. A, Prestenting diffusion-weighted MRI (MR-DWI)
Figure 1. A 58-year-old man presenting with embolic infarctions.
showed acute perforator-type infarction in the left lateral len-
A, Prestenting diffusion-weighted MRI (MR-DWI) showed acute
ticulostriate artery territory and 2 small embolic infarctions in the
infarctions in the left occipital and temporal lobes. B, Catheter
left temporoparietal lobes (not shown). B, Catheter angiogram
angiograms showed a severe degree of stenosis in the left intra-
showed a severe degree of stenosis at the left middle cerebral
cranial vertebral artery which supplies the entire posterior circula-
artery M1 portion with decreased perfusion in the left middle
tion because of chronic occlusion of the right vertebral artery (not
cerebral artery territory. C, Poststenting angiogram revealed a
shown). C, Poststenting angiogram showed only a minimal resid-
mild degree of residual stenosis with no angiographic abnor-
ual stenosis without any angiographic abnormality. D, Poststent-
mality. D, Poststenting MR-DWI showed a mixed type of new
ing MR-DWI showed acute embolic infarction in the right middle
stenosis-associated perforator infarct and embolic lesions in the
cerebellar peduncle and cerebellar hemisphere (not shown).
left frontal cortex.
3300 Stroke November 2014
distribution were presented as means±SD. Continuous variables
without a normal distribution were presented as medians and rang-
MR-DWI has been used to monitor cerebral embolism after
es. Categorical variables were presented as percentages. Statistical analysis was performed to characterize the association between
various cardiac and neurovascular procedures.3–14 Recently,
DWI (+) and possible risk factors. Statistical analysis was also per-
DWI (+) has been identified as a possible marker of SIC risk
formed to determine the relationship between number of DWI (+) and
factors postaneurysm coiling and carotid revascularization.5,7,9
the distribution of DWI (+) and SIC. A χ2 test or Fisher exact test were
However, to our knowledge, there is only one small case study
performed for categorical variables as appropriate. An independent t test or the Mann–Whitney U test were used for continuous variables
of DWI (+) after intracranial angioplasty with or without
as appropriate. The univariate cutoff for inclusion in logistic regres-
stenting for ICAS.4 In that study, DWI (+) was detected in 8
sion was P<0.20. All tests were 2-tailed. α was set at P<0.05 with a
(47.1%) of the 16 patients who underwent angioplasty with
95% confidence interval.
(n=10) or without stenting (n=7). DWI (+) appeared more fre-quently after balloon angioplasty followed by stent placement
than after balloon angioplasty alone or primary stent place-
Patient and Target ICAS Characteristics
ment. Length of stenosis was also significantly correlated with
A total of 134 patients underwent intracranial stenting. One
DWI (+). However, that study seemed too small to identify
hundred twenty-three patients (88 men and 35 women with
risk factors associated with DWI (+).
a mean age of 64.1±9.1 years) were included in this study.
In this study, the incidence of DWI (+) was 35.0%, which
Eleven patients were excluded: 9 who underwent intracranial
was lower than the previous case study. Middle cerebral
stenting performed as a part of intra-arterial therapy for acute
artery location of the target stenosis, smaller distal parent
stroke and 2 patients because poststenting MR-DWI was not
artery, and treatment-related dissection were independent
obtained as a result of hemorrhagic complications. Of the 2
risk factors for DWI (+) (Table 1). These independent risk
patients who had poststenting hemorrhagic complication, one
factors may be associated with the difficulty of the stent-
had intraparenchymal hemorrhage because of hyperperfusion
ing procedure. It is likely more difficult to deliver a stent to
syndrome and the other had subarachnoid hemorrhage prob-
target stenoses in the middle cerebral artery than in other
ably because of microguidewire perforation. One hundred
locations (internal carotid artery, vertebral artery, or basilar
sixteen (94.3%) of the 123 patients were symptomatic. The
artery). This may also be true for smaller distal parent arter-
location of target ICAS was the internal carotid artery in 44
ies. Furthermore, because dissection itself can cause overt
(35.8%), vertebral artery in 43 (35.0%), middle cerebral artery
infarction, it is not surprising that treatment-related dissection
in 20 (16.3%), and basilar artery in 16 patients (13.0%). The
significantly increased the rate of DWI (+). Greater age is a
mean degree and length of target ICAS were 76.1±7.7% and
previously documented risk factor for DWI (+) after coiling
9.4±3.4 mm (Table 1).
of intracranial aneurysm or carotid artery stenting.9,20 This suggests that greater baseline atherosclerosis and vascular
Morbidity and Mortality of Elective Stenting
tortuosity in older patients may increase microembolisms dur-
Except for emergent stenting as a part of intra-arterial
ing the stenting procedure.9,21 In this study, greater age was a
therapy for acute stroke, a total of 125 patients underwent
significant risk factor for DWI (+) in univariate analysis but
intracranial stenting. Treatment-related symptomatic compli-
was not significant in multivariate analysis, probably because
cations occurred in 6 patients, 4 ischemic and 2 hemorrhagic.
of low statistical power. The Wingspan stent was also a risk
Treatment-related morbidity and mortality were 4.0% (5 of
factor in univariate analysis and showed a trend for DWI (+)
125) and 0.8% (1 of 125), respectively.
in the multivariate analysis. In the recent study assessing DWI (+) after carotid artery stenting, more porous open-
MR-DWI and SIC
cell stents showed a significantly higher rate of DWI
MR-DWI (+) was observed in 43 (35.0%) of 123 patients. The
(+) than closed-cell design stents.7 The Wingspan has
total number of DWI (+) was 162 (median 3 per patient, range
an open-cell design and is composed of thinner struts
1–11 per patient). The median dimension of DWI (+) was 4.0
than the coronary BES. This may increase the rate of
mm (range, 1.6–16.4 mm). The median total volume of DWI
distal microemboli during or after stenting. Wingspan
(+) per patient was 119.5 mm3 (range, 32.5–883.5 mm3). The
stent was a significant risk factor for embolic-only type
distribution of DWI (+) was embolic-alone in 32 and stenosis-
DWI (+) on univariate analysis but did not remain significant
associated perforator/mixed type in 11 patients. After adjusting
in the logistic regression analysis (Table I in the online-only
for age, smoking status, length of target stenosis, prestenting
Data Supplement). Also, there was no significant difference
angioplasty, and stent type, middle cerebral artery location of
in the distribution of DWI (+) between Wingspan and BES
the target stenosis, smaller distal parent artery, and treatment-
(Table II in the online-only Data Supplement). It might be
related dissection were independent risk factors for DWI (+)
because of low statistical power.
(Table 1). SIC occurred in 4 (3.3%) of the 123 patients, all of
Importantly, the rate of SIC in this study was 3.3%, all of
whom showed DWI (+) (Table 2). There was no significant
whom showed DWI (+). However, there was no significant risk
risk factor for SIC. Of the 43 patients with DWI (+), there was
factor for SIC. This was likely because of the low incidence
no difference in the number or in the total volume of DWI
of SIC in this data set. Acute in-stent thrombosis occurred in
(+) between SIC and asymptomatic patients. However, SIC
13.8% of our cases. The reported rates of in-stent thrombosis
occurred more frequently in the perforator/mixed type than in
after Wingspan stenting in the previous 2 studies were 10.8%
the embolic-alone type (Table 3).
and 14.6%, respectively.18,22 If not detected, acute in-stent
Park et al DWI (+) Lesion After Intracranial Stenting 3301
Table 1. Risk Factors for MR-DWI (+) Lesions After Intracranial Stenting
P Value (OR, 95% CI)
Time from the last symptom to stenting
0.009 (10.443, 1.817–60.032)
Length of stenosis
0.049 (2.124, 1.004–4.490)
0.020 (7.766, 1.379–443.728)
BES indicates balloon-expandable coronary stent; CAOD, coronary artery occlusive disease; CI, confidence interval; DP
the parent artery distal to the target stenosis; DP
, diameter of the parent artery proximal to the target stenosis; ICA, internal carotid
artery; MCA, middle cerebral artery; OR, odds ratio; P , P value in the univariate analysis; and P , P value in the logistic regression analysis.
*Fisher exact test.
3302 Stroke November 2014
Table 2. Characteristics and Outcomes of 4 Patients With
(SAMMPRIS) trial, smoking was protective against isch-
Periprocedural Symptomatic Ischemic Complications
emic stroke poststenting. Also, in our study, smoking seemed to show a protective effect against DWI (+) poststenting
Discharge Final mRS
Pre-MR Stent Type Post-MR
(Table 1). Bang et al26 reported that current smoking was independently and negatively correlated to poor long-term
outcome after atherosclerotic stroke. Although there are still
VA Stroke Embolic
many controversies, several possible mechanisms were sug-
gested: (1) effects of nicotine on angiogenesis or hemostasis,
F MCA Stroke Mixed Wingspan
(2) chronic obstruction resulting in increased tissue threshold
BA indicates basilar artery; BES, balloon-expandable coronary stent; F,
or ischemic preconditioning and enhancing collateral flows to
female; Loc, location of the target stenosis; M, male; MCA, middle cerebral
the ischemic penumbra, and (3) short-acting increase in blood
artery; MR, magnetic resonance; mRS, modified Rankin scale score; Sx, type
pressure as a compensatory mechanism enhancing perfusion
of presenting symptom; TIA, transient ischemic attack; and VA, vertebral artery.
to the ischemic penumbra.27
Of the patients with DWI (+), there was no difference in
thrombosis can cause a severe infarction. Fortunately, acute
the number or the total volume of DWI (+) between SIC and
in-stent thrombosis in our study and the previous 2 reports
asymptomatic patients. However, SIC occurred more fre-
could be resolved by intra-arterial or intravenous glycoprotein
quently in stenosis-associated perforator/mixed type than in
IIb/IIIa inhibitor infusion with or without small amount of a
embolic-alone type. This result seemed to correspond with
fibrinolytic agent. As a result, there was no case of a neurolog-ical sequelae in the 3 case series including this study.
post hoc analyses of a recent randomized controlled trial on
rate of in-stent thrombosis after Wingspan stenting seemed
stenting versus aggressive medical therapy for intracranial
to be higher than that after stenting for coiling. It is likely
arterial stenosis.28–30 In those analyses, most symptomatic peri-
because Wingspan stent was applied to ICAS, an entirely dif-
procedural ischemic strokes were perforator territory infarc-
ferent neurovascular disease from aneurysm.
tions (71.4%) in close proximity to the target stenosis. Unlike
22 In addition, the
cause of acute in-stent thrombosis may be related to resistance
carotid artery stenting, where DWI (+) was exclusively caused
to antiplatelet drugs. Aspirin and clopidogrel resistance occurs
by distal emboli from carotid atheromatous plaques or aortic
in an ≈17% of patients undergoing coronary stent placement.23
arches, DWI (+) after intracranial stenting can occur because
Procedure-related thromboembolic events in coil emboliza-
of distal emboli, perforator compromise from the snowplow
tion occurred more frequently in nonresponder to antiplatelet
effect of plaques during angioplasty, or both. Patients with
premedication.24 In our study and the previous 2 reports, anti-
prestenting perforator infarction closely related to target ste-
platelet drug resistance test was not performed routinely, and
nosis showed a higher perforator stroke rate after elective
therefore, adjustment or change of antiplatelet premedication
stenting.31 Therefore, in line with previous studies, our results
for nonresponder was not done. It might affect the rates of
suggest that ICAS presenting with adjacent perforator isch-
in-stent thrombosis and intracranial hemorrhage in our study.
emia may contraindicate intracranial stenting.
Recently, Alexander et al25 reported a proceeding in which,
This study has the several limitations inherent in the ret-
with adjustment or change of antiplatelet premedication for
rospective nature. In addition, another limitation is that
nonresponders or hyperresponder, no case of acute in-stent
MR-DWI was not obtained between diagnostic angiography
thrombosis or intraparenchymal hemorrhage occurred after
and the stenting procedure in all patients. Therefore, silent
Wingspan stenting in 154 patients. This result suggests that
embolism during diagnostic angiography or from the target
antiplatelet resistance test and adjustment of mediation for
lesion between prestenting and poststenting MR might have
nonresponder or hyperresponder should be performed before
increased the rate of DWI (+). To decrease the influence of
such silent embolism on our results, only obvious new lesions
In Stenting and Aggressive Medical Management for
in brain parenchyma downstream from the location of the
Preventing Recurrent Stroke in Intracranial Stenosis
guiding catheter during the stenting procedure were assessed. Pre- and poststenting cognitive functions were not assessed in this study so that the relationship between cognitive function
Table 3. Relationship Between DWI (+) and Symptomatic
and silent DWI (+) could not be evaluated. It may be another
limitation of this study. Silent DWI (+) may affect cognitive
function decline.32 However, another studies failed to show
Complications, n (%)
the correlation between silent DWI (+) and cognitive function
change.33,34 Therefore, it should be addressed in the further
Numbers, median (range)
Volume, median (range), mm3 329.8 (76–883.5) 119.5 (32.5–873.0) 0.280*Distribution, n (%)
The incidence of DWI (+) after intracranial stenting was
Perforator or mixed
35.0%. Middle cerebral artery, smaller distal parent artery, and treatment-related dissection were independent risk factors
DWI indicates diffusion-weighted imaging.
*Mann–Whitney U test.
for DWI (+). Of the patients with DWI (+), there was no dif-
†Fisher exact test.
ference in the number or in the volume of DWI (+) between
Park et al DWI (+) Lesion After Intracranial Stenting 3303
SIC and asymptomatic patients. However, SIC occurred more
15. Qureshi AI, Feldmann E, Gomez CR, Johnston SC, Kasner SE, Quick
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Sources of Funding
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This study was supported by a faculty research grant of Yonsei
symptomatic intracranial stenosis after Wingspan stenting. Stroke.
University College of Medicine for 6-2014-0071.
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Int. J. LifeSc. Bt & Pharm. Res. 2012 R Aarthi et al., 2012 ISSN XXXX-XXXX www.ijlbpr.com Vol.1, Issue. 1, January 2012 © 2012 IJLBPR. All Rights Reserved VIRTUAL SCREENING OF ANDROGRAPHOLIDE INHIBITOR FOR HIV ENV GP 160 R Aarthi1*, R S Narmadha2 and Puniethaa Prabhu3 *Corresponding Author: R Aarthi, [email protected] The AIDS is caused by HIV, a pandemic disease. The search for effective therapies to treatAIDS is needed. The synthetic drugs like EFV (Efavirenz), TDF (Tenofovir), FTC (Emtricitabine),d4T (Zerit/Stavudine) and many are used in the antiretroviral treatment which causes perilouseffect to patients. Thus, herbal medicines can be used as an alternative medicinal therapy forHIV positive patient. Efforts for identification of more effective and less toxic anti-HIV agents arerequired. Andrographis paniculata is an herbaceous plant in family Acanthaceae, which iseconomically available source used in Siddha and Ayurvedic system of medicine in India andother countries. Protease inhibition is the mechanism for therapeutic value of Andrographispaniculata. Andrographolide is an active secondary metabolite in Andrographis paniculata. Inthis paper, we report the Virtual screening of Andrographolide using Docking tools against HIV-1 env gp160. The envelope glycoprotein (env gp160) of HIV interacts with the CD4 moleculespresent on the membrane of CD4+ cells and involved in the pathobiology of HIV infection. Theseenv gp160 is chopped into pieces as env gp120 and env gp41 on viral membrane. From thisstudy a new inhibitor is developed for the HIV through docking tools with a good dock score.
This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Proteomics reveals multiple routes to the osteogenic phenotype in mesenchymal stem cells BMC Genomics 2007, 8:380 Kristin P Bennett () Charles Bergeron Scott L Vandenberg ()