The presence of intracranial large artery disease (ICLAD) is associated with poor composite vascular outcomes, myocardial infarction (MI), and vascular death, but not recurrence, in patients with acute ischaemic stroke, suggests a Singapore study.
“Our findings of poor prognostic impact of ICLAD on long-term recurrent vascular events after ischaemic stroke provide evidence for the need of specific, emphasized screening and secondary prevention, especially for coronary artery disease in this high-risk group,” said lead author Dr Wan-Yun Sabrina Liu, Duke-NUS Medical School, Singapore, Singapore.
Liu and her team included 581 ischaemic stroke patients (median age 63 years, 71 percent male) in this longitudinal observational study, whom 354 (60.9 percent) had ICLAD. They followed patients for recurrent stroke, MI, or vascular death up to a median of 86 months. ICLAD was diagnosed using transcranial colour-coded Doppler.
Regression analyses, adjusted for covariates, revealed a higher risk of long-term composite vascular outcomes (hazard ratio [HR], 1.44, 95 percent confidence interval [CI], 1.02‒2.03; p=0.041), MI (HR, 2.89, 95 percent CI, 1.71‒4.91; p<0.001), and vascular death (HR, 3.52, 95 percent CI, 1.67‒7.52; p=0.001), but not recurrent stroke (HR, 1.10, 95 percent CI, 0.72‒1.70; p=0.652), among patients with vs without ICLAD. [Singapore Med J 2026;67:156-161]
These findings are consistent with those of other studies with shorter timelines. [Stroke 2003;34:2361-2366; Stroke 2017;48:2819-2826]
“Our finding that stroke patients with ICLAD have a higher recurrent vascular risk profile provides evidence that these are high-risk patients who require aggressive management for vascular risk reduction,” Liu and colleagues said.
Recurrence
In a recent study assessing the association between risk factor control and early recurrent stroke risk in patients with symptomatic ICLAD, recurrent stroke did not occur in any of the patients with optimal risk factor control at 6‒8 weeks of follow-up after the index event (0 percent vs 31.8 percent; p<0.01). [J Stroke Cerebrovasc Dis 2021;30:105914]
“In our study, surprisingly, we did not find an increased risk of events in symptomatic ICLAD compared to asymptomatic ICLAD patients,” Liu said.
Two factors could potentially explain such outcome. Firstly, the current study required participants to meet the criteria appropriate for retinal imaging, which favoured those with fewer disabilities. This might have resulted in a “skewed representation” of more severe ICLAD cases.
Secondly, the observed outcome could have been driven by the limited statistical power for this subgroup analysis.
“Our results suggest that even patients with no symptoms of coronary artery disease should be screened if they have ICLAD to further identify high-risk individuals who may benefit from aggressive risk factor management,” Liu said.
Diabetes, old age
Previous studies have shown the relationship of diabetes mellitus and older age with an increased vascular risk following stroke. However, in the current study, neither of these factors bolstered the association between ICLAD and the incidence of long-term post-stroke composite vascular outcomes. [Stroke 2018;49:e215-e217; J Neurol Sci 2004;224:49-55; Front Neurol 2020;11:2]
“There have been no previous studies examining the interactions between diabetes mellitus or older age and the presence of ICLAD on vascular outcomes. This novel finding needs to be confirmed in other cohorts,” Liu and colleagues said.
“These preliminary findings indicate that, as stroke patients with ICLAD are at risk of composite vascular outcomes regardless of their diabetic status or age, all stroke patients with ICLAD should be screened, managed and monitored in a similar manner,” they added.