J Stroke.  2023 May;25(2):223-232. 10.5853/jos.2023.00185.

Borderzone Infarcts and Recurrent Cerebrovascular Events in Symptomatic Intracranial Arterial Stenosis: A Systematic Review and Meta-Analysis

• Das S
• Shu L
• Morgan RJ
• Shah A
• Fayad FH
• Goldstein ED
• Chahien D
• Maglinger B
• Bokka SK
• Owens C
• Abbasi M
• Kvernland A
• Siegler JE
• Grory BM
• Nguyen TN
• Furie K
• Khatri P
• Mistry E
• Prabhakaran S
• Liebeskind DS
• Romano JG
• Havenon Ad
• Palaiodimou L
• Tsivgoulis G
• Yaghi S

• KMID: 2542473
• DOI: http://doi.org/10.5853/jos.2023.00185

Abstract

Background and Purpose
Intracranial arterial stenosis (ICAS)-related stroke occurs due to three primary mechanisms with distinct infarct patterns: (1) borderzone infarcts (BZI) due to impaired distal perfusion, (2) territorial infarcts due to distal plaque/thrombus embolization, and (3) plaque progression occluding perforators. The objective of the systematic review is to determine whether BZI secondary to ICAS is associated with a higher risk of recurrent stroke or neurological deterioration.
Methods
As part of this registered systematic review (CRD42021265230), a comprehensive search was performed to identify relevant papers and conference abstracts (with ≥20 patients) reporting initial infarct patterns and recurrence rates in patients with symptomatic ICAS. Subgroup analyses were performed for studies including any BZI versus isolated BZI and those excluding posterior circulation stroke. The study outcome included neurological deterioration or recurrent stroke during follow-up. For all outcome events, corresponding risk ratios (RRs) and 95% confidence intervals (95% CI) were calculated.
Results
A literature search yielded 4,478 records with 32 selected during the title/abstract triage for full text; 11 met inclusion criteria and 8 studies were included in the analysis (n=1,219 patients; 341 with BZI). The meta-analysis demonstrated that the RR of outcome in the BZI group compared to the no BZI group was 2.10 (95% CI 1.52–2.90). Limiting the analysis to studies including any BZI, the RR was 2.10 (95% CI 1.38–3.18). For isolated BZI, RR was 2.59 (95% CI 1.24–5.41). RR was 2.96 (95% CI 1.71–5.12) for studies only including anterior circulation stroke patients.
Conclusion
This systematic review and meta-analysis suggests that the presence of BZI secondary to ICAS may be an imaging biomarker that predicts neurological deterioration and/or stroke recurrence.

Keyword

Borderzone Infarct; Stroke; Recurrence; Intracranial arterial diseases; Intracranial atherosclerosis

Figure

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  Figure 1. Study selection flow chart.

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  Figure 2. Risk of bias assessment using the Risk of Bias in Nonrandomized Studies (ROBINS-I) tool.

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  Figure 3. Forest plot showing association between BZI and recurrent cerebrovascular events. (A) Association between BZI and recurrent cerebrovascular events. (B) Association between any BZI and recurrent cerebrovascular events. (C) Association between isolated BZI and recurrent cerebrovascular events. (D) Association between BZI and recurrent cerebrovascular cerebrovascular events in patients with anterior circulation. BZI, borderzone infarct; CI, confidence interval; REML, restricted maximum likelihood.

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  Figure 4. Forest plot showing subgroup analyses by outcome definition and timing. (A) Association between BZI and recurrent ischemic stroke. (B) Association between BZI and recurrent cerebrovascular events in studies whose outcome included or was limited to in-hospital neurological deterioration outcome. (C) Association between BZI and in-hospital recurrent cerebrovascular events. (D) Association between BZI and recurrent cerebrovascular events within 90 days. (E) Association between BZI any recurrent cerebrovascular events in studies with >90-day follow-up. BZI, borderzone infarct; CI, confidence interval; REML, restricted maximum likelihood.

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