Longitudinal hemodynamic trajectories in severe symptomatic intracranial atherosclerotic stenosis under endovascular versus medical management

Hemodynamic compromise plays an important role in stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). We aimed to characterize longitudinal CT perfusion (CTP) changes in patients with severe sICAS managed with endovascular treatment (EVT) or medical management (MM). This retrospective cohort study included patients with severe sICAS (70%-99% stenosis) and recent ischemic stroke (<3 months) identified from a CTP database. Patients were grouped according to treatment received: MM alone or EVT plus MM. Baseline and follow-up CTP examinations were obtained at least 5 months apart. Changes in perfusion deficit volumes defined by relative cerebral blood flow (rCBF) and time-to-maximum (Tmax) thresholds were evaluated using adjusted longitudinal models. Propensity score overlap-weighted generalized estimating equation models were used for sensitivity analyses. Clinical events were recorded descriptively. Among 102 patients (44 MM; 58 EVT), perfusion deficit volumes defined by rCBF < 38% and < 34% significantly expanded in the MM group (both P = 0.018), whereas the EVT group showed no significant change. Primary adjusted analyses showed significant treatment-by-time interactions for rCBF < 38% and < 34% (both interaction P = 0.021). Overlap-weighted estimates remained directionally consistent but were not statistically significant (P = 0.162 and P = 0.160, respectively). The 1-year rates of target-territory recurrent ischemic stroke were 9.1% with MM and 8.6% with EVT. Primary adjusted analyses suggested different longitudinal rCBF trajectories between groups, but these differences were not statistically significant after overlap weighting. These findings should be considered exploratory and require confirmation in larger prospective studies.