Natural History of Hemodynamics in Vertebrobasilar Disease: Temporal Changes in the VERiTAS Study Cohort

Abstract

Background and purpose: The role of regional hypoperfusion as a contributor to stroke risk in atherosclerotic vertebrobasilar disease has recently been confirmed by the observational VERiTAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) Study. We examined the stability of hemodynamic status over time and its relationship to stroke risk in patients from this prospective cohort.

Methods: VERiTAS enrolled patients with recently symptomatic ≥50% atherosclerotic stenosis/occlusion of vertebral and/or basilar arteries. Large vessel flow in the vertebrobasilar territory was assessed using quantitative magnetic resonance angiography, and patients were designated as low or normal flow based on distal territory regional flow, incorporating collateral capacity. Patients underwent standard medical management and follow-up for primary outcome event of vertebrobasilar territory stroke. Quantitative magnetic resonance angiography imaging was repeated at 6, 12, and 24 months. Flow status over time was examined relative to baseline and relative to subsequent stroke risk using a cause-specific proportional hazard model, with flow status treated as a time-varying covariate. Mean blood pressure was examined to assess for association with changes in flow status.

Results: Over 19±8 months of follow-up, 132 follow-up quantitative magnetic resonance angiography studies were performed in 58 of the 72 enrolled patients. Of the 13 patients with serial imaging who had low flow at baseline, 7 (54%) had improvement to normal flow at the last follow-up. Of the 45 patients who had normal flow at baseline, 3 (7%) converted to low flow at the last follow-up. The mean blood pressure did not differ in patients with or without changes in flow status. The time-varying flow status remained a strong predictor of subsequent stroke (hazard ratio, 10.3 [95% CI, 2.2-48.7]).

Conclusions: There is potential both for improvement and worsening of hemodynamics in patients with atherosclerotic vertebrobasilar disease. Flow status, both at baseline and over time, is a risk factor for subsequent stroke, thus serving as an important prognostic marker. Registration: URL: https://ichgcp.net/clinical-trials-registry/NCT00590980" title="See in ClinicalTrials.gov">NCT00590980.

Keywords: atherosclerosis; blood pressure; hemodynamics; ischemic attack, transient; magnetic resonance angiography; stroke; vertebrobasilar insufficiency.

Figures

Figure 1.

Timeline plots of flow status and follow-up for patients. The x axis indicates months of follow-up starting at enrollment. Boxes represent timing of imaging assessing flow designations. Solid boxes represent low-flow designation, hollow boxes represent normal-flow designations. The short vertical bars at the end of a line indicate the end of clinical follow-up, which often coincides with timepoints of imaging follow-up. The x marks indicate a stroke event along the timeline, following which further clinical and radiographic follow-up was censored A. Flow status over time for patients with low flow at baseline. B. Flow status over time for patients with normal flow at baseline.