Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2023 May;25(2):223-232.
doi: 10.5853/jos.2023.00185. Epub 2023 May 30.

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

Saurav Das  1 , Liqi Shu  2 , Rebecca J Morgan  3 , Asghar Shah  2 , Fayez H Fayad  2 , Eric D Goldstein  2 , Dalia Chahien  4 , Benton Maglinger  5 , Satish Kumar Bokka  6 , Cory Owens  1 , Mehdi Abbasi  7 , Alexandra Kvernland  8 , James E Siegler  9 , Brian Mac Grory  10 , Thanh N Nguyen  11 , Karen Furie  2 , Pooja Khatri  12 , Eva Mistry  12 , Shyam Prabhakaran  13 , David S Liebeskind  14 , Jose G Romano  15 , Adam de Havenon  7 , Lina Palaiodimou  16 , Georgios Tsivgoulis  16 , Shadi Yaghi  2
Affiliations
Review

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

Saurav Das et al. J Stroke. 2023 May.

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.

Keywords: Borderzone Infarct; Intracranial arterial diseases; Intracranial atherosclerosis; Recurrence; Stroke.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest

The authors have no financial conflicts of interest.

Figures

Figure 1.
Figure 1.
Study selection flow chart.
Figure 2.
Figure 2.
Risk of bias assessment using the Risk of Bias in Nonrandomized Studies (ROBINS-I) tool.
Figure 3.
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.
Figure 4.
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.
See this image and copyright information in PMC

References

    1. Banerjee C, Chimowitz MI. Stroke caused by atherosclerosis of the major intracranial arteries. Circ Res. 2017;120:502–513. - PMC - PubMed
    1. Wong LK. Global burden of intracranial atherosclerosis. Int J Stroke. 2006;1:158–159. - PubMed
    1. Sacco RL, Kargman DE, Zamanillo MC. Race-ethnic differences in stroke risk factors among hospitalized patients with cerebral infarction: the Northern Manhattan Stroke Study. Neurology. 1995;45:659–663. - PubMed
    1. Tsivgoulis G, Vadikolias K, Heliopoulos I, Katsibari C, Voumvourakis K, Tsakaldimi S, et al. Prevalence of symptomatic intracranial atherosclerosis in Caucasians: a prospective, multicenter, transcranial Doppler study. J Neuroimaging. 2014;24:11–17. - PubMed
    1. Yaghi S, Rostanski SK, Boehme AK, Martin-Schild S, Samai A, Silver B, et al. Imaging parameters and recurrent cerebrovascular events in patients with minor stroke or transient ischemic attack. JAMA Neurol. 2016;73:572–578. - PMC - PubMed