Stroke recurrences in patients with symptomatic vs asymptomatic middle cerebral artery disease

Although the natural history of extracranial carotid artery disease has been investigated systematically, limited data are available on the course of middle cerebral artery (MCA) disease.The authors observed 102 consecutive patients (67 men, 35 women; mean age 61.9 years) with significant MCA stenosis or occlusion as demonstrated by transcranial Doppler and transcranial color-coded duplex ultrasonography. Forty-six patients entered the study after TIA (n = 17) or stroke (n = 29); 56 patients were asymptomatic. Neurologic and ultrasound investigations were performed at regular intervals with a mean follow-up of 31 (range 6 to 117) months. Patients were continuously treated with either platelet inhibitors (n = 75) or anticoagulation (n = 27).Nineteen cerebral ischemic events (11 strokes, 8 TIAs) occurred during follow-up, resulting in an overall annual rate of 7.3%. Thirteen events (8 strokes, 5 TIAs) were attributable to the vascular territory ipsilateral to MCA disease. Patients with symptomatic MCA disease at study entry had an overall stroke risk of 12.5% per year (ipsilateral: 9.1%), whereas the annual incidence in primarily asymptomatic MCA disease was only 2.8% (ipsilateral: 1.4%; p < 0.01). Symptomatic MCA disease was an independent predictor for overall (hazard ratio [HR] 7.91, 95% CI 2.03 to 30.79; p < 0.01) and ipsilateral (HR 9.66, 95% CI 1.5 to 62.25; p = 0.02) cerebrovascular events.Compared with asymptomatic middle cerebral artery disease, there was a high and continuous recurrence rate of ischemic events in symptomatic patients, which was even higher than in patients with symptomatic extracranial carotid artery disease.