J Neurosurg. 2026 Mar 6:1-6. doi: 10.3171/2025.10.JNS251032. Online ahead of print.
ABSTRACT
OBJECTIVE: Patients experiencing ischemic strokes typically develop substantial cognitive decline. Intracranial atherosclerotic disease (ICAD) is a common stroke etiology that exposes patients to high and prolonged risks of recurrence. The ERSIAS-PC (Encephaloduroarteriosynangiosis revascularization for symptomatic intracranial atherosclerotic steno-occlusive performance criterion) phase II trial showed a lower risk of recurrent stroke in patients who underwent encephaloduroarteriosynangiosis (EDAS) plus intensive medical management (IMM). In the current study, the authors evaluate factors contributing to cognitive decline in patients with symptomatic ICAD treated with EDAS revascularization.
METHODS: ERSIAS-PC patients without aphasia who had completed at least 1 year of follow-up were included this post hoc analysis. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) at baseline and each follow-up and was classified as improved/preserved or worsened. Classification and regression tree (CART) analysis was used to identify factors associated with changes in cognitive function. The factors considered were age, sex, stenosis versus occlusion, baseline modified Rankin Scale score, good collateralization, and compliance with diabetes mellitus (DM), hypertension, and hyperlipidemia (HLD) treatments.
RESULTS: Of the 52 ERSIAS-PC patients, 39 were included in this subgroup analysis. The median age was 46 (IQR 37.0-56.0) years, and 27 (69.2%) patients were female. The mean MoCA score was 22.4 ± 4.9 at baseline and 23.9 ± 4.9 at the 1-year follow-up among the 52 patients in the ERSIAS-PC trial population. Among the 39 patients in this subgroup analysis, the MoCA score improved or remained stable in 33 (84.6%) and declined in 6 (15.4%). CART analysis indicated that the most relevant factor for an improved MoCA score after surgery was compliance with DM treatment (94.5% yes vs 74.2% no, p = 0.02). Other factors indicating a nominal though not statistically significant influence were HLD treatment (83.3% yes vs 60.5% no, p = 0.2) and stenosis (99.1% vs 80.9% occlusion, p = 0.6).
CONCLUSIONS: Compliance with DM treatment was significantly associated with cognitive preservation in patients with symptomatic ICAD treated with EDAS. The study findings emphasize the importance of the IMM of stroke risk factors in patients with intracranial atherosclerosis, even after surgical revascularization.
PMID:41791115 | DOI:10.3171/2025.10.JNS251032
