Hemodynamic biomarkers in symptomatic intracranial atherosclerotic stenosis: evidence boundaries and research pathways from prognostic stratification to treatment-effect prediction
- 1Oriental Pan-Vascular Devices Innovation College, University of Shanghai for Science and Technology
- 2Neurovascular Center, Changhai Hospital, Naval Medical University
Abstract
Symptomatic intracranial atherosclerotic stenosis (sICAS) has traditionally been stratified primarily according to angiographic stenosis severity. However, this anatomical approach does not adequately capture the heterogeneity of ischemic mechanisms, distal hemodynamic compromise, or treatment response, prompting increasing interest in hemodynamic biomarkers for mechanism-based risk stratification. In this review, we propose an evidence framework that evaluates these biomarkers across measurement validity, mechanistic coherence, prognostic association, treatment-effect prediction, external validation, and clinical utility, while integrating lesion function, distal perfusion, compensatory capacity, and parallel embolic and perforator pathways. Although several measures, particularly distal hypoperfusion and borderzone infarction, have shown prognostic value, the evidence identified in this review remains dominated by single-center studies, platform-specific definitions, and incompletely validated thresholds. Among the completed direct sICAS studies identified, we found no prospective validation of a hemodynamic biomarker as a treatment-effect modifier. Translation requires standardized measurement, prespecified biomarker definitions, and external validation. Claims of treatment-effect modification additionally require prespecified interaction analyses within appropriate treatment comparisons, preferably randomized. Biomarker-guided treatment selection should be supported by reliable estimates of absolute benefits and harms and evidence of clinical utility.
Related
- The clinical application of a low-profile stent for symptomatic intracranial atherosclerotic stenosis in the middle cerebral artery: a retrospective study of the Atlas stent
- Angiography-derived fractional flow and clinical outcomes in symptomatic intracranial atherosclerotic stenosis
- Clinical Characteristics and In-Hospital Course of Symptomatic Intracranial Hemorrhage After Intravenous Alteplase in Older Adults with Acute Ischemic Stroke: A Retrospective Cohort Study
- Stent retriever angioplasty with the Tigertriever as a bailout strategy for intracranial atherosclerotic disease–related large-vessel occlusion: illustrative cases
- Hemodynamic Induction of Intracranial Aneurysms via Bilateral Common Carotid Artery Ligation in Rabbits: A Systematic Review and Meta-Analysis
BibTeX
@article{hu2026hemodynamic,
title = {{Hemodynamic biomarkers in symptomatic intracranial atherosclerotic stenosis: evidence boundaries and research pathways from prognostic stratification to treatment-effect prediction}},
author = {Ruying Hu and Zizhao Zhang and Zipeng Wang and Jianmin Liu and Lei Zhang and Hongjian Zhang},
journal = {Frontiers in Neurology},
year = {2026},
month = oct,
doi = {10.3389/fneur.2026.1980919},
url = {https://www.frontiersin.org/articles/10.3389/fneur.2026.1980919/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Hemodynamic biomarkers in symptomatic intracranial atherosclerotic stenosis: evidence boundaries and research pathways from prognostic stratification to treatment-effect prediction
AU - Ruying Hu
AU - Zizhao Zhang
AU - Zipeng Wang
AU - Jianmin Liu
AU - Lei Zhang
AU - Hongjian Zhang
PY - 2026
DA - 2026/10/15
JO - Frontiers in Neurology
DO - 10.3389/fneur.2026.1980919
UR - https://www.frontiersin.org/articles/10.3389/fneur.2026.1980919/full
AB - Symptomatic intracranial atherosclerotic stenosis (sICAS) has traditionally been stratified primarily according to angiographic stenosis severity. However, this anatomical approach does not adequately capture the heterogeneity of ischemic mechanisms, distal hemodynamic compromise, or treatment response, prompting increasing interest in hemodynamic biomarkers for mechanism-based risk stratification. In this review, we propose an evidence framework that evaluates these biomarkers across measurement validity, mechanistic coherence, prognostic association, treatment-effect prediction, external validation, and clinical utility, while integrating lesion function, distal perfusion, compensatory capacity, and parallel embolic and perforator pathways. Although several measures, particularly distal hypoperfusion and borderzone infarction, have shown prognostic value, the evidence identified in this review remains dominated by single-center studies, platform-specific definitions, and incompletely validated thresholds. Among the completed direct sICAS studies identified, we found no prospective validation of a hemodynamic biomarker as a treatment-effect modifier. Translation requires standardized measurement, prespecified biomarker definitions, and external validation. Claims of treatment-effect modification additionally require prespecified interaction analyses within appropriate treatment comparisons, preferably randomized. Biomarker-guided treatment selection should be supported by reliable estimates of absolute benefits and harms and evidence of clinical utility.
SN - 1664-2295
ER -