Endovascular Therapy for Acute Ischemic Stroke of Intracranial Atherosclerotic Origin—Neuroimaging Perspectives

Abstract

Large vessel occlusion (LVO) due to intracranial atherosclerosis (ICAS) is a common cause of acute ischemic stroke (AIS) in Asians. Endovascular therapy (EVT) has been established as the mainstay of treatment in patients with AIS and LVO. However, only a few patients of Asian descent with ICAS-related LVO (ICAS-LVO) were included in recent randomized controlled trials of EVT for AIS. Therefore, the findings of these trials cannot be directly applied to Asian patients with ICAS-LVO. In embolic LVO due to thrombus from the heart or a more proximal vessel, rapid, and complete recanalization can be achieved in more than 70–80% of patients, and it is important to exclude patients with large cores. In contrast, patients with ICAS-LVO usually have favorable hemodynamic profiles (good collateral status, small core, and less severe perfusion deficit), but poor response to EVT (more rescue treatments and longer procedure times are required for successful recanalization due to higher rates of reocclusion). Patients with ICAS-LVO may have different anatomic (plaque, angioarchitecture), hemodynamic (collateral status), and pathophysiologic (thrombus composition) features on neuroimaging compared to patients with embolic LVO. In this review, we discuss these neuroimaging features, their clinical implications with respect to determination of EVT responses, and the need for development of specific EVT devices and procedures for patients with ICAS-LVO.

Predictors of delayed reocclusion after successful recanalization in acute basilar artery occlusion patients

“…Many patients considered ICAS were treated with balloon dilatation or stent implantation directly instead of stent thrombectomy. In our study, univariate analysis showed that patients with DR had significantly higher frequencies of ICAS (94.1% vs. 61.8%; P = 0.01) and intracranial angioplasty (88.2% vs. 57.2%; P = 0.02) and most of these patients were treated with balloon dilatation or stent first which can damage the fibrous cap and lead to aggravation of in situ reocclusion [ 22 , 23 ]. Our further analysis showed that there was no significance related to in patients treated with remedial measures after stent thrombectomy.…”

Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes

“…21,22 The differential diagnosis for ICAD-LVO includes vasospasm, dissection, and residual embolus. 8,23,24 Vasospasm is characterized by a transient focal narrowing in the arterial lumen which may improve with intraarterial vasodilators, such as verapamil or nicardipine. 25,26 Intracranial dissection, which can be iatrogenic, traumatic, or spontaneous, is recognized when a dissection flap is visualized.…”

Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease

“…Additionally, OCT can provide good-quality imaging of vessel wall layers to identify patients with ICAD-LVO. 56…”

“…Additionally, OCT can provide good-quality imaging of vessel wall layers to identify patients with ICAD-LVO. 56 In summary, early prediction of ICAD-LVO prior to an endovascular procedure is challenging. An integration of baseline clinical history, vascular risk factors, and imaging indicators can increase the accuracy of ICAD-LVO prediction.…”