Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment

Abstract

Background and PurposeLittle is known about prognosis after endovascular therapy (EVT) for acute large artery occlusion (LAO) caused by underlying intracranial atherosclerotic stenosis (ICAS). Therefore, we investigated the prognosis following EVT according to the underlying etiology of LAO. MethodsPatients from the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention-Korean Retrospective (ASIAN KR) registry (n=720) were included if their occlusion was in the intracranial anterior circulation and their onset-to-puncture time was <24 hours. Occlusion was classified according to etiology as follows: no significant stenosis after recanalization (Embolic group), and fixed significant focal stenosis in the occlusion site with flow impairment or re-occlusion observed during EVT (ICAS group). Patients were excluded when significant extracranial carotid lesions existed, and when the intracranial occlusion was intractable to EVT so that the etiology was undetermined. The effect of angiographic etiologic classification on outcomes was evaluated using multivariable analysis that was adjusted for potential confounders. ResultsAmong eligible patients (n=520), 421 and 99 were classified in the Embolic and ICAS groups, respectively. Patients in the Embolic and ICAS groups had similar successful reperfusion rates with EVT (79.6% vs. 76.8%, P=0.537) and 3-month functional independence (54.5% vs. 45.5%, P=0.104). In multivariable analysis, ICAS-related occlusion (odds ratio, 0.495; 95% confidence interval, 0.269 to 0.913; P=0.024) showed poorer 3-month functional independence compared to embolic occlusion. ConclusionsAfter EVT, patients with acute ICAS-related occlusion have relatively poor functional outcomes compared to those with embolic occlusion. Novel strategies need to be developed to improve EVT outcomes for ICAS occlusion.

Local Tirofiban Infusion for Remnant Stenosis in Large Vessel Occlusion: Tirofiban ASSIST study

“…The median age of the patients was higher in the tirofiban group than in the non-tirofiban group (non-tirofiban group versus tirofiban group; 63 [55-75] versus 71 [61-78], p = 0.015). The median initial NIHSS scores (15 [12][13][14][15][16][17][18][19][20][21] versus 14 [10][11][12][13][14][15][16][17][18][19][20], p = 0.322) and the median ASPECTS scores (8 [4.5-9.5] vs. 8 [6][7][8][9], p = 0.530) did not significantly differ between the two groups. Further, the intravenous recombinant tissue plasminogen activator (rtPA) did not significantly differ between the two groups (49.2% versus 33.9%, p = 0.093).…”

“…However, if the occlusion is caused by intracranial atherosclerotic stenosis (ICAS), these MT methods may not be sufficient for recanalization and reperfusion, and rescue treatment are frequently required following MT [6][7][8][9]. Until now, angiographic and clinical outcomes after ERT for ICAS-LVO have been reported to be challenging [10][11][12].…”

Immediate Effects of First-line Thrombectomy Devices for Intracranial Atherosclerosis-Related Occlusion: Stent Retriever versus Contact Aspiration

“…Underlying ICAS, which should be differentiated from embolism or other etiologies, was de ned based on the remaining xed focal stenosis during EVT. The step-by-step evaluations for differentiation were described previously [11]. Brie y, after con rmation of arterial occlusion, patients with uncommon stroke etiologies, such as dissection, Moyamoya disease, and vasculitis were excluded.…”

“…Brie y, after con rmation of arterial occlusion, patients with uncommon stroke etiologies, such as dissection, Moyamoya disease, and vasculitis were excluded. Embolic occlusion was classi ed based on complete vessel recanalization after thrombectomy, and ICAS-related occlusion was classi ed when a remnant stenosis of >70%, or a lesser degree of stenosis with a tendency toward reocclusion and/or ow impairment after thrombectomy was observed [11,17]. This classi cation was further con rmed by repeat angiography during admission.…”

“…Intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusion (ICAS-LVO) is a common cause of stroke, especially among the Asian population [5][6][7][8][9]. In ICAS-LVO, immediate reocclusion occurs frequently, requiring further rescue treatment, and the nal reperfusion rate tends to be lower than that of embolic occlusions [10,11]. Because of these features, a different approach may be needed for ICAS-LVO than that for general embolic occlusions [12].…”