Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage

Abstract

Background: The ideal treatment for patients who survive from acute vertebrobasilar artery occlusion but develop aggressive ischemic events despite maximal medical therapy in the early non-acute stage is unknown. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion.Methods: Ten consecutive patients who presented with aggressive ischemic events in the early non-acute stage of intracranial vertebral artery occlusion from Jan 2015 to Nov 2020 were retrospectively reviewed. Among them, eight male and two female patients with a mean age of 66.7 years developed aggressive ischemic events, and the NIHSS score was elevated by a median of 7 points despite medical therapy. All patients received staged endovascular treatment 4–21 days from onset, at an average of 11 days. The strategy of staged treatment was as follows: first, a microwire was passed through the portion of the occlusion, which was then dilated with balloon inflation to maintain the perfusion above TICI grade 2b. Then, with the use of antiplatelet drugs, the residual intravascular thrombus was gradually eliminated by the continuous perfusion and an activated fibrinolytic system, leaving the residual stenosis. A second stage of angioplasty with stent implantation was subsequently performed if residual stenosis was ≥50%. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period.Results: Technical success was achieved in 9 patients who received staged endovascular treatment (perforation occurred in one patient during the first stage). The NIHSS scores were significantly improved, with a median score 7 points lower on discharge compared with the scores for the most severe status. Favorable outcomes with mRS score ≤ 2 were achieved in 7 and 9 patients at the 3-month follow-up and the latest follow-up, respectively, which was better than the preoperative status.Conclusion: Staged endovascular treatment might be a safe, efficient, and viable option in carefully selected patients with symptomatic intracranial vertebral artery occlusion in the early non-acute stage. However, this needs to be confirmed by further investigation, preferably in a large, controlled setting.

Time correlation of success recanalization for endovascular recanalization of medically refractory non-acute intracranial arterial occlusions

“…This study shows that interventional recanalization therapy is feasible and effective for screened sNAA-ICAO patients. The recanalization rate of this study technique reached 73.91%, which is an acceptable range compared with recanalization rates of 53.1%-95.5% in published articles in the past 3 years (16)(17)(18)(19)(20); the Ic-VA occlusion recanalization rate was 63.33%, which was the lowest. In addition, this study retrospectively analyzed the patient data from 2013 to 2021.…”

Rescue Endovascular Treatment to Prevent Neurological Deterioration in Acute Symptomatic Bilateral Vertebral Artery Occlusion

“…However, BVAO can cause low flow in the posterior circulation, leading to stepwise stroke progression in the brain stem and cerebellum [ 9 ]. Despite intensive medical treatment, patients may experience neurological deterioration and relapse of ischemic stroke due to collateral flows which usually supply insufficient cerebral perfusion in the presence of increased oxygen demand [ 10 ]. As shown in Table 1 , almost all patients who received conventional treatment presented neurological deterioration during hospitalization due to bilateral ischemic stroke lesions in the pons and/or midbrain, which are well known to have a grave prognosis [ 11 ].…”

“…9 Despite intensive medical treatment, patients may experience neurological deterioration and relapse of ischemic stroke due to collateral flows which usually supply insufficient cerebral perfusion in the presence of increased oxygen demand. 10 As shown in Table 1, almost all patients who received conventional treatment presented neurological deterioration during hospitalization due to bilateral ischemic stroke lesions in the pons and/or midbrain, which are well known to have a grave prognosis. 11 Decreased bilateral vertebral artery flow induces neurological deterioration due to inadequate perfusion of the basilar artery through poor collaterals despite medical treatment.…”

Effects of endovascular recanalization on symptomatic non-acute occlusion of intracranial arteries

“…In earlier studies, low flow extracranial-intracranial artery bypass did not show advantages over drug treatment, nor did it reduce the risk of ipsilateral ischemic stroke 12 , 13 . Recently, some small-sample studies have been performed on the effect of endovascular recanalization on symptomatic non-acute occlusion of intracranial internal carotid artery (ICA) 14 – 16 , middle cerebral artery (MCA) 2 , 17 – 19 , and vertebrobasilar artery (VBA) 20 , 21 . For non-acute occlusion of the initial segment of the ICA, hybrid surgery involving endarterectomy and endovascular stenting has achieved a high success rate of 97% 15 , and for non-acute occlusion of intracranial MCA and VBA, endovascular recanalization is the primary approach which may result in heterogeneous outcomes.…”