Background and Purpose— Intracranial atherosclerosis (ICAS) is an important cause of large vessel occlusion and poses unique challenges for emergent endovascular thrombectomy. The risk factor profile and therapeutic outcomes of patients with ICAS-related occlusions (ICAS-O) are unclear. We performed a systematic review and meta-analysis of studies reporting the clinical features and thrombectomy outcomes of large vessel occlusion stroke secondary to underlying ICAS (ICAS-O) versus those of other causes (non–ICAS-O). Methods— A literature search on thrombectomy for ICAS-O was performed. Random-effect meta-analysis was used to analyze the prevalence of stroke risk factors and outcomes of thrombectomy between ICAS-O and non–ICAS-O groups. Results— A total of 1967 patients (496 ICAS-O and 1471 non–ICAS-O) were included. The ICAS-O group had significantly higher prevalence of hypertension (odds ratio [OR] 1.46; 95% CI, 1.10–1.93), diabetes mellitus (OR, 1.68; 95% CI, 1.29–2.20), dyslipidemia (OR, 1.94; 95% CI, 1.04–3.62), smoking history (OR, 2.11; 95% CI, 1.40–3.17) but less atrial fibrillation (OR, 0.20; 95% CI, 0.13–0.31) than the non–ICAS-O group. About thrombectomy outcomes, ICAS-O had higher intraprocedural reocclusion rate (OR, 23.7; 95% CI, 6.96–80.7), need for rescue balloon angioplasty (OR, 9.49; 95% CI, 4.11–21.9), rescue intracranial stenting (OR, 14.9; 95% CI, 7.64–29.2), and longer puncture-to-reperfusion time (80.8 versus 55.5 minutes, mean difference 21.3; 95% CI, 11.3–31.3). There was no statistical difference in the rate of final recanalization (modified Thrombolysis in Cerebral Infarction score of 2b/3; OR, 0.67; 95% CI, 0.36–1.27), symptomatic intracerebral hemorrhage (OR, 0.79; 95% CI, 0.50–1.24), good functional outcome (modified Rankin Scale score of 0–2; OR, 1.16; 95% CI, 0.85–1.58), and mortality (OR, 0.94; 95% CI, 0.64–1.39) between ICAS-O and non–ICAS-O. Conclusions— Patients with ICAS-O display a unique risk factor profile and technical challenges for endovascular reperfusion therapy. Intraprocedural reocclusion occurs in one-third of patients with ICAS-O. Intraarterial glycoprotein IIb/IIIa inhibitors infusion, balloon angioplasty, and intracranial stenting may be viable rescue treatment to achieve revascularization, resulting in comparable outcomes to non–ICAS-O.

Background and objectivePulsatile tinnitus (PT) can be debilitating and lead to significant morbidity. Cerebral venous sinus lesions, such as venous sinus stenosis, diverticula, and high-riding jugular bulb, are uncommon causes of PT, for which there is no standard treatment. Endovascular interventions have shown promising results for PT secondary to idiopathic intracranial hypertension, and may be a valid therapeutic option for isolated venous PT.MethodsWe conducted a systematic literature review on the outcome and safety of endovascular treatment for patients with isolated, debilitating venous PT. The venous lesion characteristics, endovascular techniques, complications, and clinical outcomes were assessed. In addition, an illustrative case of endovascular stenting for PT caused by venous sinus stenosis was included.ResultsA total of 41 patients (90.2% female) from 26 papers were included. The median age was 46 years (IQR 23; range 25–72 years). Focal venous sinus stenosis (20 patients) and sinus diverticula (14 patients) were the most common culprit lesions. Endovascular treatment included venous sinus stenting in 35 patients, 11 of whom had adjuvant coil embolization, and coil embolization alone in six patients. Complete resolution of the tinnitus was achieved in 95.1% of patients. There was one complication of cerebellar infarct, and no procedure-related mortality.ConclusionsIn patients with debilitating PT secondary to venous sinus lesions, endovascular treatment by stenting and/or coil embolization appears to be safe and effective. Prospective randomized studies with objective outcome assessments are needed to confirm the treatment benefits.

Endovascular thrombectomy revolutionized the treatment of acute ischemic stroke. Nevertheless, access to endovascular thrombectomy is limited in many parts of the world. Asia holds 60% of the world’s population and its countries carry some of the highest stroke disease burden. To understand the availability of endovascular thrombectomy and intravenous thrombolysis in this region, we interviewed stroke neurologists and neuro-interventionists of 19 Asian countries, and found a large disparity in access to endovascular thrombectomy and intravenous thrombolysis between high- and low-income countries. Lack of neuro-interventionists, comprehensive stroke units, stroke triage systems and high treatment cost are the major obstacles to wider accessibility of endovascular thrombectomy, especially among developing countries. The potential solutions to provide equitable access to stroke revascularization therapy are discussed.