Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis

Abstract

OBJECTIVE The optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients. METHODS A total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed. RESULTS Overall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0-2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094-0.689, p = 0.007). CONCLUSIONS Both intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.

Immediate effects of first-line thrombectomy devices for intracranial atherosclerosis-related occlusion: stent retriever versus contact aspiration

“…Taken together, SR can be considered more advantageous as a first-line device than CA for treatment of ICAS-LVO. However, despite this immediate advantage, there was no significant difference in the outcome following aggressive rescue treatment and device switching [31,32].…”

Current endovascular strategies for posterior circulation large vessel occlusion stroke: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

“…93 Both intracranial angioplasty/ stenting and intra-arterial infusion of a glycoprotein IIb/IIIa inhibitor were found to be safe and effective in treating underlying severe atherosclerotic stenosis in acute stroke patients with ELVO in a series of 140 patients in Korea, although only 1 in 5 patients in this study had basilar occlusions. 94 Also, a higher stroke complication rate has been noted in angioplasty and stenting of perforator bearing arteries in the posterior circulation versus the anterior circulation. 95 Angioplasty and stenting may be considered for pc-ELVO if there is a persistent severe stenosis following thrombectomy, particularly if there is poor reperfusion or a perceived high risk of re-occlusion(AHA Class IIb, Level of Evidence C-EO).…”

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

“…Taken together, SR can be considered more advantageous as a rst-line device than CA for treatment of ICAS-LVO. However, despite this immediate advantage, there was no signi cant difference in the outcome following aggressive rescue treatment and device switching [31,32].…”