Imaging Predictors for Endovascular Recanalization of Non-acute Occlusion of Internal Carotid Artery Based on 3D T1-SPACE MRI and DSA

Abstract

Objectives: To investigate the predictive factors for successful recanalization based on digital subtraction angiography and three-dimensional T1W sampling perfection with application-optimized contrasts using different flip angle evolutions (3D T1-SPACE) high-resolution magnetic resonance imaging (MRI) signal features.Methods: Consecutive internal carotid artery occlusion cases with ipsilateral ischemic stroke refractory to therapy who visited our institution between February 2017 and August 2020 were retrospectively analyzed. Epidemiology, symptomatology, imaging morphology on angiography and MRI, peri-procedural complications, technical success rate, and follow-up results were summarized. Factors related to technical success were analyzed using univariate and multivariate analyses.Results: In total, 75 cases (53 men, mean age 57.51 ± 9.71 years) were included. The total successful recanalization rate was 72.00% (54/75), with a complication rate of 13.33% (9/75). Through multivariate analysis, first ischemic stroke in <3 months (OR: 2.57; 95% CI: 1.13–4.58), tapered stump (OR: 4.31; 95% CI: 1.37–13.55), reversed flow of the ophthalmic artery (OR: 2.99; 95% CI: 1.06–8.49), high intraluminal signal on unenhanced T1-SPACE sequence (OR: 16.15; 95% CI: 3.40–76.72), no vessel wall collapse (OR: 17.00; 95% CI: 3.57–81.02), short occlusion length (OR: 9.87; 95% CI: 2.09–46.64), and primary occlusion site at the cervical internal carotid artery (OR: 8.42; 95% CI: 1.04–68.19) were associated with successful recanalization.Conclusion: Besides traditional features such as short ischemic event time, tapered stump, and distal ICA reconstitution by the ophthalmic artery, our study demonstrates that luminal and mural changes determined by 3D SPACE high-resolution MRI could also predict successful endovascular recanalization. Endovascular recanalization for non-acute internal carotid artery occlusion is feasible, but prudent case selection is mandatory considering the high periprocedural complication rate.

High-resolution magnetic resonance imaging for predicting successful recanalization in patients with chronic internal carotid artery occlusion

“…However, the predictive value of their method has not been validated due to the limited number of surgery cases ( n = 13). In accordance with traditional DSA features like a tapered stump and reversed the flow of ophthalmic artery, we found that occlusions involving the C6 segment or above and nontapered stump on HR-MRI were independent negative predictors for technical success ( 4 , 17 , 19 ), which may be explained by the significantly increased difficulty of guide wire manipulation in patients with these factors. Theoretically, it is difficult to negotiate the wire through the long CICAO due to the variable vessel course, and it easily induces pseudoaneurysm formation and artery dissection.…”

Predictors of successful endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion

“…However, few studies have investigated the effects of occlusion duration on the technical success of endovascualr recanalization in patients with symptomatic nonacute ILAO. Several recent studies on endovascualr recanalization for nonacute ILAO showed that patients with successful recanalization had a shorter occlusion time, suggesting that the occlusion duration may be associated with technical success [ 11 , 24 , 26 ], but this association was not found in other studies [ 22 ]. These inconsistencies may be partly attributable to the difficulty and inherent limitations of estimating the duration of occlusion from clinical information.…”

“…Our technical success and periprocedural complication rates were comparable to those in recently reported case series [ 7 , 8 , 12 , 13 , 18 – 23 , 26 ]. The technical success and periprocedural complication rates for endovascular recanalization of nonacute ILAO have been reported to range from 53.1 to 100% and 4-44.4%, respectively [ 9 – 13 , 15 , 17 – 21 , 23 , 24 ], while the 30-day stroke and mortality rate has been reported to be 3.8-16.7% [ 11 , 18 – 21 , 23 ]. The differences in the successful recanalization and periprocedural complication rates in these studies may be due to differences in operator experience, intracranial occlusion location, occluded segment characteristics, the interval from vessel occlusion to endovascualr recanalization, and the roadmap techniques used.…”

“…Successful revascularization was defined as antegrade flow with a modified thrombolysis in cerebral infarction (TICI) grade ≥ 2b and residual stenosis of ≤ 50% [ 22 ]. Brain CT was performed immediately after the operation to rule out intracranial hemorrhage, after which all patients were typically monitored in neuro critical care units for 24 h postprocedure with a target systolic blood pressure < 120 mm Hg to reduce the risk of reperfusion hemorrhage [ 10 , 18 – 20 , 24 ].…”

Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke

“…One important point to note is that while it is relatively easy to differentiate ACICAO from dissection, it is often difficult to differentiate ACICAO from chronic carotid artery occlusion. [28][29][30] EVT for chronic carotid artery occlusion is considered technically feasible; however, the risks are fairly high. [31][32][33] In patients with mild symptoms, the possibility of chronic occlusion should be considered and the risks and benefits of intervention with EVT should be carefully assessed.…”