Impact of Target Arterial Residual Stenosis on Outcome After Endovascular Revascularization

Abstract

Background and Purpose Acute intracranial occlusion can be associated with “in situ thrombo-occlusion” in relation to pre-existing intracranial atherosclerotic disease (ICAD). We aimed to assess residual stenosis at the site of a target arterial lesion (TAL) to determine whether residual stenosis at the TAL is associated with underlying ICAD. Methods One hundred and sixty-three patients who underwent endovascular therapy for M1 middle cerebral artery occlusion and achieved angiographic reperfusion were selected for analysis. The presence of residual stenosis at the TAL was classified using the Arterial Occlusive Lesion (AOL) scale at post-procedural angiography, and the severity of stenosis was grouped into none, mild (<50%), moderate (50–69%), severe (70–99%), and occlusion on post-procedural and follow-up angiography. We also recorded the incidence of instant reocclusion occurring during the procedure and delayed reocclusion detected on follow-up angiography. Results Seventy-four patients (45.5%) showed target arterial residual stenosis (AOL 2). As to the TAL etiology, 40 patients were classified into in situ thrombo-occlusion (54.1% of AOL 2 and 24.5% of M1 occlusion). The occurrence of instant or delayed reocclusion was independently associated with a low chance of favorable 3-month outcome. Further, the occurrence of delayed reocclusion was associated with excellent pretreatment collateral-flow and early neurological worsening, but not the severity of residual stenosis at the TAL. Conclusions In population with a high prevalence of ICAD, residual stenosis may be attributed to in situ thrombo-occlusion with underlying ICAD about 25% of cases, hindering functional recovery via the occurrence of instant or delayed reocclusion.

Vessel Patency at 24 Hours and Its Relationship With Clinical Outcomes and Infarct Volume in REVASCAT Trial (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset)

“…A potential underlying intracranial atherosclerotic disease has been hypothesized as reason of delayed arterial reocclusion, especially when residual stenosis remains at the target vessel immediately after thrombectomy. 21 Patients with arterial reocclusion had similar poor outcome to those with lack of recanalization after the procedure and significantly worse than those with partial or complete revascularization at 24 hours, supporting the fact that vessel status at 24 hours strongly determines clinical outcome. The effect of arterial reocclusion on functional recovery should be addressed in further meta-analysis because of the small sample of arterial reocclusion in the intervention group of REVASCAT.…”

“…Patients in the thrombectomy group with an absence of revascularization (mAOL grade 0) at 24 hours showed a nonsignificant higher infarct volume than nonrecanalizers in the medical group, finding that has also been observed in the SWIFT-PRIME study. 11 Little is known about the incidence of arterial reocclusion after successful endovascular revascularization and its effect on clinical outcome, [19][20][21] and no data are available to date from the recent large endovascular clinical trials. [1][2][3][4][5][6] In REVASCAT, arterial reocclusion was infrequent (3.1%) in patients with complete postprocedural revascularization (mTICI 2b/3), whereas reocclusion rate was significantly higher (26%) in those patients who only achieved partial revascularization (mTICI 2a).…”

Impact of stroke mechanism in acute basilar occlusion with reperfusion therapy

“…To evaluate the association of stroke mechanism with the clinical outcomes, a logistic regression analysis including the stroke mechanism and the previously recognized outcome parameters such as age, hypertension, NIHSS scores, location of occlusion, collateral status, onset‐to‐treatment time, and reperfusion/recanalization,2, 4, 5, 7, 10, 14, 18, 19, 20 as well as the parameters with a P < 0.20 in univariate analysis, was performed for the entire study population using a full model fit. Then, a full model fit logistic regression analyses for the outcome factors were performed again separately in each group of stroke mechanism.…”

Automated CT Perfusion Prediction of Large Vessel Acute Stroke from Intracranial Atherosclerotic Disease

“…Indeed, patients with in-situ thrombosis have been demonstrated to have better angiographic collaterals as compared to patients embolic LVOS [12]. In an Asian study of 86 patients evaluated with MR perfusion imaging, the severity of the perfusion defect was determined by a ratio of Tmax ≥8 s/Tmax ≥2 s volumes, and was found to be lower in ICAD as compared to other stroke subtypes [6].…”