Thrombectomy Outcomes of Intracranial Atherosclerosis-Related Occlusions

Abstract

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.

Endovascular Treatment in Patients with Cerebral Artery Occlusion of Three Different Etiologies

“…9 However, most studies did not report differences in 3 month clinical outcome after EVT between patients with ICAS-O and those with embolism, 7,[10][11][12][13][14][15][16]26 which has also been highlighted by a recent meta-analysis. 31 These studies reported that 16% to 89% of patients with ICAS-O required stenting, and many were treated with tirofiban. 6,7,12,26 One study found that rescue stenting, tirofiban treatment, or repeated thrombectomy resulted in favorable outcomes in 45% of pa- tients with ICAS-O who underwent instant vascular reocclusion.…”

“…On the other hand, they tend to be younger and have less severe initial clinical symptoms, which are associated with better developed collaterals, while CA-O is associated with more severe initial symptoms and higher rates of hemorrhagic transformation. 28,31 Moreover, adequate rescue treatment including angioplasty, stenting, and administration of glycoprotein IIb/IIIa inhibitors has been used in patients with ICAS-O and AT-O. Thus, the functional outcomes were overall similar among patients with AT-O, ICAS-O, and CA-O.…”

Local Tirofiban Infusion for Remnant Stenosis in Large Vessel Occlusion: Tirofiban ASSIST study

“…The median age of the patients was higher in the tirofiban group than in the non-tirofiban group (non-tirofiban group versus tirofiban group; 63 [55-75] versus 71 [61-78], p = 0.015). The median initial NIHSS scores (15 [12][13][14][15][16][17][18][19][20][21] versus 14 [10][11][12][13][14][15][16][17][18][19][20], p = 0.322) and the median ASPECTS scores (8 [4.5-9.5] vs. 8 [6][7][8][9], p = 0.530) did not significantly differ between the two groups. Further, the intravenous recombinant tissue plasminogen activator (rtPA) did not significantly differ between the two groups (49.2% versus 33.9%, p = 0.093).…”

“…However, if the occlusion is caused by intracranial atherosclerotic stenosis (ICAS), these MT methods may not be sufficient for recanalization and reperfusion, and rescue treatment are frequently required following MT [6][7][8][9]. Until now, angiographic and clinical outcomes after ERT for ICAS-LVO have been reported to be challenging [10][11][12].…”

Current knowledge of large vascular occlusion due to intracranial atherosclerosis: focusing on early diagnosis

“…Secondly, the rescue strategy for failed MT in dealing with ICAS-LVO was undetermined. It had been illustrated that rescue therapies were often required for full recanalization of ICAS-LVO, which might increase the complexity of the procedure and prolong the procedure time [5,29]. However, there is a lack of study focusing on the optimal rescue strategy for ICAS-LVO, which is a pending issue in clinical practice.…”