Utility of Leptomeningeal Collaterals in Predicting Intracranial Atherosclerosis-Related Large Vessel Occlusion in Endovascular Treatment

Abstract

Earlier or preprocedural identification of occlusion pathomechanism is crucial for effective endovascular treatment. As leptomeningeal collaterals tend to develop well in chronic ischemic conditions such as intracranial atherosclerosis (ICAS), we investigated whether leptomeningeal collaterals can be a preprocedural marker of ICAS-related large vessel occlusion (ICAS-LVO) in endovascular treatment. A total of 226 patients who underwent endovascular treatment were retrospectively reviewed. We compared the pattern of leptomeningeal collaterals between patients with ICAS-LVO and without. Leptomeningeal collaterals were assessed by preprocedural computed tomography angiography (CTA) and basically categorized by three different collateral assessment methods. Better leptomeningeal collaterals were significantly associated with ICAS-LVO, although they were not independent for ICAS-LVO. When leptomeningeal collaterals were dichotomized to incomplete (<100%) and complete (100%), the latter was significantly more frequent in patients with ICAS-LVO (52.5% versus 20.4%) and remained an independent factor for ICAS-LVO (odds ratio, 3.32; 95% confidence interval, 1.52–7.26; p = 0.003). The area under the curve (AUC) value of complete leptomeningeal collateral supply was 0.660 for discrimination of ICAS-LVO. Incomplete leptomeningeal collateral supply was not likely ICAS-LVO, based on the high negative predictive value (88.6%). Considering its negative predictive value and the independent association between complete leptomeningeal collateral supply and ICAS-LVO, leptomeningeal collaterals could be helpful in the preprocedural determination of occlusion pathomechanism.

Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease

“…Likewise, the occurrence of complete leptomeningeal collaterals on the baseline CTA is highly indicative of ICAD-related LVOS (OR, 3.32; 95% confidence interval [CI], 1.52 to 7.26; P=0.003). 41 The evaluation of the baseline CTA or of the https://doi.org/10.5853/jos.2021.01375 DSA during first deployment of stent-retriever may disclose a (bifurcation sparing) truncal-type occlusion versus a (bifurcation involving) branching-site occlusion which favor ICAD and embolic etiologies, respectively. [42][43][44] A Tmax profile of Tmax >4 seconds/Tmax >6 seconds ratio ≥2 on CT perfusion reflects good collaterals and is also suggestive of ICAD-related LVO.…”

Preprocedural determination of an occlusion pathomechanism in endovascular treatment of acute stroke: a machine learning-based decision

“…All features were those that could be typically observed before EVT. These preprocedural features included basic demographics (age and sex), risk factors for stroke (hypertension, diabetes, hypercholesterolemia, smoking, and coronary artery occlusive disease), occlusion location (ICA or middle cerebral artery), initial National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score (ASPECTS), and specific preprocedural findings inferring an occlusion pathomechanism (AF, HAS, leptomeningeal collateral status, and occlusion type determined on the CT angiography scan (CTA-determined occlusion type)) 11 20…”

Rescue Endovascular Treatment for Emergent Large Vessel Occlusion With Underlying Intracranial Atherosclerosis: Current State and Future Directions

“…In this study, 8/10 (80%) patients with ICAS-related ELVO had excellent collateral grade compared with 19/43 (44.2%) of patients with embolic ELVO ( p = 0.032) ( 13 ). A recent study by Baek et al investigated the utility of pre-procedural leptomeningeal collateral status in predicting ICAS-related ELVO ( 28 ). The authors used CTA to assess collateral status utilizing Tan's collateral grading system ( 29 ).…”

“…In the study by Baek et al 40 patients with ICAS-related ELVO and 186 with embolic ELVO were included. Complete (100%) collateral status was significantly higher among patients with ICAS-related ELVO (52.5% vs. 20.4%) ( 28 ).…”