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

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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.

ABBREVIATIONS DWI = diffusion weighted imaging; ELVO = emergent large vessel occlusion; ICA = internal carotid artery; ICAS = intracranial atherosclerotic stenosis; IQR = interquartile range; IV = intravenous; MCA = middle cerebral artery; mRS = modified Rankin scale; m-TICI = modified treatment in cerebral infarction; NIHSS = National Institutes of Health Stroke Scale; rt-PA = recombinant tissue plasminogen activator; TIA = transient ischemic attack; WASID = Warfarin-Aspirin Symptomatic Intracranial Disease.

Article Information

Correspondence Woong Yoon: Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea. radyoon@jnu.ac.kr.

INCLUDE WHEN CITING Published online June 22, 2018; DOI: 10.3171/2018.1.JNS172350.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Brain images from a 73-year-old man with acute ischemic stroke. A: Initial catheter angiography shows the occlusion (arrow) in the proximal M1 segment of the left MCA. B: Angiography obtained after one passage of the Trevo stent-retriever reveals an eccentric severe underlying stenosis (arrow) at the occlusion site. C: Angiography after intracranial angioplasty with a balloon catheter with a diameter of 2.75 mm shows complete reperfusion in the left MCA territory and mild residual stenosis (arrow).

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    Brain images from a 69-year-old woman with acute ischemic stroke. A: Initial catheter angiography shows the occlusion (arrow) in the terminal segment of the right ICA. B: Angiography obtained after manual aspiration thrombectomy with a Penumbra reperfusion catheter reveals a concentric severe underlying stenosis (arrow) at the occlusion site. C: Angiography after intraarterial infusion of 0.5 mg of tirofiban through a microcatheter over 10 minutes shows complete reperfusion in the right MCA territory and severe residual stenosis (arrow). This patient has an aplasia of the A1 segment of the right anterior cerebral artery.

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