Endovascular Therapy for Acute Ischemic Stroke of Intracranial Atherosclerotic Origin—Neuroimaging Perspectives

Oh Young Bang,Pyoung Jeon,Byung Moon Kim,Woo-Keun Seo

doi:10.3389/fneur.2019.00269

Abstract

Large vessel occlusion (LVO) due to intracranial atherosclerosis (ICAS) is a common cause of acute ischemic stroke (AIS) in Asians. Endovascular therapy (EVT) has been established as the mainstay of treatment in patients with AIS and LVO. However, only a few patients of Asian descent with ICAS-related LVO (ICAS-LVO) were included in recent randomized controlled trials of EVT for AIS. Therefore, the findings of these trials cannot be directly applied to Asian patients with ICAS-LVO. In embolic LVO due to thrombus from the heart or a more proximal vessel, rapid, and complete recanalization can be achieved in more than 70–80% of patients, and it is important to exclude patients with large cores. In contrast, patients with ICAS-LVO usually have favorable hemodynamic profiles (good collateral status, small core, and less severe perfusion deficit), but poor response to EVT (more rescue treatments and longer procedure times are required for successful recanalization due to higher rates of reocclusion). Patients with ICAS-LVO may have different anatomic (plaque, angioarchitecture), hemodynamic (collateral status), and pathophysiologic (thrombus composition) features on neuroimaging compared to patients with embolic LVO. In this review, we discuss these neuroimaging features, their clinical implications with respect to determination of EVT responses, and the need for development of specific EVT devices and procedures for patients with ICAS-LVO.

Highlights

Large vessel occlusion (LVO), thought to originate from intracranial atherosclerosis (ICAS), is a common cause of acute ischemic stroke (AIS) in Asians [1]
Recanalization failure, residual stenosis, and reocclusion were more frequently observed than embolic occlusion and rescue therapy with permanent stent placement or adjuvant antithrombotics are often required after Endovascular therapy (EVT) in ICAS-LVO patients [2,3,4, 9]
While recent randomized controlled trials (RCTs) of EVT showed that appropriate selection is important in AIS, selection of appropriate EVT procedures may be more important in patients with ICAS-LVO

Summary

INTRODUCTION

Large vessel occlusion (LVO), thought to originate from intracranial atherosclerosis (ICAS), is a common cause of acute ischemic stroke (AIS) in Asians [1]. Recanalization failure, residual stenosis, and reocclusion were more frequently observed than embolic occlusion and rescue therapy with permanent stent placement or adjuvant antithrombotics are often required after EVT in ICAS-LVO patients [2,3,4, 9]. Longer procedure times were required and higher complication rates and poorer long-term outcomes were reported after EVT in patients with ICAS-LVO than in those with embolic occlusion [5, 6, 8]. Increased complication rate with the permanent placement of stent in the perforator bearing segment should be considered, especially in the setting of EVT for LVO when appropriate antiplatelet premedication before the procedure is not possible. Further studies are needed because a higher peri-procedural ischemic stroke rate was reported in the treatment of perforator-bearing arteries, and there was no difference between angioplasty alone and balloon mounted/self-expandable stenting [33]

Erythrocyte-poor thrombus

Findings

CONCLUSIONS