Optimal endovascular therapy technique for isolated intracranial atherothrombotic stroke-related large vessel occlusion in the acute to subacute stage

Mikiya Beppu; Kazutaka Uchida; Nobuyuki Sakai; Hiroshi Yamagami; Kazunori Toyoda; Yuji Matsumaru; Yasushi Matsumoto; Kenichi Todo; Mikito Hayakawa; Seigo Shindo; Shinzo Ota; Masafumi Morimoto; Masataka Takeuchi; Hirotoshi Imamura; Hiroyuki Ikeda; Kanta Tanaka; Hideyuki Ishihara; Hiroto Kakita; Takanori Sano; Hayato Araki; Tatsufumi Nomura; Fumihiro Sakakibara; Manabu Shirakawa; Shinichi Yoshimura; RESCUE AT-LVO Investigators

doi:10.3174/ajnr.A8399

Optimal endovascular therapy technique for isolated intracranial atherothrombotic stroke-related large vessel occlusion in the acute to subacute stage

AJNR Am J Neuroradiol. 2024 Jul 1:ajnr.A8399. doi: 10.3174/ajnr.A8399. Online ahead of print.

Authors

Mikiya Beppu¹, Kazutaka Uchida¹, Nobuyuki Sakai¹, Hiroshi Yamagami¹, Kazunori Toyoda¹, Yuji Matsumaru¹, Yasushi Matsumoto¹, Kenichi Todo¹, Mikito Hayakawa¹, Seigo Shindo¹, Shinzo Ota¹, Masafumi Morimoto¹, Masataka Takeuchi¹, Hirotoshi Imamura¹, Hiroyuki Ikeda¹, Kanta Tanaka¹, Hideyuki Ishihara¹, Hiroto Kakita¹, Takanori Sano¹, Hayato Araki¹, Tatsufumi Nomura¹, Fumihiro Sakakibara¹, Manabu Shirakawa¹, Shinichi Yoshimura¹; RESCUE AT-LVO Investigators

Affiliation

¹ From the Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan (M.B., K.U., M.S., S.Y., F.S.); Neurovascular Research & Neuroendovascular Therapy, Kobe City Medical Center General Hospital, Kobe, Japan (N.S.), Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan (H.Y.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T., K.T.); Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.M.); Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Japan (Y.M.); Department of Neurology, Osaka University Graduate School of Medicine, Suita, Japan (K.T.); Department of Neurology, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan (M. H.); Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan (S.S.); Department of Neurology, Kumamoto University, Kumamoto, Japan (S.S.); Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, Fukuyama, Japan (S.O.); Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan (M.M.); Department of Neurosurgery, Seisho Hospital, Odawara, Japan (M.T.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.I.); Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan (H.I.); Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan (H.I.); Department of Neurosurgery, Shimizu Hospital, Kyoto, Japan (H.K.); Department of Neurosurgery, Japanese Red Cross Ise Hospital, Ise, Japan (T.S.); Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan (H.A.); Neuroendovascular Therapy Center, Ohkawara Neurosurgical Hospital, Muroran, Hokkaido, Japan (T.N.).

PMID: 38951032
DOI: 10.3174/ajnr.A8399

Abstract

Background and purpose: Reocclusion after treatment is a concern in endovascular therapy (EVT) for isolated intracranial atherothrombotic stroke-related large vessel occlusion (AT-LVO). However, the optimal EVT technique for AT-LVO has not yet been investigated. This study evaluated the optimal EVT technique for AT-LVO in a real-world setting.

Materials and methods: We conducted a historical multicenter registry study at 51 centers that enrolled patients with AT-LVO. We divided the patients into three groups based on the EVT technique: mechanical thrombectomy alone (MT-only), percutaneous transluminal angioplasty (PTA), and stent deployment (Stent). MT alone was classified into the MT-only group, PTA and MT-PTA into the PTA group, and MT-Stent, MT-PTA-Stent, PTA-Stent, and Stent-only into the Stent group. The primary outcome was the incidence of reocclusion of the treated vessels within 90 days of EVT completion.

Results: We enrolled 770 patients and analyzed 509 patients. The rates in the MT-only, PTA, and Stent groups were 40.7, 44.4, and 14.9%, respectively. The incidence rate of residual stenosis >70% of final angiography was significantly higher in the MT-only group than in the PTA and Stent groups (MT-only vs. PTA vs. Stent: 34.5% vs. 26.3% vs. 13.2%, p=0.002). The reocclusion rate was significantly lower in the PTA group than in the MT-only group (adjusted hazard ratio [95% confidence interval], 0.48 [0.29-0.80]). Of the patients, 83.5% experienced reocclusion within 10 days after EVT. Alarmingly, a substantial subset (approximately 62.0%) of patients underwent reocclusion within 2 days of EVT. The incidence of modified Rankin scale scores of 0-2 90 days after EVT was not significantly different among the three groups. The incidences of symptomatic intracranial hemorrhage (ICH), any other ICH, and death were not significantly different.

Conclusions: The incidence rate of reocclusion was significantly lower in the PTA group than in the MT-only group. We found no significant difference in reocclusion rates between the Stent and MT-only groups. In Japan, GP IIb/IIIa inhibitors are not reimbursed. Therefore, PTA might be the preferred choice for AT-LVOs due to the higher reocclusion risk with MT-only. Reocclusion was likely to occur within 10 days, particularly within 2 days post-EVT.

Abbreviations: EVT = endovascular treatment; LVO = large vessel occlusion; MT = mechanical thrombectomy; PTA = percutaneous transluminal angioplasty; ICH = intracranial hemorrhage; SD = standard deviation; IQR = interquartile range; HRs = hazard ratios; BMI = body mass index; LDL = low-density lipoprotein; HDL = high-density lipoprotein; DAPT = dual antiplatelet therapy; TAPT = triple antiplatelet therapy.