The only independent predictor of good outcome in the observational study was lack of previous stroke or TIA.
Intracranial angioplasty with or without stenting and intra-arterial infusion of a glycoprotein IIb/IIIa inhibitor are both safe and effective strategies for the treatment of emergent large vessel occlusion (ELVO) in patients with underlying severe intracranial atherosclerotic stenosis (ICAS), according to a recent retrospective analysis. Published online recently in the Journal of Neurosurgery, it is the largest study to date examining use of endovascular therapy in this clinical context.
Investigators led by Dong-Hun Kang, MD (Kyungpook National University, Daegu, Korea), retrospectively analyzed data on 140 consecutive patients with ELVO attributable to severe ICAS who underwent endovascular therapy at one of two stroke centers in the Republic of Korea. Intracranial angioplasty/stenting was primarily performed at Center A, while intra-arterial infusion of the glycoprotein IIb/IIIa inhibitor tirofiban was primarily performed at Center B.
Overall, successful reperfusion, defined as an mTICI score of 2b/3, was achieved in 95% (133/140) of patients. Good outcome, defined as a 3-month mRS 0-2, was seen in 60% (84/140). The overall mortality rate was 7.9%. Symptomatic intracranial hemorrhage (ICH) occurred in one patient at Center A. There were no significant differences between the groups of patients treated at Center A versus Center B with respect to any of these outcomes.
Outcomes by Treatment Center
|
|
Center A (n = 72) |
Center B (n = 68) |
P Value |
|
mTICI 2b/3 |
95.8% |
94.1% |
0.713 |
|
mRS 0-2 |
56.9% |
63.2% |
0.448 |
|
Overall Mortality |
9.7% |
5.9% |
0.534 |
|
Symptomatic ICH |
1.4% |
0 |
1 |
Multivariate logistic regression analysis revealed that the only independent predictor of good outcome was a history of previous stroke or TIA (OR 0.254; 95% CI 0.094-0.689, P = 0.007). According to Kang et al, “more meticulous management of vascular risk factors is needed to prevent secondary stroke in patients with first-ever stroke and severe ICAS.”
‘Reassuring’ Findings Require Confirmation
“The study provides some initial safety and efficacy experience of angioplasty and stenting and infusion of glycoprotein IIb/IIIa inhibitors in acute ELVO due to ICAS,” said Shyam Prabhakaran, MS, MD (Northwestern Memorial Hospital, Chicago, IL), who was not involved in the research.
“While reassuring, I would caution extrapolating this to practice without first devising larger multicenter, prospective trials,” he commented to Neurovascular Exchange. “This was a non-controlled, retrospective study with potential for selection bias and limited generalizability to all settings. It is not always possible to know angiographically that the underlying mechanism is ICAS versus another etiology, such as partially recanalized/adherent thrombus, vasospasm, or dissection.” He added that the safety of this approach in unselected patients remains unknown.
“Although many ELVOs are embolic, . . . some ELVOs are clearly due to local (in-situ) thrombus at a site of atherosclerotic plaque rupture, especially in Asia where ICAS is the leading mechanism of ischemic stroke,” Prabhakaran explained. “In these instances, thrombectomy would not be expected to restore normal caliber to the artery, and other techniques may be required to treat the atherosclerotic plaque and persistent stenosis. . . . A balloon angioplasty or deployed stent may be required after attempted thrombectomy/aspiration. However, this is unproven and carries considerable risks, given the findings from the SAMMPRIS and VISSIT trials.”
The current gold-standard approach, he said, is to attempt thrombectomy using approved devices and manage the underlying plaque medically, usually with dual antiplatelet therapy for 90 days and aggressive risk factor management. But additional studies are needed to confirm what the ideal approach might be.
Kang and colleagues agree that multicenter, randomized controlled trials are needed to confirm the findings.
Source:
Kang DH, Yoon W, Kim SK, et al. Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis. J Neurosurg. 2018;Epub ahead of print.
Disclosures:
Kang and Prabhakaran report no relevant conflicts of interest.
