Stroke

Increased use of glycoprotein IIb/IIIa inhibitors, angioplasty, or stenting may be required to achieve good outcomes in this population.

Patients whose large-vessel occlusion (LVO) strokes are related to intracranial atherosclerosis have certain unique features, according to a new meta-analysis that also identifies which thrombectomy complications are more likely to arise in this group and which additional measures might be indicated.

Of note, thrombectomy appears to be more technically difficult in patients with intracranial atherosclerosis-associated strokes, as shown by a longer puncture-to-reperfusion time and a high rate of intraprocedural reocclusion, investigators led by Anderson Chun On Tsang, MBBS (Queen Mary Hospital, Hong Kong), report in their paper published online May 14, 2019, ahead of print in Stroke.

“Although the optimal rescue treatment remains to be defined, successful revascularization may be achieved by intraarterial glycoprotein IIb/IIIa inhibitors infusion, balloon angioplasty, or intracranial stenting,” they write.

Commenting for Neurovascular Exchange, Matthew Alexander, MD (University of Utah, Salt Lake City), noted that “intracranial atherosclerosis is a common cause of ischemic stroke. However, its prevalence is higher in some populations compared with others. For instance, in Asia, this is the most common cause of stroke, so many acute stroke treatments will have this scenario occur. Conversely, in North America, this scenario is a small minority of acute stroke treatment cases, so practitioners may be less versed in these techniques. It is helpful for both groups of providers to have data to support their treatment algorithms.”

The researchers performed a meta-analysis of 10 retrospective studies and one prospective study that included a total of 1,967 patients with LVO stroke. Among these patients, 496 were found to have occlusions related to intracranial atherosclerosis. In the remaining 1,471, intracranial atherosclerosis was not identified as a contributing factor to their LVO stroke.

Patients with occlusions related to intracranial atherosclerosis were significantly more likely than those whose occlusions were not atherosclerosis-related to have hypertension, diabetes, dyslipidemia, and a history of smoking, but they were less likely to have atrial fibrillation.

With respect to thrombectomy outcomes, patients with intracranial atherosclerosis-related occlusions had higher rates of intraprocedural reocclusion, rescue balloon angioplasty, and rescue intracranial stenting. They also had a longer puncture-to-reperfusion time (80.8 vs 55.5 min; P < 0.001). There were no differences between the two groups with respect to rates of final recanalization (mTICI 2b/3), symptomatic intracranial hemorrhage, or good functional outcome (mRS 0-2) or mortality at 90 days.

Thrombectomy Outcomes

Alexander identified two main implications of the findings. “The first is that this is a difficult disease to manage. Knowing one-third of these cases will have reocclusion occur is helpful,” he said. “Additionally, this study shows that escalating measures to achieve durable recanalization (IIb/IIIa inhibitors, angioplasty, stenting) can be appropriate. When considering performing techniques with higher risks of complications, it is very helpful to have high-quality data to back up your decisions. This paper provides such data.”

But questions remain. “It still remains to be seen which techniques are superior among the options and which lesions deserve treatment with which techniques,” Alexander pointed out. “Additionally, if two-thirds of these cases do not have reocclusion, which of these cases merit escalation of therapy? These are difficult questions that remain to be answered.”

Source:

Tsang ACO, Orru E, Klostranec JM, et al. Thrombectomy outcomes of intracranial atherosclerosis-related occlusions: a systematic review and meta-analysis. Stroke. 2019;Epub ahead of print.

Disclosures:

Tsang and Alexander report no relevant conflicts of interest.