Dual-roadmap guidance for endovascular recanalization of medically refractory non-acute intracranial arterial occlusions: consecutive multicenter series and technical review

Clinical Study of Symptomatic Nonacute Intracranial Large Arterial Occlusion with Endovascular Recanalization

Objectives  This study reported a single-center clinical trial of endovascular treatment for symptomatic nonacute occlusion of the intracranial large artery (NA-ILAO). The aim of this study was to evaluate the safety, feasibility, and clinical effect of simple balloon dilatation and stent implantation. Methods  The patients diagnosed with symptomatic NA-ILAO were enrolled. A total of 40 cases were included in this study. While recanalization failed in 4 patients, it was successful in 36 patients, who were then divided into two groups for further analysis: balloon dilatation group ( n  = 24) and stent implantation group ( n  = 12). The perioperative complications, clinical outcome, and follow-up results were analyzed. Results  Perioperative complications in the stent implantation group were significantly higher than those in the simple balloon dilatation group ( p  < 0.05). There were 21 and 10 cases of 90-day good clinical outcome (modified Rankin scale [mRS] ≤ 2) in the balloon and stent groups, respectively ( p  = 0.518). All patients with successful recanalization underwent digital subtraction angiography (DSA) or CT angiography (CTA) during an average follow-up of 14 months. There were two cases of restenosis in the balloon dilatation group and one in the stent implantation group ( p  = 1.000). There were two cases of re-occlusion in the stent group and none in the balloon dilatation group ( p  < 0.001). Stroke recurred in two cases in the stent group and in one case in the simple balloon dilatation group ( p  = 0.013). Conclusion  Endovascular recanalization is safe and feasible for patients with symptomatic NA-ILAO. Compared with stent implantation, simple balloon dilation may be a better recanalization method, but larger randomized controlled trials are needed to confirm it.

Effects and safety of endovascular recanalization for non-acute symptomatic intracranial vertebral artery occlusion with different risks

There is no consensus on the optimal treatment for non-acute symptomatic intracranial vertebral artery occlusion, and endovascular recanalization is a challenging procedure. We report our clinical experience of endovascular recanalization in patients with non-acute symptomatic intracranial vertebral artery occlusion to assess the feasibility and safety of endovascular recanalization and determine the candidate patients for this procedure. Ninety-two patients with non-acute symptomatic intracranial vertebral artery occlusion who underwent endovascular recanalization from January 2019 to December 2021 were retrospectively analyzed. we grouped all patients according to imaging examination findings, occlusion length, duration, nature, calcification, and angulation to evaluate the risk of endovascular recanalization. The overall success rate of endovascular recanalization was 83.7% (77/92), and the perioperative complication rate was 10.9% (10/92). Among the 3 classification groups, the recanalization success rate gradually decreased from the low-risk group to the high-risk group (low-risk: 100%, medium-risk: 93.3%, high-risk group: 27.8%, P = .047), while the overall perioperative complication rate showed the opposite trend (0%, 10.0%, 38.9%, respectively, P = .001); the proportion of patients with 90-day modified Rankin Scale scores of 0-2 decreased successively (100%, 83.3%, and 22.2%, respectively, P < .026); 77 patients with successful recanalization were followed; the rate of restenosis/reocclusion increased sequentially (0%, 17.9%, and 80%, respectively, P = .000). Patients in the low- and medium-risk groups showed a good clinical course after endovascular recanalization. Among 88 patients (four patients lost to follow-up), with a median clinical follow-up of 13 months (interquartile range ¼, 7-16), the rate of stroke or death after 30 days was 17.4% (16/92). Endovascular recanalization is safe and feasible for low- and medium-risk patients with non-acute symptomatic intracranial vertebral artery occlusion; it is also an alternative to conservative therapy for the patients.

Predictors of successful endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion

BACKGROUND

Endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion (ILAO) has been reported to be feasible, but technically challenging. This study aimed to determine the predictors of successful endovascular recanalization in patients with symptomatic nonacute ILAO.

METHODS

The outcomes of endovascular recanalization attempts performed in 70 consecutive patients showing symptomatic nonacute ILAO with hemodynamic cerebral ischemia between January 2016 to December 2022 were reviewed. Potential variables, including clinical and radiological characteristics related to technical success, were collected. Univariate analysis and multivariate logistic regression were performed to identify predictors of successful recanalization for nonacute ILAO.

RESULTS

Technically successful recanalization was achieved in 57 patients (81.4%). The periprocedural complication rate was 21.4% (15 of 70), and the overall 30-day morbidity and mortality rates were 7.1% (5 of 70) and 2.9% (2 of 70), respectively. Univariate analysis showed that successful recanalization was associated with occlusion duration, stump morphology, occlusion length, slow distal antegrade flow sign, and the presence of bridging collateral vessels. Multivariate analysis showed that occlusion duration ≤ 3 months (odds ratio [OR]: 22.529; 95% confidence interval [CI]: 1.636-310.141), tapered stump (OR: 7.498; 95% CI: 1.533-36.671), and occlusion length < 10 mm (OR: 7.049; 95% CI: 1.402-35.441) were independent predictive factors for technical success of recanalization.

CONCLUSIONS

Occlusion duration ≤ 3 months, tapered stump, and occlusion length < 10 mm were independent positive predictors of technical success of endovascular recanalization for symptomatic nonacute ILAO. These findings may help predict the likelihood of successful recanalization in patients with symptomatic nonacute ILAO and also provide a reference for the selection of appropriate patients. Further prospective and multicenter studies are required to validate our findings.

Drug-Coated Balloon Treatment for Delayed Recanalization of Symptomatic Intracranial Artery Occlusion

Patients with medically refractory non-acute intracranial artery occlusion (ICAO) are difficult to treat. The optimal intervention for these patients is not known. We evaluated the feasibility and safety of drug-coated balloon (DCB) treatment for non-acute ICAO. Consecutive patients with symptomatic medically refractory atherosclerotic non-acute ICAO from January 2015 to July 2021 who underwent DCB treatment were retrospectively analyzed. The rates of stroke, transient ischemic attack, and death within 30 days and the follow-up results were evaluated. A total of 148 patients were enrolled in this study. The 30-day rate of stroke, transient ischemic attack, and death was 8.8%. During the 25.8 ± 15.8-month clinical follow-up period, the rate of outcome beyond 30 days was 4.7%. In the 66 patients with vessel imaging follow-up, 13.6% (9/66) had restenosis. The present study suggests that DCB dilatation is a feasible and effective alternative in carefully selected patients with symptomatic non-acute ICAO.

High-resolution magnetic resonance vessel wall imaging-guided endovascular recanalization for nonacute intracranial artery occlusion

OBJECTIVE

On the basis of the characteristics of occluded segments on high-resolution magnetic resonance vessel wall imaging (MR-VWI), the authors evaluated the role of high-resolution MR-VWI-guided endovascular recanalization for patients with symptomatic nonacute intracranial artery occlusion (ICAO).

METHODS

Consecutive patients with symptomatic nonacute ICAO that was refractory to aggressive medical treatment were prospectively enrolled and underwent endovascular recanalization. High-resolution MR-VWI was performed before the recanalization intervention. The characteristics of the occluded segments on MR-VWI, including signal intensity, occlusion morphology, occlusion angle, and occlusion length, were evaluated. Technical success was defined as arterial recanalization with modified Thrombolysis in Cerebral Infarction grade 2b or 3 and residual stenosis < 50%. Perioperative complications were recorded. The characteristics of the occluded segments on MR-VWI were compared between the recanalized group and the failure group.

RESULTS

Twenty-five patients with symptomatic nonacute ICAO that was refractory to aggressive medical treatment were consecutively enrolled from April 2020 to February 2021. Technical success was achieved in 19 patients (76.0%). One patient (4.0%) had a nondisabling ischemic stroke during the perioperative period. Multivariable logistic analysis showed that successful recanalization of nonacute ICAO was associated with occlusion with residual lumen (OR 0.057, 95% CI 0.004-0.735, p = 0.028) and shorter occlusion length (OR 0.853, 95% CI 0.737-0.989, p = 0.035).

CONCLUSIONS

The high-resolution MR-VWI modality could be used to guide endovascular recanalization for nonacute ICAO. Occlusion with residual lumen and shorter occlusion length on high-resolution MR-VWI were identified as predictors of technical success of endovascular recanalization for nonacute ICAO.

Case Report: Trigeminocardiac Reflex in Endovascular Recanalization of Intracranial Internal Carotid Artery Occlusion

Background

The trigeminocardiac reflex (TCR) is a unique brainstem reflex that manifests as sudden negative hemodynamic changes. Although rare, TCR may develop during interventional neuroradiology procedures. Intracranial internal carotid artery occlusion (ICAO) is a cause or risk factor of ischemic stroke. Endovascular recanalization is an effective treatment for intracranial ICAO. The occurrence of TCR during the endovascular treatment of intracranial ICAO has not been reported previously.

Methods

We identified and reviewed four intracranial ICAO cases who suffered a sudden negative hemodynamic change during endovascular therapy at our hospital between March 2019 and December 2020.

Results

There were five sudden heart rate and/or blood pressure drops in the four cases; all occurred just after contrast agents were injected. Some angioarchitectural characteristics were common among the four cases. First, the intracranial internal carotid artery distal to the ophthalmic artery was occluded, leaving the ophthalmic artery as the only outflow tract. Second, there were obstructive factors proximal to the end of the guiding catheter, including a vasospasm or dilated balloon. This type of angioarchitecture with a limited outflow tract creates a “blind alley.” The five negative hemodynamic events all recovered: two spontaneously and three after drug administration. Postoperatively, two of the four patients developed ocular symptoms.

Conclusions

Intracranial ICAOs may produce a distinctive angioarchitecture, such as a blind alley, that predisposes patients to TCR. Surgeons should pay special attention to the possibility of TCR during the endovascular recanalization of intracranial ICAO. Low-pressure contrast injections should be attempted, and anticholinergics should be ready for use.

Endovascular recanalization for non-acute basilar artery occlusions with progressive or recurrent ischemic symptoms: a multicenter clinical experience

BACKGROUND

There is no consensus on the optimal treatment of non-acute basilar artery occlusion (BAO), and endovascular recanalization still poses a therapeutic challenge for these patients. We report a multicenter clinical experience of endovascular recanalization for symptomatic non-acute BAO and propose an angiographic grouping to determine which patient subgroup most benefits from this treatment.

METHODS

Forty-two patients with non-acute BAO with progressive or recurrent vertebrobasilar ischemic symptoms who underwent endovascular recanalization were retrospectively analyzed from January 2015 to December 2019. These patients were classified into three subtypes based on their occlusion length and distal collateral reconstruction on angiograms. The rates of technical success, periprocedural complications and outcome, any stroke or death within 1 month, and follow-up data were examined.

RESULTS

The success rate of endovascular recanalization was 76.2% (32/42). The rate of periprocedural complications was 14.3% (6/42). In the three subgroups (types I-III) the success rates of endovascular recanalization were reduced (90.0%, 71.4% and 50%, respectively, p=0.023), while the overall rates of periprocedural complications were increased (5.0%, 14.3% and 37.5%, respectively, p=0.034). Type I lesions, with short-segment occlusions and good distal BA collateral reconstruction, showed favorable responses to endovascular recanalization. The median follow-up time was 1 year (IQR 11.0-19.5 months), with any stroke or death during follow-up at a rate of 7.9%.

CONCLUSION

Endovascular recanalization can be safe and feasible for reasonably selected patients with non-acute BAO, especially type I lesions, and offers an alternative choice for those with progressive or recurrent vertebrobasilar ischemic symptoms despite aggressive medical therapy.