Outcomes of Rescue Endovascular Treatment of Emergent Large Vessel Occlusion in Patients With Underlying Intracranial Atherosclerosis: Insights From STAR

Stent Retriever AssIsted Lysis Technique with Tirofiban: A Potential Bailout Alternative to Angioplasty and Stenting

BACKGROUND AND PURPOSE

Angioplasty and stent placement have been described as a bailout technique in individuals with failed thrombectomy. We aimed to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban before angioplasty and stent placement.

MATERIALS AND METHODS

Patients from 2 comprehensive stroke centers were reviewed (2020-2023). We included patients with failed thrombectomy and/or underlying intracranial stenosis who received SAIL with tirofiban before the intended angioplasty and stent placement. SAIL consisted of deploying a stent retriever through the occluding lesion to create a bypass channel and infuse 10 mL of tirofiban for 10 minutes either intra-arterially or IV. The stent retriever was re-sheathed before retrieval. The primary end points were successful reperfusion (expanded TICI 2b-3) and symptomatic intracerebral hemorrhage. Additional end points included 90-day mRS 0-2 and mortality.

RESULTS

After a median of 3 (interquartile range, 2-4) passes, 44 patients received the SAIL bridging protocol with tirofiban, and later they were considered potential candidates for angioplasty and stent placement bailout (43.2%, intra-arterial SAIL). Post-SAIL successful reperfusion was obtained in 79.5%. A notable residual stenosis (>50%) after successful SAIL was observed in 45.7%. No significant differences were detected according to post-SAIL: successful reperfusion (intra-arterial SAIL, 80.0% versus IV-SAIL, 78.9%; P = .932), significant stenosis (33.3% versus 55.0%; P = .203), early symptomatic re-occlusion (0% versus 8.0%; P = .207), or symptomatic intracerebral hemorrhage (5.3% versus 8.0%; P = .721). Rescue angioplasty and stent placement were finally performed in 15 (34.1%) patients (intra-arterial SAIL 21.0% versus IV-SAIL 44%; P = .112). At 90 days, mRS 0-2 (intra-arterial SAIL 50.0% versus IV-SAIL 43.5%; P = .086) and mortality (26.3% versus 12.0%; P = .223) were also similar.

CONCLUSIONS

In patients with stroke in which angioplasty and stent placement are considered, SAIL with tirofiban, either intra-arterial or IV, seems to safely induce sustained recanalization, offering a potential alternative to definitive angioplasty and stent placement.

Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry

OBJECTIVE

We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT).

METHODS

This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

RESULTS

Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009).

INTERPRETATION

Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.

Thrombectomy Outcomes in Acute Basilar Artery Occlusions Due to Intracranial Atherosclerotic Disease

BACKGROUND AND OBJECTIVES

Intracranial atherosclerotic disease (ICAD) large vessel occlusion (LVO) is responsible for up to 30% of LVO. In this study, we aimed to determine the likelihood of favorable functional outcomes (modified Rankin Scale 0-3) in acute ICAD-LVO basilar occlusion compared with embolic basilar occlusion.

METHODS

This is an analysis of the Posterior Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy Registry in which patients with acute basilar artery occlusions from 8 comprehensive stroke centers were included from 2015 to 2021. Patients were dichotomized into with (ICAD-LVO) or without underlying ICAD (embolic). Descriptive statistics for each group and multivariate logistic analysis were performed on the primary outcome.

RESULTS

Three hundred forty-six patients were included. There were 215 patients with embolic (62%) and 131 patients with ICAD-LVO (38%). Baseline demographics were equivalent between the 2 groups except for sex (male 47% vs 67%; P < .001), history of stroke (12% vs 25%; P = .002), and atrial fibrillation (31% vs 17%; P = .003). At 90 days, patients in the ICAD-LVO cohort were less likely to achieve favorable functional outcomes (odds ratio [OR] 0.41, 95% CI 0.22-0.72; P = .003) after adjusting for potentially confounding factors. In addition, ICAD-LVO strokes were less likely to achieve thrombolysis in cerebral infarction ≥2b (OR 0.29, 95% CI 0.14-0.57; P < .001). ICAD-LVO lesions were more likely to require stent placement (OR 14.94, 95% CI 4.91-45.49; P < .001). Subgroup analysis demonstrated favorable functional outcomes in patients who underwent stenting and angioplasty compared with failed recanalization cohort (OR 4.96, 95% CI 1.68-14.64; P < .004).

CONCLUSION

Patients with acute basilar ICAD-LVO have higher morbidity and mortality compared with patients with embolic source. Lower rates of successful recanalization in the ICAD-LVO cohort support this finding. Our subgroup analysis demonstrates that stenting should be considered in patients with recanalization failure. Rates of symptomatic intracranial hemorrhage were similar between the ICAD-LVO and embolic cohorts.

Patchy profile sign in RAPID software: a specific marker for intracranial atherosclerotic stenosis in acute ischemic stroke

Purpose

Identifying the etiology of acute ischemic stroke (AIS) before endovascular treatment (EVT) is important but challenging. In CT perfusion imaging processed by perfusion software, we observed a phenomenon called patchy profile sign (PPS), that is, the hypoperfusion morphology in RAPID software is a discontinuous sheet pattern. This phenomenon is predominantly observed in patients diagnosed with intracranial atherosclerotic stenosis (ICAS). The study intends to assess whether the PPS can be used to differentiate ICAS from intracranial embolism.

Method

Patients with AIS due to M1 segment occlusion of the MCA who underwent mechanical thrombectomy were retrospectively enrolled. The receiver operating characteristic (ROC) curve analysis was performed to assess the value of PPS in predicting ICAS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the PPS for prediction of ICAS were calculated.

Results

A total of 51 patients were included in the study. The PPS was observed in 10 of 19 (52.6%) patients with ICAS, and in 2 of 32 (6.3%) patients with intracranial embolism (p < 0.001). Interobserver agreement for identifying PPS was excellent (κ = 0.944). The sensitivity, specificity, PPV, NPV, and accuracy of the PPS for predicting ICAS were 52.6, 93.8, 83.3, 76.9, and 78.4%, respectively.

Conclusion

The PPS on RAPID software is an imaging marker with high specificity for ICAS. Larger sample sizes are imperative to validate the findings.

Monocyte to high-density lipoprotein ratio as an independent predictor of intracranial atherosclerotic stenosis-related emergency large vessel occlusion

OBJECTIVE

To evaluate the correlation between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and intracranial atherosclerotic stenosis-related emergent large vessel occlusion (ICAS-ELVO) in acute ischemic stroke patients with endovascular thrombectomy.

METHODS

Included in this study were 215 patients who underwent endovascular thrombectomy. They were randomly assigned to training and testing datasets. The patients in training dataset (n=128) were divided into ICAS group (n=65) and embolism group (n=63). MHR was compared between the two groups. According to the cut-off value, patients in testing dataset (n=87) were divided into low-MHR group (n=54) and high-MHR group (n=33). MHR was compared between the two groups.

RESULTS

In training dataset, the proportion of male patients, diabetic patients and smokers in ICAS group was significantly higher than that in embolism group [(50 (76.9%) vs. 30 (47.6%), P=0.001; 29 (44.6%) vs. 14(22.2%), P=0.007; 37(56.9%) vs. 14 (22.2%), P=0.001; 37 (56.9%) vs. 14 (22.2%), P=0.001], while the mean age and the proportion of patients with coronary heart disease (CHD), stroke and atrial fibrillation were significantly lower [(64.74±9.13 vs. 71.38±13.34, P=0.001; 6 (9.2%) vs. 14 (22.2%), P=0.043; 12 (18.5%) vs. 22 (34.9%), P=0.035; 5 (7.7%)vs. 56 (88.9%), P<0.001)]. The laboratory test results showed that monocyte count was significantly higher and high-density lipoprotein level was significantly lower in ICAS group than those in embolism group (0.61±0.26 vs. 0.45±0.13, P=0.001; 1.17±0.28 vs. 1.37±0.27, P=0.001). MHR in ICAS group was significantly higher than that in embolism group (0.55±0.26 vs. 0.34±0.11, P=0.001). In training set, MHR was found to be an independent predictor for the occurrence of ICAS-ELVO with an adjusted OR of 2.39 (95%CI 1.29-4.48, P=0.006). ROC curve analysis showed that the area under the curve (AUC) of MHR was 0.8 (95% CI, 0.72-0.87, p < 0.001), with a sensitivity of 0.60 and a specificity of 0.873. The optimal cut-off value of the MHR level was 0.46. In testing dataset, the rate of ICAS-ELVO in higher quartile was significantly higher than that in the lower quartile (81.8% vs. 33.3%, P<0.001). Patients with a low MHR had a higher rate of cerebral hemorrhagic than those with a high MHR.

CONCLUSION

MHR was associated with ICAS-ELVO in acute ischemic stroke patients with endovascular thrombectomy, and the higher level of MHR does benefit to differentiate ICAS from intracranial embolism, suggesting that MHR may prove to be an independent predictor for ICAS-ELVO.

Yield of Whole Body Computed Tomography in Hyper-Acute Stroke Patients With Large Vessel Occlusion

PURPOSE

In the majority of cases, large vessel occlusion (LVO) in ischemic stroke patients has an embolic origin. Systemic embolism can occur simultaneously with brain thrombosis. This retrospective study evaluated the frequency and locations of systemic embolism in LVO stroke patients receiving revascularization therapy.

MATERIALS AND METHODS

In our facility, we use contrast-enhanced computed tomography (CE-CT) to assess suspected stroke patients and routinely perform CE-CT from the chest to the abdomen after brain CT angiography to rule out contraindications like aortic dissection and trauma for thrombolysis. Systemic embolism is also assessed using these images, while myocardial infarction is evaluated based on electrocardiograms and laboratory findings. Other relevant clinical features of each patient are also analyzed.

RESULTS

In total, 612 consecutively admitted stroke patients and 32 LVO patients who underwent revascularization therapy were included in the present study. Systemic embolism was identified in four patients (13%). The spleen was the most commonly affected organ, followed by the heart, kidneys, limbs, and lungs. All four patients with systemic embolism exhibited LVO resulting from embolism as the underlying mechanism.

CONCLUSION

Systemic embolism was observed in 13% of our LVO patients, all of whom had LVO of embolic origin.

Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment

The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50-0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR .15, 95% CI 1.64-26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23-13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83-0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations.

Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions

This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.

Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry

BACKGROUND

Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases.

OBJECTIVE

To investigate factors that predict MTF.

METHODS

This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF (

RESULTS

A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis.

CONCLUSION

Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.

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Key Words Collapse

MESH Headings

• Humans
• Stroke/surgery
• Thrombectomy/methods
• Cerebral Hemorrhage
• Retrospective Studies
• Aneurysm
• Registries
• Treatment Outcome
• Brain Ischemia/therapy

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Affiliation(s)

Matthew Webb Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
Muhammed Amir Essibayi Medical University of South Carolina, Charleston , South Carolina , USA
Sami Al Kasab Medical University of South Carolina, Charleston , South Carolina , USA
Ilko L Maier University Medical Center Göttingen, Göttingen , Germany
Marios-Nikos Psychogios University Hospital Basel, Basel , Switzerland
Jonathan A Grossberg Emory University, Atlanta , Georgia , USA
Ali Alawieh Emory University, Atlanta , Georgia , USA
Stacey Quintero Wolfe Wake Forest University, Winston-Salem , North Carolina , USA
Adam Arthur University of Tennessee Health Science Center, Memphis , Tennessee , USA
Travis Dumont Bannner University of Arizona Medical Center, Tucson , Arizona , USA
Peter Kan University of Texas Medical Branch, Galveston , Texas , USA
Joon-Tae Kim Chonnam National University Hospital, Gwangju , South Korea
Reade De Leacy Mount Sinai Health System, New York , New York , USA
Joshua Osbun Washington University in St. Louis, St. Louis , Missouri , USA
Ansaar Rai Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
Pascal Jabbour Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
Min S Park Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
Roberto Crosa University of Virginia, Charlottesville , Virginia , USA
Michael R Levitt Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
Adam Polifka University of Washington, Seattle , Washington , USA
Shinichi Yoshimura University of Florida, Gainesville , Florida , USA
Charles Matouk Hyogo College of Medicine, Nishinomiya , Japan
Richard W Williamson Yale School of Medicine, New Haven , Connecticut , USA
Isabel Fragata Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
Shakeel A Chowdhry Centro Hospitalar Universitário de Lisboa Central, Lisboa , Portugal
Robert M Starke NorthShore University Health System, Evanston , Illinois , USA
Edgar A Samaniego University of Miami Health System, Miami , Florida , USA
Hugo Cuellar University of Iowa, Iowa City , Iowa , USA
Alejandro Spiotta Medical University of South Carolina, Charleston , South Carolina , USA
Justin Mascitelli Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA

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General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis

BACKGROUND

There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA).

METHODS

We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.

RESULTS

Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups.

CONCLUSIONS

Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

Intracranial atherosclerotic disease: current management strategies

A stroke due to underlying intracranial large artery occlusion, which is atherosclerotic in nature, is known as intracranial atherosclerotic disease (ICAD). It is important to recognize that ischaemic stroke due to ICAD differs from extracranial disease and other stroke aetiologies and requires a nuanced approach. It is a significant cause of stroke worldwide, and severe symptomatic ICAD can present challenges from a therapeutic standpoint, including recurrent ischaemic stroke despite optimal management. Furthermore, exploring the underlying pathophysiological mechanisms responsible for the disease may be necessary while considering treatment options. This narrative review aims to provide an all-encompassing overview of this disease. Epidemiology and clinical pathophysiology will be explored in detail. The findings of large clinical trials will serve as a guide to finding the most optimized management strategies. Another critical question that arises is the treatment of acute ischaemic stroke due to large vessel occlusion with underlying intracranial atherosclerosis, is the treatment and clinical diagnosis the same as for other aetiologies of stroke (i.e. extracranial disease and nonvalvular atrial fibrillation)? Consequently, secondary prevention of patients with ischaemic stroke or transient ischaemic attack will be divided into medical therapy, risk factor control, and endovascular and surgical treatment options.

Novel technique of stent placement via gateway balloon in intracranial atherosclerosis-associated large vessel occlusion

BACKGROUND AND PURPOSE

Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis-associated large vessel occlusions.

METHODS

Patients were identified through mechanical thrombectomy (MT) database from January 2020 to June 2022 at our institutions. Due to reocclusion or impending occlusion, rescue angioplasty with stent placement was performed after initial standard MT. Primary outcomes were good angiographic recanalization with modified thrombolysis in cerebral infarction (mTICI) score of 2b-3, rate of intracranial hemorrhage (ICH), and favorable functional outcome at 3 months, that is, modified Rankin Scale (mRS) score of 0-3.

RESULTS

We identified 22 patients treated using this technique. Among those, 11 were females with their average age at 66 years (range: 52-85). Initial median National Institute of Health Stroke Scale score was 11 (range: 5-30) and all patients received loading doses of aspirin and P2Y₁₂ inhibitor. After performing submaximal angioplasty and Neuroform Atlas stent deployment through the gateway balloon, we achieved final mTICI of 2b-3 in 20 (90%) patients. One patient had ICH post-op that was asymptomatic. Eight (36%) patients had mRS of 0-3 at 90 days.

CONCLUSION

Our preliminary experience suggests possible safety and feasibility of deploying Neuroform Atlas stent through a compatible Gateway balloon microcatheter without the need for ICH-associated microcatheter exchange. Further studies with long-term clinical and angiographic follow-up are warranted to corroborate our initial findings.

Stent reconstruction in intracranial atherosclerotic disease related acute ischemic stroke results in high revascularization rates

OBJECTIVES

Intracranial atherosclerotic disease (ICAD) is a major cause of large vessel occlusion (LVO) in acute ischemic stroke (AIS). Our study aimed to analyze the effect of percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAD undergoing rescue treatment in terms of functional outcome and mortality rate at 90 days and compare the results to LVO with thromboembolic origins.

MATERIALS AND METHODS

A retrospective review of a mechanical thrombectomy (MT) single center database from 01/2019 to 09/2021 was carried out using chart review and angiogram analysis. From 469 acute stroke patients, 361 patients were enroled in the study, of whom twenty-four (6.6%) were diagnosed with underlying ICAD and treated with angioplasty and stent reconstruction (PTAS) with a standardized medication protocol. Successful reperfusion, peri-procedural complications, and functional independence at 90 days were collected as outcomes.

RESULTS

There was no difference in age or admission National Institutes of Health Stroke Scale (NIHSS). Onset to groin puncture (median 460 vs 277 min, P = 0.019) was significantly longer in the ICAD group. The procedure time (median 73 vs 60 min, P = 0.137) did not differ. Successful reperfusion was achieved in 95.8% of ICAD and 91.1% of the remaining patients (P = 0.445). Functional independence (mRS ≤ 2) at 90 days was achieved in 45.8% (11/24) and 42.7% (144/337, (P = 0.767)). The mortality rates (mRS 6) at 90 days were similar (29.2% vs 29.4% (P = 0.983)).

CONCLUSION

Despite significantly longer treatment delays, the outcome and revascularization rates of ICAD patients were similar to the thromboembolic cohort. Our proposed protocol of PTAS and medication protocol in ICAD was effective with a similar safety profile as MT in general.

Mechanical thrombectomy for middle cerebral artery occlusion caused by intracranial internal carotid artery stenosis: A case report

Tandem internal carotid artery (ICA)/middle cerebral artery (MCA) occlusions are occasionally observed in patients with acute ischemic stroke. Most of them are caused by lesions at the origin of the ICA. In cases of intracranial ICA stenosis, the formation of a large thrombus causing MCA occlusion is extremely rare. Herein We report a case of acute MCA occlusion caused by intracranial ICA stenosis. A 62-year-old female presented with aphasia, right-side weakness, and a National Institute of Health Stroke Scale (NIHSS) score of 5. Magnetic resonance imaging (MRI) showed early ischemic infarction at the precentral gyrus. Left ICA and M1 occlusion were suspected on magnetic resonance angiography. However, the patient had complained of right-side numbness 6 days before the onset. Hence the stroke was assumed to have progressed slowly, and acute occlusion of the left ICA was eliminated as a suspected diagnosis. After admission, the symptoms worsened. MRI showed enlargement of the cerebral infarction. Computed tomography angiography showed complete occlusion of the left M1 and recanalization of the left ICA with severe stenosis of the petrous portion. The etiology of the MCA occlusion was determined to be atherothromboembolism. Percutaneous transluminal angioplasty (PTA) was performed for ICA stenosis, followed by mechanical thrombectomy (MT) for the MCA occlusion. Recanalization of the MCA was achieved. After Seven days, the NIHSS score reduced from a pre-MT assessment of 17-2. PTA followed by MT was safe and effective for treating MCA occlusion caused by intracranial ICA stenosis.

Management of intracranial arterial stenosis during mechanical thrombectomy: Survey of neuro-interventionalists

BACKGROUND

The optimal management of emergent large vessel occlusion due to underlying intracranial stenosis (intracranial stenosis related large vessel occlusion) remains unknown. The primary aim of this survey analysis was to measure variation in the clinical management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy.

METHODS

A survey was designed using a web-based survey-building platform and distributed via the Society of NeuroInterventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN) websites for a response. Predictors of respondents' level of comfortability stenting were estimated using a binomial logistic regression model.

RESULTS

We received 105 responses to the survey. Most respondents (54.3%) practiced at an academic Stroke Center. Nearly half of the respondents (49%) had been practicing for 5 or more years independently after fellowship. An average of 54 mechanical thrombectomies were performed by each respondent annually. There was variation in the definition of intracranial stenosis related large vessel occlusion, number of passes performed before pursuing rescue stenting, as well as intra and post-procedural antiplatelet management. Of respondents, 58% felt rescue stenting was very risky, and 55.7% agreed that there was equipoise regarding emergent angioplasty and/or stenting versus medical therapy for intracranial stenosis related large vessel occlusion. Respondents who encountered intracranial stenosis related large vessel occlusion more frequently thought that rescue stenting was less risky.

CONCLUSION

There is notable variability in the diagnosis and management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. While most respondents felt rescue stenting was risky, the majority believed the benefit could outweigh the risk. The majority of respondents agreed that equipoise exists regarding the management of intracranial stenosis related large vessel occlusion, highlighting the need for clinical trials in this rare patient population.

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

BACKGROUND

Data on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce.

OBJECTIVE

To compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT).

METHODS

We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy.

RESULTS

Among 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).

CONCLUSION

Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.

Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke worldwide. Patients with acute large vessel occlusion due to underlying ICAD (ICAD-LVO) often do not achieve successful recanalization when undergoing mechanical thrombectomy (MT) alone, requiring rescue treatment, including intra-arterial thrombolysis, balloon angioplasty, and stenting. Therefore, early detection of ICAD-LVO before the procedure is important to enable physicians to select the optimal treatment strategy for ICAD-LVO to improve clinical outcomes. Early diagnosis of ICAD-LVO is challenging in the absence of consensus diagnostic criteria on noninvasive imaging and early digital subtraction angiography. In this review, we summarize the clinical and diagnostic criteria, prediction of ICAD-LVO prior to the procedure, and EVT strategy of ICAD-LVO and provide recommendations according to the current literature.

Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes

Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.

The REMIT scale: A novel prediction scale for embolism in hyperacute stroke with large vessel occlusion

BACKGROUND AND PURPOSE

Large vessel occlusion (LVO) in hyperacute ischemic stroke occurs mainly by one of two mechanisms, embolism or atherosclerosis. However, the mechanism is difficult to identify prior to treatment. We aimed to investigate the factors associated with embolic LVO in hyperacute ischemic stroke, and to develop a preoperative predictive scale for the event.

MATERIALS AND METHODS

This retrospective multicenter study was conducted with consecutive ischemic stroke patients with LVO who underwent thrombectomy, thrombolysis, or both. The embolic LVO was defined as an occlusion that underwent recanalization with no residual stenosis. Multivariate logistic regression analysis for embolic LVO was performed to identity the independent risk factors. With this approach, a novel prediction scale (Rating of Embolic Occlusion for Mechanical Thrombectomy [REMIT] scale) was developed.

RESULTS

A total of 162 patients (104 men; median age 76 years; interquartile range 68-83) were included in this study. Embolic LVO was observed in 121 patients (75%). Multivariate logistic regression analysis showed that embolic LVO was independently associated with high brain natriuretic peptide (BNP), high National Institutes of Health Stroke Scale (NIHSS) on admission, and absence of non-culprit stenosis (NoCS). The REMIT scale comprises high BNP (>100 pg/dL), high NIHSS (>14) and absence of NoCS, with one point for each risk factor. The frequencies of embolic LVO for the REMIT scale scores were as follows: score 0, 25%; score 1, 60%; score 2, 87%; score 3, 97% (C-statistic 0.80, P < 0.001).

CONCLUSION

The novel REMIT scale has predictive value for embolic LVO.

Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban

PURPOSE

Intracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban.

MATERIALS AND METHODS

We performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures.

RESULTS

Thirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable.

CONCLUSION

The results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.

Predictors of Futile Recanalization in Patients with Intracranial Atherosclerosis-Related Stroke Undergoing Endovascular Treatment

OBJECTIVE

The predictors of futile recanalization in patients with intracranial atherosclerosis (ICAS)-related stroke are not understood. This study aimed to identify the predictors of futile recanalization after endovascular treatment (EVT) in patients who experience an acute stroke caused by ICAS-related occlusion.

METHODS

We retrospectively reviewed the data of patients with ICAS-related stroke who underwent EVT from January 2018 to July 2021. Futile recanalization was defined as functional dependence (modified Rankin scale 3-6) despite successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2 b/3). Multivariate logistic regression analysis was used to determine the risk factors associated with futile recanalization. The receiver operating characteristic curve was used to examine the predictive value of the risk prediction model for futile recanalization.

RESULTS

Of the 87 patients enrolled, futile recanalization was observed in 32 (36.8%). Multivariate logistic analysis showed that older age (OR, 1.05; 95% CI, 1.01-1.10; P = 0.026), a higher National Institutes of Health Stroke Scale (NIHSS) score on admission (OR, 1.25; 95% CI, 1.08-1.45; P = 0.003), and poor collaterals (OR, 5.49; 95% CI, 1.70-17.79; P = 0.004) were independently associated with futile recanalization after EVT in patients with ICAS-related stroke. The receiver operating characteristic curve showed that the model in combination with age, admission NIHSS score, and collateral status could accurately predict futile recanalization in these patients (areas under the curve, 0.85; 95% CI, 0.76-0.92; P < 0.001).

CONCLUSIONS

Older age, higher NIHSS score on admission, and poor collaterals are predictors of futile recanalization in patients with ICAS-related stroke.

Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis

OBJECTIVE

The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients.

METHODS

We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed.

RESULTS

Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2 months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality.

CONCLUSIONS

Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.

European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.

Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy

BACKGROUND:

Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT.

METHODS:

The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS:

A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P <0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14–12.76]; P <0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31–0.96]; P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P <0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11–28.92]; P <0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25–0.94]; P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes.

CONCLUSIONS:

Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

A comparison between different endovascular treatment strategies for acute large vessel occlusion due to intracranial artery atherosclerosis: data from ANGEL-ACT Registry

PURPOSE

The aim of our study is to compare the characteristics and clinical outcomes among the different endovascular treatment (EVT) strategies for large vessel occlusion underlying intracranial atherosclerosis (ICAS-LVO) in a recent nationwide registry.

METHODS

Patients with isolated ICAS-LVO were enrolled in our analysis and were categorized into three groups: first-line mechanical thrombectomy (MT) with rescue angioplasty and/or stenting (MT + RS), direct angioplasty and/or stenting without thrombectomy (DA), and MT alone. Baseline and periprocedural characteristics, successful recanalization, and 90-day functional outcomes were compared.

RESULTS

Of 396 patients with isolated ICAS-LVO in our study, successful recanalization was achieved in 94.5%, 100%, and 90.9% of patients in the MT + RS, DA, and MT groups, respectively. The 90-day functional independence in the three groups was 50.8%, 59.0%, and 45.1%. The main efficacy and safety outcomes showed no significant differences among the groups. First-pass recanalization (FPR) was more observed in the MT group (43.4%), the recanalization rate per attempt in the MT group gradually decreased until the fourth attempt, and further maneuvers showed recanalization rates of ≈0% per attempt. MT + RS (adjusted odds ratio [aOR] 0.10, p < 0.0001) and DA (aOR 0.18, p = 0.0013) were associated with lower FPR rate than MT alone in the multivariable logistic regression.

CONCLUSIONS

The technical feasibility and favorable outcomes of several EVT strategies for ICAS-LVO were established in our study. First-line MT with a bailout angioplasty is a reasonable option for ICAS-LVO, and DA is an effective option for the cases when ICAS-LVO is strongly suspected before EVT procedure.

Rescue Endovascular Treatment for Emergent Large Vessel Occlusion With Underlying Intracranial Atherosclerosis: Current State and Future Directions

Intracranial atherosclerosis (ICAS) is one of the most common causes of stroke worldwide and is associated with high risk of stroke recurrence. While the most common clinical presentation is acute–subacute transient ischemic attack or ischemic stroke, occasionally, patients with underlying ICAS present with acute occlusion of the affected vessel. Diagnosis and endovascular management of ICAS-related emergent large vessel occlusion (ELVO) can be challenging. Herein, we review the current evidence supporting endovascular management of ICAS-related ELVO and discuss future directions.

Stent Opening Visualization During Mechanical Thrombectomy; Relationship with the Retrieved Clot and Procedural Success

PURPOSE

The angiographic visualization of the stent during mechanical thrombectomy (MT) may provide information regarding the characteristics of the underlying occluding clot, device-clot interaction, and recanalization. The purpose of this study was to evaluate the open stent sign in relation to the retrieved clot and recanalization.

METHODOLOGY

78 patients treated with the stent retriever for acute stroke were retrospectively reviewed. The open stent sign was defined as full opening (>80% of normal vessel diameter) of the stent on DSA after deployment across the occlusion. The retrieved clot was visually classified as red or non-red clots. The relationship between the open stent sign and the patient characteristics, recanalization, retrieved clot, and clinical outcome were analyzed.

RESULTS

Overall successful recanalization and good outcome was achieved in 68 (87.2%) and 35 (44.9%) patients, respectively. Open stent sign was seen in 52 patients (66.7%). Occlusions showing positive open stent sign was associated with significantly higher first pass effect (44.2% vs 19.2%, p=0.044) and successful recanalization rate (94.2% vs 73.1%, p=0.013) compared to negative open stent sign. The open stent sign was associated with higher incidence of red clot (75.0% vs 38.9%, p=0.008). On multivariate analysis, the open stent sign (OR 22.721, 95% CI 1.953-264.372, p=0.013) was a predictor of successful recanalization.

CONCLUSIONS

The visualization of the open stent during MT of acute ischemic stroke may provide added information in terms of clot characteristics and procedural success. The open stent sign is associated with red clots, higher first pass effect and successful recanalization.