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Angioplasty, stenting, or both — rescue maneuvers and reperfusion after endovascular therapy for intracranial atherosclerosis-related occlusion

  • Interventional Neuroradiology
  • Published:
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Abstract

Purpose

Data concerning reperfusion strategies of intracranial atherosclerosis-related occlusion (ICARO) and clinico-angiographic outcomes remain scarce, particularly in Caucasians. We aim to compare the reperfusion rate and functional outcome between reperfusion strategies in the setting of the ICARO.

Methods

Retrospective analysis of prospectively maintained endovascular thrombectomy (EVT) registries at three high-volume stroke centers were retrospectively analyzed for consecutive ICARO patients from January 2015 to December 2019. We defined ICARO as any fixed high-degree (> 70%) focal narrowing or stenosis of any degree with a perpetual tendency for reocclusion. We categorized reperfusion strategies into four groups: EVT [group 1], balloon angioplasty [(BAp), group 2], placement of self-expandable stents [(SES), group 3], and BAp combined with implantation of SES; or direct placement of balloon mounted stents (BMS) [(BAp-SES/BMS), group 4]. We evaluated the association with the successful reperfusion [mTICI 2b − 3] and favorable outcome [mRS 0–2] with logistic regression analysis.

Results

Out of 2550 EVT, 124 patients (median age, 70 (61–80) years; 76 men) with ICARO and 130 reperfusion attempts [36 EVT, 38 BAp, 17 SES, and 39 BAp + SES/BMS] were analyzed. SES implantation showed the highest frequency of post-procedural symptomatic intracranial hemorrhage [(18%, 3/17), p = .03]; however, we observed no significant differences in the mortality rate. Overall, we achieved successful reperfusion in 71% (92/130) and favorable outcomes in 42% (52/124) of the patients. BAp + SES/BMS was the only independent predictor of the final successful reperfusion [aOR, 4.488 (95% CI, 1.364–14.773); p = .01], which was significantly associated with the 90-day favorable outcome [aOR, 10.837 (95% CI, 3.609–32.541); p =  < .001] after adjustment for confounding variables between the reperfusion strategies.

Conclusion

Among patients with ICARO, the rescue angioplasty stenting effectively contributed to higher odds of successful reperfusion with no increased risk for intracranial hemorrhage.

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Data availability

Anonymized individual participant data will be provided by the corresponding author upon reasonable request from any qualified investigator for 12 months after the date of publication.

Change history

  • 21 January 2023

    The author Douraied Ben Salem has ben updated to correct the citation.

Abbreviations

ASPECTs:

Alberta Stroke Program Early Computed Tomography Score

BAp:

Balloon angioplasty

BMS:

Balloon-mounted stent

EVT:

Endovascular thrombectomy

GPI:

Glycoprotein IIb/IIIa inhibitors

ICARO:

Intracranial atherosclerosis-related occlusion

mRS:

Modified Rankin Scale

mTICI:

Modified treatment in cerebral infarction

NIHSS:

National Institutes of Health Stroke Scale

SES:

Self-expandable stent

sICH:

Symptomatic intracranial hemorrhage

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Acknowledgements

Collaborators

PICASO group investigators: Mohamed Abdelrady, Imad Derraz, Pierre-Henri Lefevre, Federico Cagnazzo, José Rodriguez, Eduardo Murias, Juan Chaviano, José Maria Jimenez, Carlos Riquelme, Gregory Gascou, Lucas Corti, Nicolas Gaillard, Mourad Cheddad El Aouni, Douraied Ben Salem, Cyril Dargazanli, Julien Ognard, Isabelle Mourand, Caroline Arquizan, Jean-Christophe Gentric, Pedro Vega, Vincent Costalat

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France

    Mohamed Abdelrady, Cyril Dargazanli, Pierre-Henri Lefevre, Imad Derraz & Vincent Costalat

  2. Department of Neuroradiology, Hôpital Cavale Blanche, Brest University Hospital, Bd Tanguy Prigent, 29200, Brest, France

    Mohamed Abdelrady, Julien Ognard, Jean-Christophe Gentric & Douraied Ben Salem

  3. Department of Neuroradiology, El-Demerdash University Hospital, Cairo, Egypt

    Mohamed Abdelrady

  4. Department of Radiology, Hospital Universitario Central de Asturias, Avda. Roma S/N 33011, Oviedo, Spain

    José Rodriguez, Eduardo Murias, Juan Chaviano & Pedro Vega

  5. Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France

    Isabelle Mourand & Caroline Arquizan

Authors
  1. Mohamed Abdelrady
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  2. José Rodriguez
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  3. Cyril Dargazanli
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Consortia

on behalf of the PICASO (Reperfusion in Intracranial Atherosclerosis-related Occlusions) Investigators Group

  • Mohamed Abdelrady
  • , Imad Derraz
  • , Pierre-Henri Lefevre
  • , Federico Cagnazzo
  • , José Rodriguez
  • , Eduardo Murias
  • , Juan Chaviano
  • , José Maria Jimenez
  • , Carlos Riquelme
  • , Gregory Gascou
  • , Lucas Corti
  • , Nicolas Gaillard
  • , Mourad Cheddad El Aouni
  • , Douraied Ben Salem
  • , Cyril Dargazanli
  • , Julien Ognard
  • , Isabelle Mourand
  • , Caroline Arquizan
  • , Jean-Christophe Gentric
  • , Pedro Vega
  •  & Vincent Costalat

Contributions

Study design: Mohamed Abdelrady. Acquisition, analysis, or interpretation of data: all the authors. The first draft of the manuscript was written by Mohamed Abdelrady, and all the authors commented on the previous versions of the manuscript. Statistical analysis: Mohamed Abdelrady and Julien Ognard. Supervision: Vincent Costalat, Jean Christophe Gentric, Isabelle Mourand, and Caroline Arquizan. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Mohamed Abdelrady.

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Competing interests

The authors have no competing interests to declare that are relevant to the content of this article.

Ethics approval

Ethical approval was waived by the local Ethics Committee of the University hospitals of Montpellier and Brest in view of the retrospective nature of the study, and all the procedures being performed were part of the routine care.

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Not applicable.

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Key messages

1. What is already known on this topic — There is no consensus on the optimal reperfusion strategy for ICARO, especially in the Caucasian population. Previous studies have illustrated the influence of the front-line reperfusion techniques and the efficiency of GPI inhibitors; yet, per our knowledge, the comparison between the reperfusion strategies has not been elucidated.

2. What this study adds — Irrespective of the stenosis degree in the setting of ICARO, rescue angioplasty combined with implantation of a self-expandable stent or direct placement of balloon-mounted stents were significantly associated with higher odds of successful reperfusion. The latter was an independent predictor of the 90-day favorable outcome. Compared to other reperfusion strategies, we observed no significant differences in the mortality rate or an associated increase in the risk for intracranial hemorrhage.

3. How this study might affect research, practice, or policy — Rescue angioplasty stenting might represent a clinico-angiographic efficacious maneuver in the treatment of intracranial atherosclerosis-related occlusion (ICARO). Prospective clinical trials are warranted to determine the optimal reperfusion strategy between balloon-mounted and self-expandable stents combined with angioplasty. Modification of glucose levels at admission in patients undergoing EVT should be investigated.

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Abdelrady, M., Rodriguez, J., Dargazanli, C. et al. Angioplasty, stenting, or both — rescue maneuvers and reperfusion after endovascular therapy for intracranial atherosclerosis-related occlusion. Neuroradiology 65, 775–784 (2023). https://doi.org/10.1007/s00234-022-03108-3

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