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.

Safety of endovascular therapy for symptomatic intracranial artery stenosis: a national prospective registry

IntroductionThe safety outcomes of endovascular therapy for intracranial artery stenosis in a real-world stetting are largely unknown. The Clinical Registration Trial of Intracranial Stenting for Patients with Symptomatic Intracranial Artery Stenosis (CRTICAS) was a prospective, multicentre, real-world registry designed to assess these outcomes and the impact of centre experience.Methods1140 severe, symptomatic intracranial arterial stenosis (ICAS) patients treated with endovascular therapy were included from 26 centres, further divided into three groups according to the annual centre volume of intracranial angioplasty and stent placement procedures over 2 years: (1) high volume for ≥25 cases/year; (2) moderate volume for 10–25 cases/year and (3) low volume for <10 cases/year.ResultsThe rate of 30-day stroke, transient ischaemic attack or death was 9.7% (111), with 5.4%, 21.1% and 9.7% in high-volume, moderate-volume and low-volume centres, respectively (p<0.05). Multivariable logistic regression confirmed high-volume centres had a significantly lower primary endpoint compared with moderate-volume centres (OR=0.187, 95% CI: 0.056 to 0.627; p≤0.0001), while moderate-volume and low-volume centres showed no significant difference (p=0.8456).ConclusionCompared with the preceding randomised controlled trials, this real-world, prospective, multicentre registry shows a lower complication rate of endovascular treatment for symptomatic ICAS. Non-uniform utilisation in endovascular technology, institutional experience and patient selection in different volumes of centres may have an impact on overall safety of this treatment.

Cone-beam CT angiography to assess the microvascular anatomy of intracranial arterial dissections

Background Intracranial artery dissection is a rare and generally under-recognized cause of ischaemic stroke or subarachnoid haemorrhage. Objectives The aim of this study was to analyse the efficacy of cone-beam computed tomography angiography (CBCT-A) to detect arterial ultrastructural alterations in intracranial artery dissection. Method This is an observational and retrospective case series. Results Between January 2018 and November 2020, four patients were admitted with an acute ischaemic stroke due to intracranial dissection studied with CBCT-A. In all cases, the CBCT-A documented vascular ultrastructural alterations related with the intracranial dissection. Conclusions CBCT-A is an intraprocedural diagnostic technique that is useful for the diagnosis of intracranial dissections.

Endovascular Recanalization and Standard Medical Management for Symptomatic Non-acute Intracranial Artery Occlusion: Study Protocol for a Non-randomized, 24-Month, Multicenter Study

Background: The management of patients with symptomatic non-acute intracranial artery occlusion (sNA-ICAO), which is a special subset with high morbidity and a high probability of recurrent serious ischemic events despite standard medical therapy (SMT), has been clinically challenging. A number of small-sample clinical studies have also discussed endovascular recanalization (ER) for sNA-ICAO; however, there is currently a lack of evidence from multicenter, prospective, large-sample cohort trials. The purpose of our present study was to evaluate the technical feasibility and safety of ER for sNA-ICAO.Methods: Our group is currently undertaking a multisite, non-randomized cohort, prospective registry study enrolling consecutive patients presenting with sNA-ICAO at 15 centers in China between January 1, 2020 and December 31, 2022. A cohort of patients who received SMT and a cohort of similar patients who received ER plus SMT were constructed and followed up for 2 years. The primary outcome is any stroke from enrollment to 2 years of follow-up. The secondary outcomes are all-cause mortality, mRS score, NIHSS score and cognitive function from enrollment to 30 days, 3 months, 8 months, 12 months, 18 months, and 2 years of follow-up. Descriptive statistics and linear/logistic multiple regression models will be generated. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat.Discussion: The management of patients with sNA-ICAO has been clinically challenging. The current protocol aims to evaluate the technical feasibility and safety of ER for sNA-ICAO.Trial Registration Number:www.ClinicalTrials.gov, identifier: NCT04864691.

EXPRESS: ESO guideline for the management of extracranial and intracranial artery dissection

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized clinical trials (RCTs) comparing anticoagulants to anti-platelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus anti-platelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion and multidisciplinary assessment of the best therapeutic approaches in specific situations.