CTA-Based Truncal-Type Occlusion Is Best Matched With Postprocedural Fixed Focal Stenosis in Vertebrobasilar Occlusions

Background: Differentiation of embolic and atherosclerotic occlusions is difficult prior to endovascular treatment (EVT) of acute ischemic stroke due to intracranial large artery occlusions. CTA-determined occlusion type has been reported to be associated with a negative cardiac embolic source and stent retriever failure, a potential of intracranial atherosclerosis (ICAS)-related occlusions. In this study, we evaluated the agreement between preprocedural identification of CTA-determined truncal-type occlusion (TTO) and postprocedural evaluation of underlying fixed focal stenosis (FFS) in the occlusion site. Methods: Patients who underwent intracranial EVT for acute ischemic stroke within 24 h of onset and who had baseline CTA were identified from a multicenter registry collected between January 2011 and May 2016. Preprocedural occlusion type was classified as TTO (target artery bifurcation saved) or branching-site occlusion (bifurcation involved) on CTA. As for postprocedural identification, FFS was evaluated by stepwise analyses of procedural and postprocedural angiographies. The agreement between TTO and FFS was evaluated in respective intracranial vascular beds. Receiver operating characteristics analyses were also performed. Results: A total of 509 patients were included [intracranial internal carotid artery (ICA): 193, middle cerebral artery (MCA) M1: 256, and vertebrobasilar artery (VBA): 60]. In preprocedural identification, 33 (17.1%), 41 (16.0%), and 29 patients (48.3%) had TTOs, respectively. TTOs had good agreement with angiographic FFS in M1 (positive predictive value: 63.4%, negative predictive value: 83.2%, likelihood ratio: 5.42, Pmultivariate < 0.001) and VBA (72.4%, 96.8%, and 4.54, respectively, Pmultivariate = 0.004), but not in intracranial ICA occlusions (Pmultivariate = 0.358). The area under the receiver operating characteristics curve was the largest for VBA (0.872, p < 0.001), followed by MCA M1 (0.671, p < 0.001), and intracranial ICA (0.551, p = 0.465). Conclusions: Agreement between preprocedural TTO and postprocedural FFS, both of which are surrogate markers for ICAS-related occlusions, is highest for VBA, followed by MCA M1 occlusions. There is no significant association in intracranial ICA.

[1]  Y. Lee,et al.  Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis. , 2019, Journal of neurosurgery.

[2]  Dong Joon Kim,et al.  Outcomes of Endovascular Treatment for Acute Intracranial Atherosclerosis–Related Large Vessel Occlusion , 2018, Stroke.

[3]  A. Demchuk,et al.  Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment , 2018, Journal of stroke.

[4]  M. Srivastava,et al.  Thrombectomy for Stroke with Selection by Perfusion Imaging. , 2018, The New England journal of medicine.

[5]  A. Demchuk,et al.  Temporal Changes in Care Processes and Outcomes for Endovascular Treatment of Acute Ischemic Stroke: Retrospective Registry Data from Three Korean Centers , 2018, Neurointervention.

[6]  M. Lou,et al.  Prediction of the Multisegment Clot Sign on Dynamic CT Angiography of Cardioembolic Stroke , 2018, American Journal of Neuroradiology.

[7]  A. Demchuk,et al.  Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging , 2018, The New England journal of medicine.

[8]  M. Chen,et al.  Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct , 2018, The New England journal of medicine.

[9]  F. Gao,et al.  Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis , 2017, Journal of NeuroInterventional Surgery.

[10]  Tommy Andersson,et al.  Thrombectomy in Acute Ischemic Stroke: Challenges to Procedural Success , 2017, Journal of stroke.

[11]  B. Kim.  Causes and Solutions of Endovascular Treatment Failure , 2017, Journal of Stroke.

[12]  Jong S. Kim,et al.  Diagnostic and Therapeutic Strategies for Acute Intracranial Atherosclerosis-related Occlusions , 2017, Journal of stroke.

[13]  A. Demchuk,et al.  Distinctive patterns on CT angiography characterize acute internal carotid artery occlusion subtypes , 2017, Medicine.

[14]  P. Brouwer,et al.  Clot friction variation with fibrin content; implications for resistance to thrombectomy , 2017, Journal of NeuroInterventional Surgery.

[15]  Dong Joon Kim,et al.  Predictive Value of Computed Tomography Angiography–Determined Occlusion Type in Stent Retriever Thrombectomy , 2017, Stroke.

[16]  M. Bonab.  randomised trial , 2022 .

[17]  Yang-Ha Hwang,et al.  Effect of Intracranial Atherosclerotic Disease on Endovascular Treatment for Patients with Acute Vertebrobasilar Occlusion , 2016, American Journal of Neuroradiology.

[18]  Dong Joon Kim,et al.  Importance of truncal-type occlusion in stentriever-based thrombectomy for acute stroke , 2016, Neurology.

[19]  A. Spiotta,et al.  Endovascular treatment for AIS with underlying ICAD , 2016, Journal of NeuroInterventional Surgery.

[20]  A. Demchuk,et al.  Imaging Predictors for Atherosclerosis-Related Intracranial Large Artery Occlusions in Acute Anterior Circulation Stroke , 2016, Journal of stroke.

[21]  D. Liebeskind,et al.  Impact of Target Arterial Residual Stenosis on Outcome After Endovascular Revascularization , 2016, Stroke.

[22]  T. Krings,et al.  What constitutes the M1 segment of the middle cerebral artery? , 2016, Journal of NeuroInterventional Surgery.

[23]  J. Hong,et al.  Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease , 2015, Journal of stroke.

[24]  F. Gaillard,et al.  Modified Fisher scale , 2015, Radiopaedia.org.

[25]  A. Demchuk,et al.  Endovascular Therapy of Cerebral Arterial Occlusions: Intracranial Atherosclerosis versus Embolism. , 2015, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[26]  A. Demchuk,et al.  Choosing a Hyperacute Stroke Imaging Protocol for Proper Patient Selection and Time Efficient Endovascular Treatment: Lessons from Recent Trials , 2015, Journal of stroke.

[27]  W. Yoon,et al.  Negative Susceptibility Vessel Sign and Underlying Intracranial Atherosclerotic Stenosis in Acute Middle Cerebral Artery Occlusion , 2015, American Journal of Neuroradiology.

[28]  H. Diener,et al.  Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. , 2015, The New England journal of medicine.

[29]  A. Demchuk,et al.  Thrombectomy within 8 hours after symptom onset in ischemic stroke. , 2015, The New England journal of medicine.

[30]  Byeong-Chae Kim,et al.  Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke. , 2015, Neurosurgery.

[31]  M. Krause,et al.  Endovascular therapy for ischemic stroke with perfusion-imaging selection. , 2015, The New England journal of medicine.

[32]  Eric E. Smith,et al.  Randomized assessment of rapid endovascular treatment of ischemic stroke. , 2015, The New England journal of medicine.

[33]  Hester F. Lingsma,et al.  A randomized trial of intraarterial treatment for acute ischemic stroke. , 2015, The New England journal of medicine.

[34]  F. Sallustio,et al.  Thrombectomy within 8 hours after symptom onset in ischemic stroke , 2015 .

[35]  T. Struffert,et al.  Clot Burden and Collaterals in Anterior Circulation Stroke: Differences Between Single-Phase CTA and Multi-phase 4D-CTA , 2016, Clinical Neuroradiology.

[36]  S. Sohn,et al.  Susceptibility Vessel Signs on T2*-Weighted Gradient Echo Images in Patients with Cerebral Atherosclerosis , 2014, International journal of stroke : official journal of the International Stroke Society.

[37]  R. Jahan,et al.  Impact of Collaterals on Successful Revascularization in Solitaire FR With the Intention for Thrombectomy , 2014, Stroke.

[38]  Elad I Levy,et al.  Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial , 2012, The Lancet.

[39]  Gregory W Albers,et al.  Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial , 2012, The Lancet.

[40]  N. Salamon,et al.  CT and MRI Early Vessel Signs Reflect Clot Composition in Acute Stroke , 2011, Stroke.

[41]  O. Kwon,et al.  Direct Thrombus Retrieval Using the Reperfusion Catheter of the Penumbra System: Forced-Suction Thrombectomy in Acute Ischemic Stroke , 2011, American Journal of Neuroradiology.

[42]  W. Reith,et al.  Stent-Assisted Mechanical Recanalization for Treatment of Acute Intracerebral Artery Occlusions , 2010, Stroke.

[43]  J. Broderick,et al.  Revascularization Results in the Interventional Management of Stroke II Trial , 2008, American Journal of Neuroradiology.

[44]  Jan Claassen,et al.  Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. , 2006, Neurosurgery.

[45]  Jane C Khoury,et al.  Revascularization End Points in Stroke Interventional Trials: Recanalization Versus Reperfusion in IMS-I , 2005, Stroke.

[46]  S. Kwon,et al.  Significance of Susceptibility Vessel Sign on T2*-Weighted Gradient Echo Imaging for Identification of Stroke Subtypes , 2005, Stroke.

[47]  À. Rovira,et al.  Hyperacute ischemic stroke: middle cerebral artery susceptibility sign at echo-planar gradient-echo MR imaging. , 2004, Radiology.

[48]  L Bozzao,et al.  Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. , 1999, Stroke.