Efficacy Study On Endovascular Treatment Of Acute Intracranial Atherosclerosis-related Large Vessel Occlusion

Part One: Study on Endovascular Treatment for Intracranial Atherosclerosis Related Acute Large Vessel Occlusion in M1 Segment of Middle Cerebral ArteryObjective To analyze the efficacy of endovascular treatment on acute intracranial atherosclerosis-related large vessel occlusion(ICAS-LVO)in the M1 segment of a middle cerebral artery(MCA)and evaluate the safety and efficacy of angioplasty as a salvage treatment.Methods Continuous retrospective analysis was performed on the clinical data of patients with acute middle cerebral artery M1 occlusion who underwent endovascular treatment in our hospital from November 2013 to December 2018.A total of 217 patients were enrolled in the two groups.According to the etiology of vascular occlusion,the patients were divided into the Embolic-LVO group and the ICAS-LVO group.The baseline characteristics and clinical outcome of the two groups were compared to evaluate the efficacy of endovascular treatment in patients with ICAS-LVO.The angioplasty success rate,reocclusion rate and restenosis rate were analyzed in 45 patients with ICAS-LVO who underwent salvage angioplasty.Results The NIHSS score in the ICAS-LVO group was significantly lower than that in the embolic group(11 vs.16,P<0.001).The median procedural time in the ICAS-LVO group was longer compared with the embolization group(63min vs.40 min,P=0.036).The pass number of device was significantly less than that of the Embolic-LVO group(1 vs.2,P<0.001).The rate of successful recanalization(m TICI ? 2b)in the ICAS-LVO group was not significantly different from that in the Embolic-LVO group(98.0% vs.94.0%,P=0.428),but the recanalization rate of m TICI 3 was higher than that in the Embolic-LVO group(84.3% vs.53.6%,P<0.001).The rate of hemorrhagic transformation in the ICAS-LVO group was lower than that in the Embolic-LVO group.The favorable outcome at 90 days(m RS0 ? 2 points)in the ICAS-LVO group was higher than that in the Embolic-LVO group(76.5% vs.54.8%,P=0.006),showing a statistical difference.Among the 45 cases who underwent salvage angioplasty in the ICAS-LVO group,the technical success rate was 97.8%,no bleeding occurred in the procedure,and 3 cases had re-occlusion within 1 week postoperation.During the imaging follow-up 3 to 12 months,the restenosis rate reached 34.5%(10/29).Conclusions In the endovascular treatment on the ICAS-LVO compared with Embolic-LVO,the pass number of thrombectomy device was less and the recanalization rate of m TICI 3 was higher.The risk of hemorrhage transformation and mortality is lower while the 90-day favorable outcome rate is higher in the ICAS-LVO group.Part Two: Study on Endovascular Treatment for Acute Basilar Artery Occlusion due to underlying Intracranial Atherosclerotic StenosisPurpose The efficacy of intravascular treatment on acute basal artery occlusion due to intracranial atherosclerotic disease is unclear.Our goal is to evaluate the efficacy of endovascular treatment on vertebrobasilar atherosclerotic disease related basal artery occlusion and the safety of angioplasty as a salvage treatment.Methods Continuous retrospective analysis was performed on the clinical data of 92 patients with acute basal artery occlusion who underwent endovascular treatment from October 2013 to December 2018.According to etiology of basal artery occlusion,the patients were divided into the ICAS-LVO group and the Embolic-LVO group,including 40 cases with basal artery occlusion due to underlying atherosclerotic disease,and 52 cases with basal artery embolism.The baseline features,treatment characteristics and clinical outcomes of patients in the two groups were compared.The angioplasty success rate and reocclusion rate were analyzed in 35 patients with ICAS-LVO who underwent salvage angioplasty.Results The successful vascular recanalization rate(mTICI?2b)in the ICAS-LVO group was not significantly different from that in the Embolic-LVO(92.5% vs.92.3%,P=1.000).The favorable outcome at 90 days(m RS0~2)didn't differ between two groups(47.5% vs.61.5%,P=0.179).The mortality and the rate of hemorrhagic transformation in the ICAS-LVO group are relatively high than those in the Embolic-LVO group(30.0% vs.15.4%;5.0% vs.1.9%),but there was no statistical difference.In prognostic multivariate analysis,hypertension and Batman score are independent factors related to the prognosis.Among the 35 cases who underwent salvage angioplasty in the ICAS-LVO group,the technical success rate was 94.3%,no bleeding occurred,and 2(5.0%)patients had re-occlusion within 1 week after procedure.Conclusions In acute basal artery occlusion,the efficacy of endovascular treatment for different occlusive etiology is consistent.Tirofiban does not increase the risk of hemorrhagic transformation.Hypertension and Batman score are independent factors related to the outcome of acute basilar occlusion.The angioplasty has good safety and success rate,but the long-term efficacy needs further research.Part Three: Study on Endovascular Treatment for Intracranial Atherosclerosis Related Acute Large Vessel Occlusion in M1 segment of Middle Cerebral Artery After Propensity Score MatchingPurpose To compare the safety and efficacy of endovascular treatment between the intracranial atherosclerosis-related occlusion group and the embolic occlusion group in the M1 segment of MCA based on propensity score matching.Methods Continuous retrospective analysis was performed on the clinical data of 217 patients with acute occlusion of the M1 segment of MCA who underwent endovascular treatment from November 2013 to December 2018.The patients were divided into the intracranial atherosclerosis-related occlusion group and the embolic occlusion group.Clinical covariates associated with endovascular therapy were selected for 1:1 propensity score matching and a new cohort of 45 cases was established for each group.The treatment characteristics and clinical prognosis of patients in the two groups were compared.Results The successful vascular recanalization rate(m TICI?2b)in the intracranial atherosclerosis-related occlusion group was not significantly different from that in the embolic occlusion group(97.8% vs.91.1%,P=0.357).However,there was a significant difference in the recanalization rate of m TICI3(84.4% vs.44.4%,P<0.001).The median procedural time in the intracranial atherosclerosis-related occlusion group was longer,but there was no statistical difference(63min vs.39 min,P=0.147).The rate of hemorrhagic transformation within 1 week,the mortality and favorable outcome at 90 days had no significant difference between the two groups.Conclusions After propensity score matching,the benefit from EVT is consistent for patients with ICAS-related occlusion and embolic occlusion.Part Four: Study on Endovascular Treatment for Acute Intracranial Atherosclerosis Related Large vessel Occlusion(Meta Analysis)Objective To evaluate the efficacy and safety of endovascular treatment(ET)of acute ischemic stroke(AIS)caused by intracranial atherosclerosis-related large vessel occlusion(ICAS-LVO).Methods A systemic review and meta-analysis were conducted on studies published between July 2005 and October 2018 on the outcomes of ET in patients with AIS due to ICAS-LVO.The outcomes of the ICAS-LVO and embolic LVO groups were also compared.Results A total of 17 studies including 1315 subjects with ICAS-LVO were included.In the single-arm meta-analysis,the pooled estimates of successful recanalization rate,favorable outcomes,symptomatic intracranial hemorrhage and mortality were 88%(95% CI(95% confidence interval),84–92%),52%(95% CI,47–56%),5%(95% CI,3–7%)and 15%(95% CI,12–19%)respectively.The preferred primary treatment was stent-retriever thrombectomy(84.1%)and the preferred rescue treatment was stent implantation with or without percutaneous transluminal angioplasty(PTA,32.7%).In the double-arm meta-analysis,the incidence of symptomatic intracranial hemorrhage was lower in the ICAS-LVO compared to the Embolic-LVO group(OR(odds ratio)= 0.60,95% CI,0.46–0.77,p< 0.01),whereas the implementation of rescue treatment(OR= 5.94,95% CI,3.15–11.19,p< 0.01)and stenting rate(OR= 10.06,95%CI,4.43–22.85,p< 0.01)were higher in the ICAS-LVO group.Other parameters were similar in both groups.Conclusion The use of ET is a safe and effective therapeutic option for AIS due to ICAS-LVO.Stent-retriever thrombectomy and stent-implement are the preferred primary and rescue therapies respectively for ICAS-LVO.Less symptomatic intracranial hemorrhage and higher stenting were observed in the ICAS-LVO compared to the Embolic-LVO group.