Abstract
Introduction: The majority of acute large vessel occlusions (LVOs) are typically embolic clot; however, some patients have in situ thrombosis of an underlying intracranial atherosclerotic stenosis (ICAS). Large vessel occlusion with underlying ICAS is estimated to be approximately 10% of cases in the United States and over 30% of cases in Asia.
Methods: The major past studies evaluating the role of angioplasty or angioplasty and stenting of underlying ICAS in the treatment of LVO versus thrombectomy alone without treatment of the underlying ICAS lesion are reviewed. The early diagnosis and technique for treating these types of lesions are reviewed as well as case examples.
Results: The review of acute stenting in addition to thrombectomy in patients with LVO and an underlying ICAS lesion showed similar, or in some cases better, results compared with thrombectomy in LVO without an underlying ICAS lesion. Of the studies reviewed, there was an 86.1% revascularization rate, an 8.3% symptomatic hemorrhage rate, and 16% mortality. Imaging characteristics such as calcified target artery or difficulty passing the microwire and microcatheter past the lesion can infer possible underlying ICAS. Clinical examples of a basilar artery occlusion and a middle cerebral artery occlusion with underlying ICAS are provided.
Conclusions: Although less common than embolic clot, in situ thrombosis of an ICAS lesion is encountered in a significant percentage of patients. Preliminary studies indicate if the stenosis is critical, 70% or greater, then stenting, during the thrombectomy procedure, may be performed without significant increase in risk to the patient, and potentially better clinical outcomes than thrombectomy without addressing severe underlying stenosis.
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Barnard, Z.R., Alexander, M.J. (2021). Large Vessel Occlusion with Underlying Atherosclerosis: Approach and Strategy. In: Hui, F.K., Spiotta, A.M., Alexander, M.J., Hanel, R.A., Baxter, B.W. (eds) 12 Strokes. Springer, Cham. https://doi.org/10.1007/978-3-030-56857-3_19
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