Skip to main content
SpringerLink
Log in

Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden

  • Interventional Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden.

Methods

Consecutive ICAS-ELVO patients presenting with microcatheter “first-pass effect” during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared.

Results

Seventy-six patients with ICAS-ELVO involving the microcatheter “first-pass effect” during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5 min vs. 89.0 min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0–1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter “first-pass effect” (adjusted odds ratio = 6.01, 95% confidence interval: 1.15–31.51, p = .034).

Conclusion

Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20. https://doi.org/10.1056/NEJMoa1411587

    Article  PubMed  CAS  Google Scholar 

  2. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018. https://doi.org/10.1056/NEJMoa1414792

    Article  PubMed  CAS  Google Scholar 

  3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030. https://doi.org/10.1056/NEJMoa1414905

    Article  PubMed  CAS  Google Scholar 

  4. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 372:2285–95. https://doi.org/10.1056/NEJMoa1415061

    Article  PubMed  CAS  Google Scholar 

  5. Jovin TG, Chamorro A, Cobo E, Miquel MAD, Munuera J (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306. https://doi.org/10.1056/NEJMoa1503780

    Article  PubMed  CAS  Google Scholar 

  6. Kim YW, Hong JM, Park DG, Choi JW, Kang DH, Kim YS et al (2016) Effect of intracranial atherosclerotic disease on endovascular treatment for patients with acute vertebrobasilar occlusion. AJNR Am J Neuroradiol 37:2072–2078. https://doi.org/10.3174/ajnr.A4844

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Hwang YH, Kim YW, Kang DH, Kim YS, Liebeskind DS (2016) Impact of target arterial residual stenosis on outcome after endovascular revascularization. Stroke 47:1805–1807. https://doi.org/10.1161/STROKEAHA.116.014694

    Article  Google Scholar 

  8. Lee JS, Lee SJ, Hong JM, Alverne F, Lima FO, Nogueira RG (2022) Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease. J Stroke 24:3–20. https://doi.org/10.5853/jos.2021.01375

    Article  PubMed  PubMed Central  Google Scholar 

  9. Tsang ACO, Orru E, Klostranec JM, Yang IH, Lau KK, Tsang FCP et al (2019) Thrombectomy outcomes of intracranial atherosclerosis-related occlusions. Stroke 50:1460–1466. https://doi.org/10.1161/STROKEAHA.119.024889

    Article  PubMed  Google Scholar 

  10. Zhang J, Jia B, Pan Y, Yu Z, Deng Y, Mo D et al (2022) A comparison between different endovascular treatment strategies for acute large vessel occlusion due to intracranial artery atherosclerosis: data from ANGEL-ACT Registry. Neuroradiology 64:1627–1638. https://doi.org/10.1007/s00234-022-02933-w

    Article  PubMed  Google Scholar 

  11. Ma G, Sun X, Tong X, Jia B, Huo X, Luo G et al (2021) Safety and Efficacy of Direct Angioplasty in Acute Basilar Artery Occlusion Due to Atherosclerosis. Front Neurol 12:651653. https://doi.org/10.3389/fneur.2021.651653

    Article  PubMed  PubMed Central  Google Scholar 

  12. Luo Y, Huang J, Yang Y, Liu H, Chen X, Li X et al (2020) Effect of direct angioplasty therapy on acute middle cerebral artery occlusion with good leptomeningeal collateral. Clin Neurol Neurosurg 190:105744. https://doi.org/10.1016/j.clineuro.2020.105744

    Article  PubMed  Google Scholar 

  13. Yi TY, Chen WH, Wu YM, Zhang MF, Zhan AL, Chen YH et al (2019) Microcatheter “First-Pass Effect” Predicts Acute Intracranial Artery Atherosclerotic Disease-Related Occlusion. Neurosurgery 84:1296–1305. https://doi.org/10.1093/neuros/nyy183

    Article  PubMed  Google Scholar 

  14. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 24:35–41. https://doi.org/10.1161/01.str.24.1.35

    Article  PubMed  Google Scholar 

  15. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K et al (2018) 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110. https://doi.org/10.1161/STR.0000000000000158

    Article  PubMed  Google Scholar 

  16. McTaggart RA, Ospel JM, Psychogios MN, Puri AS, Maegerlein C, Lane KM et al (2020) Optimization of endovascular therapy in the neuroangiography suite to achieve fast and complete (Expanded treatment in cerebral ischemia 2c–3) reperfusion. Stroke 51:1961–1968. https://doi.org/10.1161/STROKEAHA.119.026736

    Article  PubMed  Google Scholar 

  17. Almekhlafi MA, Mishra S, Desai JA, Nambiar V, Volny O, Goel A et al (2014) Not all “successful” angiographic reperfusion patients are an equal validation of a modified TICI scoring system. Interv Neuroradiol 20:21–27. https://doi.org/10.15274/INR-2014-10004

    Article  PubMed  PubMed Central  Google Scholar 

  18. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG et al (2012) Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:1241–1249. https://doi.org/10.1016/S0140-6736(12)61384-1

    Article  PubMed  Google Scholar 

  19. Kang DH, Yoon W (2019) Current Opinion on Endovascular Therapy for Emergent Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Stenosis. Korean J Radiol 20:739–748. https://doi.org/10.3348/kjr.2018.0809

    Article  PubMed  PubMed Central  Google Scholar 

  20. Treurniet KM, Yoo AJ, Berkhemer OA, Lingsma HF, Boers AM, Fransen PS et al (2016) Clot Burden Score on Baseline Computerized Tomographic Angiography and Intra-Arterial Treatment Effect in Acute Ischemic Stroke. Stroke 47:2972–2978. https://doi.org/10.1161/STROKEAHA.116.014565

    Article  PubMed  Google Scholar 

  21. Derraz I, Bourcier R, Soudant M, Soize S, Hassen WB, Hossu G et al (2019) Does clot burden score on baseline T2*-MRI impact clinical outcome in acute ischemic stroke treated with mechanical thrombectomy? J Stroke 21:91–100. https://doi.org/10.5853/jos.2018.01921

    Article  PubMed  PubMed Central  Google Scholar 

  22. Derraz I, Pou M, Labreuche J, Legrand L, Soize S, Tisserand M et al (2021) Clot burden score and collateral status and their impact on functional outcome in acute ischemic stroke. AJNR Am J Neuroradiol 42:42–48. https://doi.org/10.3174/ajnr.A6865

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  23. Nikoubashman O, Dekeyzer S, Riabikin A, Keulers A, Reich A, Mpotsaris A et al (2019) True first-pass effect. Stroke 50:2140–2146. https://doi.org/10.1161/STROKEAHA.119.025148

    Article  PubMed  Google Scholar 

  24. Jia B, Feng L, Liebeskind DS, Huo X, Gao F, Ma N et al (2018) Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis. J Neurointerv Surg 10:746–750. https://doi.org/10.1136/neurintsurg-2017-013489

    Article  PubMed  Google Scholar 

  25. Yoon W, Kim SK, Park MS, Kim BC, Kang HK (2015) Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke. Neurosurgery. 76:680–6. https://doi.org/10.1227/NEU.0000000000000694. (discussion 6)

    Article  PubMed  Google Scholar 

  26. Kim YW, Sohn SI, Yoo J, Hong JH, Kim CH, Kang DH et al (2020) Local tirofiban infusion for remnant stenosis in large vessel occlusion: tirofiban ASSIST study. BMC Neurol 20:284. https://doi.org/10.1186/s12883-020-01864-4

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  27. Investigators RBT, Qiu Z, Li F, Sang H, Luo W, Liu S et al (2022) Effect of Intravenous Tirofiban vs Placebo Before Endovascular Thrombectomy on Functional Outcomes in Large Vessel Occlusion Stroke: The RESCUE BT Randomized Clinical Trial. JAMA 328:543–553. https://doi.org/10.1001/jama.2022.12584

    Article  CAS  Google Scholar 

  28. Li H, Ma HY, Zhang L, Liu P, Zhang YX, Zhang XX et al (2022) Early diagnosis of intracranial atherosclerotic large vascular occlusion: A prediction model based on DIRECT-MT data. Front Neurol 13:1026815. https://doi.org/10.3389/fneur.2022.1026815

    Article  PubMed  PubMed Central  Google Scholar 

  29. Liang W, Wang Y, Du Z, Mang J, Wang J (2021) Intraprocedural angiographic signs observed during endovascular thrombectomy in patients with acute ischemic stroke: a systematic review. Neurology 96:1080–1090. https://doi.org/10.1212/WNL.0000000000012069

    Article  PubMed  Google Scholar 

  30. Baek JH, Kim BM (2019) Angiographical Identification of Intracranial, Atherosclerosis-Related, Large Vessel Occlusion in Endovascular Treatment. Front Neurol 10:298. https://doi.org/10.3389/fneur.2019.00298

    Article  PubMed  PubMed Central  Google Scholar 

  31. Zhang Y, He G, Lu J, Miao G, Liang D, Wang J et al (2023) Thrombus Enhancement Sign May Differentiate Embolism From Arteriosclerosis-Related Large Vessel Occlusion. J Stroke 25:233–241. https://doi.org/10.5853/jos.2022.03489

    Article  PubMed  PubMed Central  Google Scholar 

  32. Kishi F, Nakagawa I, Kimura S, Ogawa D, Yagi R, Yamada K et al (2023) Tmax volume can predict clinical type in patients with acute ischemic stroke. Brain Behav 13:e3163. https://doi.org/10.1002/brb3.3163

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We would like to thank Editage (www.editage.cn) for English language editing and Charlesworth (www.cwauthors.com.cn) for statistical review.

Funding

This study was supported by the Natural Science Foundation of Guangdong Province (NO.2022A1515012563).

Author information

Author notes

  1. LZ and XH contributed equally.

Authors and Affiliations

  1. Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China

    Liang Zhang, Min Peng & Li’an Huang

  2. Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China

    Xiong’jun He, Kai’feng Li, Li Ling & Ya’jie Liu

Authors
  1. Liang Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xiong’jun He
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kai’feng Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Li Ling
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Min Peng
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Li’an Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ya’jie Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

L.Z. and X.H. analyzed and interpreted the data and drafted the manuscript. Y.L. conceived and designed the research. M.P. and K.L. evaluated the image. L.L. and L.H. made critical revisions of the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Li’an Huang or Ya’jie Liu.

Ethics declarations

Competing interests

The authors declare that they have no competing interests.

Ethics statement

The studies involving human participants were reviewed and approved by the Clinical Research Ethics Committee of Shenzhen Hospital of Southern Medical University (NYSZYYEC20180001).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

The authors affirm that human research participants provided informed consent for publication of the images in Fig. 2 (a-h).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, L., He, X., Li, K. et al. Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden. Neuroradiology 66, 399–407 (2024). https://doi.org/10.1007/s00234-023-03278-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-023-03278-8

Keywords

Search

Navigation