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. 2021 Oct 25:12:734971.
doi: 10.3389/fneur.2021.734971. eCollection 2021.

Rescue Endovascular Treatment for Emergent Large Vessel Occlusion With Underlying Intracranial Atherosclerosis: Current State and Future Directions

Sami Al Kasab  1   2 , Eyad Almallouhi  1   2 , Alejandro M Spiotta  1
Affiliations

Rescue Endovascular Treatment for Emergent Large Vessel Occlusion With Underlying Intracranial Atherosclerosis: Current State and Future Directions

Sami Al Kasab et al. Front Neurol. .

Abstract

Intracranial atherosclerosis (ICAS) is one of the most common causes of stroke worldwide and is associated with high risk of stroke recurrence. While the most common clinical presentation is acute-subacute transient ischemic attack or ischemic stroke, occasionally, patients with underlying ICAS present with acute occlusion of the affected vessel. Diagnosis and endovascular management of ICAS-related emergent large vessel occlusion (ELVO) can be challenging. Herein, we review the current evidence supporting endovascular management of ICAS-related ELVO and discuss future directions.

Keywords: intracranial atherosclerosis; rescue; stenting; stroke; thrombectomy.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
ADAPT vs. SR for EVT in ICAS ELVO. (A) Aspiration catheter engulfing the proximal end of the thrombus. (B) Stent retriever engulfing the thrombus—the stent retriever shape is changed at the location of the plaque. SR, stent retriever; ADAPT, a direct aspiration first pass technique; MT, mechanical thrombectomy; ICAS, intracranial atherosclerosis; ELVO, emergent large vessel occlusion.
Figure 2
Figure 2
Post-thrombectomy angiographic appearance in ICAS-related ELVO requiring rescue therapy. (A) Severe residual stenosis. (B) Re-occlusion. ICAS, intracranial atherosclerosis; ELVO, emergent large vessel occlusion.
Figure 3
Figure 3
Illustrative case of ICAS-related LVO in the M1 segment of the left middle cerebral artery. (A) Pre-MT angiographic image demonstrating complete occlusion of M1 segment of the left middle cerebral artery. (B) Post-MT angiographic image demonstrating partial recanalization of M1 segment of the left middle cerebral artery with persistent severe flow-limiting stenosis. Of note, ADAPT technique was used in this case. (C) Native (left) and digitally subtracted (right) angiographic images demonstrating successful intracranial stenting with Neuro-Form atlas stent as a rescue therapy with a goal of maintaining cerebral flow through the stenotic portion of M1 segment of the left middle cerebral artery. ADAPT, direct aspiration first pass technique; MT, mechanical thrombectomy; ICAS, intracranial atherosclerosis; ELVO, Emergent large vessel occlusion.
Figure 4
Figure 4
Illustrative case of ICAS-related LVO in the cavernous segment of the right internal carotid artery. (A) Pre-MT angiographic image demonstrating complete occlusion of cavernous segment of the right internal carotid artery. (B) Post-MT angiographic image demonstrating partial recanalization of cavernous segment of the right internal carotid artery with persistent severe stenosis. (C) Delayed angiographic image 5 min post-MT demonstrating re-occlusion of the intracranial internal carotid artery. (D) Native (left) and digitally subtracted (right) angiographic images demonstrating successful angioplasty and stenting as a rescue therapy, with a significant improvement in the severe stenosis and near complete recanalization of the right internal carotid artery. ADAPT, a direct aspiration first pass technique; MT, mechanical thrombectomy; ICAS, intracranial atherosclerosis; ELVO, emergent large vessel occlusion.
See this image and copyright information in PMC

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