Identificación precoz del ictus isquémico relacionado con ateromatosis intracraneal e implicaciones en el tratamiento endovascular

Abstract

Background:_x000D_ Endovascular treatment (EVT) has become the standard of care for patients presenting with ischemic stroke due to a large-vessel occlusion (LVO). However, the optimal therapeutic strategy for patients with Intracranial Atherosclerosis-related Large Vessel Occlusion (ICAS LVO) remains uncertain, as it can be challenging and is one of the most common causes of failed recanalization. Early identification of this etiology before the procedure could lead to individualized EVT strategy and target the underlying pathophysiology. This approach may anticipate the use of mechanical and pharmacological rescue maneuvers to optimize angiographic outcomes and clinical prognosis in this subgroup of patients._x000D_ _x000D_ Aim:_x000D_ To identify clinical and radiological biomarkers of ICAS LVO available prior to EVT and evaluate their predictive capacity as well as their implications for endovascular therapeutic strategies._x000D_ _x000D_ Identificación precoz del ictus isquémico relacionado con ateromatosis intracraneal e implicaciones en el tratamiento endovascular_x000D_ _x000D_ Methods:_x000D_ First, two retrospective studies were conducted using a prospective database from the Hospital Universitari Vall d'Hebron, which included consecutive patients with ischemic stroke treated with mechanical thrombectomy between 2020 and 2022. Variables associated with the diagnosis of ICAS LVO and easily identifiable prior to EVT were analyzed. Statistical analysis was performed to evaluate their predictive and prognostic capabilities._x000D_ _x000D_ Second, a retrospective study of two European comprehensive stroke centers was conducted, including patients treated with the Stent Retriever Assisted Lysis (SAIL) technique using tirofiban due to suspected ICAS LVO and/or failed recanalization. Angiographic outcomes and safety were analyzed, with particular focus on mortality rates and symptomatic hemorrhagic transformation. Statistical analysis was performed using logistic and/or ordinal regression models depending on the nature of the outcome variable._x000D_ _x000D_ Results:_x000D_ In our cohort, the absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p=0.040), lower hypoperfusion intensity ratio (HIR [Tmax>10s/Tmax>6s], OR 0.69, 95% CI 0.50-0.95; p=0.025), symptomatic intracranial arterial calcification (sIAC, OR 4.15, 95% CI 1.64-26.42; p=0.006), more proximal occlusions (ICA, MCA M1: OR 4.00, 95% CI 1.23-13.03; p=0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p=0.035) were associated with the diagnosis of ICAS LVO. This clinico-radiological model showed good predictive capability for identifying ICAS LVO (AUC=0.88, 95% CI 0.83-0.94; p<0.001)._x000D_ _x000D_ Furthermore, symptomatic intracranial arterial calcifications emerged as an independent predictor of failed recanalization (OR 11.89; 95% CI 3.94-35.91; p<0.001), the need for rescue procedures (OR 12.38; 95% CI 2.22-69.09; p=0.004), and poor functional outcomes (mRS≥3; OR 3.51, 95% CI 1.02-12.00; p=0.046)._x000D_ _x000D_ In 44 patients presenting with ICAS LVO and/or failed recanalization, the Stent Retriever Assisted Lysis (SAIL) technique with tirofiban was performed. A sustained successful reperfusion rate of 79.5% was achieved, regardless of the administration route of tirofiban (IV SAIL 80% vs IA SAIL 78.9%, p=0.932). Rescue procedures, which included angioplasty and/or intracranial stenting, were required in only 15 patients (34.1%: IA SAIL 21.1% vs IV SAIL 44.0%; p=0.112). The rate of symptomatic hemorrhagic transformation was 6.8%. No significant differences were observed in terms of successful reperfusion, safety, or unfavorable clinical prognosis between the tirofiban administration routes._x000D_ _x000D_ Conclusions:_x000D_ The combination of baseline clinico-radiological biomarkers (absence of atrial fibrillation, smoking, proximal occlusion location, lower hypoperfusion intensity ratio, and the presence of symptomatic intracranial arterial calcification) is useful for pre-procedural identification of ICAS LVO. This strategy could anticipate the need for rescue procedures (such as angioplasty and/or stenting) and lead to a tailored, pathophysiology-driven approach. In these cases, the SAIL technique is effective in achieving successful recanalization, potentially avoiding and/or preparing for definitive intracranial stent placement.

Date of Award	3 Apr 2025
Original language	Spanish
Supervisor	Manuel Requena Ruiz (Director) & Marc Ribo Jacobi (Director)