Endovascular recanalization of complete subacute to chronic atherosclerotic occlusions of intracranial arteries

Objective/background: Symptomatic subacute/chronic large artery intracranial occlusive disease represents a common medical dilemma. We now report a multicenter experience of endovascular recanalization of intracranial atherosclerotic occlusions refractory to medical therapy.

Methods: Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (transient ischemic attack (TIA) or stroke) subacute (>48 h) or chronic complete occlusion of an intracranial artery of presumed atherosclerotic etiology. All of the patients were considered to be in the high risk category with symptomatic intracranial occlusions and progression or recurrence of their symptoms despite the best medical therapies.

Results: 24 patients (median age 63 years; mean pretreatment National Institutes of Health Stroke Scale (NIHSS) score 10; 66% men) presenting with recurrent TIAs (n=1) or strokes (n=23) were treated in two academic centers from April 2005 to June 2012. Median time from symptoms/documented occlusion to treatment was 5 days. Periprocedural complications included one symptomatic intracranial hemorrhage, one reperfusion syndrome, three asymptomatic dissections, and one asymptomatic perforation. There were no periprocedural strokes. Immediate postprocedural improvement (NIHSS decrease ≥4 at hospital discharge) occurred in 43% (10/23) of patients. There were no recurrent TIAs or strokes in the 22 patients with clinical follow-up at 90 days. At 90 days, there were two deaths (unrelated to the procedure) and 9/22 patients with an available modified Rankin Scale (mRS) score achieved a good outcome (mRS score of 0-2).

Conclusions: Endovascular recanalization can be performed with an acceptable safety profile in selected patients with symptomatic complete subacute to chronic intracranial atherosclerotic occlusion. Additional studies are warranted to investigate whether this treatment compares favorably with best medical management.