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Salim HA, Pulli B, Yedavalli V, Milhem F, Musmar B, Adeeb N, Lakhani DA, Essibayi MA, Heit JJ, Faizy TD, El Naamani K, Henninger N, Sundararajan SH, Kuhn AL, Khalife J, Ghozy S, Scarcia L, Yeo LL, Tan BY, Regenhardt RW, Cancelliere NM, Rouchaud A, Fiehler J, Sheth SA, Puri AS, Dyzmann C, Colasurdo M, Renieri L, Filipe JP, Harker P, Radu RA, Abdalkader M, Klein P, Marotta TR, Spears J, Ota T, Mowla A, Jabbour P, Biswas A, Clarençon F, Siegler JE, Nguyen TN, Varela R, Baker A, Altschul D, Gonzalez N, Möhlenbruch MA, Costalat V, Gory B, Stracke P, Hecker C, Marnat G, Shaikh H, Griessenauer CJ, Liebeskind DS, Pedicelli A, Alexandre AM, Tancredi I, Kalsoum E, Lubicz B, Patel AB, Mendes Pereira V, Wintermark M, Guenego A, Dmytriw AA. Endovascular therapy versus medical management in isolated anterior cerebral artery acute ischemic stroke: a multinational multicenter propensity score-weighted study. J Neurointerv Surg 2025:jnis-2024-022467. [PMID: 39613322 DOI: 10.1136/jnis-2024-022467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Accepted: 10/22/2024] [Indexed: 12/01/2024]
Abstract
BACKGROUND Isolated anterior cerebral artery occlusions (ACAo) in patients with acute ischemic stroke present significant challenges due to their rarity. The efficacy and safety of endovascular therapy (EVT) in comparison with best medical therapy (BMT) for ACAo remains unclear. This study aimed to assess the outcomes of these treatments. METHODS This multinational, multicenter study analyzed data from the MAD-MT registry. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse probability of treatment weighting (IPTW) was applied to balance confounding variables. The primary outcome was functional independence (modified Rankin Scale (mRS) scores of 0-2) at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality at 90 days, and NIH Stroke Scale (NIHSS) score on day 1 post treatment. RESULTS Of the 108 patients, 36 received BMT and 72 underwent EVT. The median age was 75 years, and 56% were male. At 90 days, 40% of patients achieved mRS 0-2, with no significant difference between EVT and BMT (38% vs 45%, p=0.46). Procedural success (mTICI 2b-3) was 91% in the EVT group, with a sICH rate of 2.9%. IPTW-adjusted analysis showed no significant difference between EVT and BMT for functional independence (OR 1.17, 95% CI 0.23 to 6.02, p=0.85), mortality (25% vs 21%, p=0.71) or day 1 NIHSS scores (Beta 2.2, 95% CI -0.51 to 4.8, p=0.11). CONCLUSIONS EVT showed high procedural success but did not significantly improve functional outcomes or mortality compared with BMT in patients with ACAo. Further randomized trials are needed to clarify EVT's role in ACAo.
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Affiliation(s)
- Hamza Adel Salim
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
- Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, USA
| | - Benjamin Pulli
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Fathi Milhem
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Basel Musmar
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Dhairya A Lakhani
- Department of Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jeremy Josef Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Program, University Medical Center, Münster, Germany
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Sri Hari Sundararajan
- Department of Endovascular Neurosurgery and Neuroradiology NJMS, NJMS, Newark, New Jersey, USA
| | - Anna Luisa Kuhn
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Scarcia
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Nicole M Cancelliere
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Aymeric Rouchaud
- Neuroradiology Department, University Hospital of Limoges, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Ajit S Puri
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | | | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | - Thomas R Marotta
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Julian Spears
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, California, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | | | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Amanda Baker
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nestor Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Benjamin Gory
- INSERM U1254, IADI, Université de Lorraine, Lorraine, France
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
| | - Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany
| | - Constantin Hecker
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Gaultier Marnat
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
| | - Christoph J Griessenauer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, California, USA
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Andrea Maria Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Illario Tancredi
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Erwah Kalsoum
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Vitor Mendes Pereira
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, USA
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada
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Liu SM, Gao G, Hao FB, Liu ST, Yang RM, Zhang HD, Wang MJ, Zou ZX, Yu D, Zhang Q, Guo QB, Wang XP, Fu HG, Li JJ, Han C, Duan L. Isolated anterior cerebral artery occlusion: an atypical form of moyamoya disease. Stroke Vasc Neurol 2024; 9:660-670. [PMID: 38460971 PMCID: PMC11791628 DOI: 10.1136/svn-2023-002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/07/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND The relationship between anterior cerebral artery (ACA) occlusion and moyamoya disease (MMD) has rarely been studied. In this study, we focused on a special type of MMD: isolated ACA-occlusive MMD. We investigated clinical attributes, genotypes and progression risk factors in patients with ACA-occlusive MMD, providing initial insights into the relationship between ACA occlusion and MMD. METHODS We retrospectively analysed digital subtraction angiography (DSA) from 2486 patients and diagnosed 139 patients with ACA-occlusive MMD. RNF213 p.R4810K (rs112735431) mutation analysis was performed. Patients were categorised into progression and non-progression groups based on whether they progressed to typical MMD. Differences in clinical characteristics, neuropsychological assessment, radiological findings and genotypes were evaluated. Logistic regression analyses identified risk factors for ACA-occlusive MMD progression. RESULTS The median age of patients with ACA-occlusive MMD was 36 years, and the primary symptom was transient ischaemic attack (TIA). 72.3% of ACA-occlusive MMD patients had cognitive decline. Of 116 patients who underwent RNF213 gene mutation analysis, 90 patients (77.6%) carried the RNF213 p.R4810K GG allele and 26 (22.4%) carried the GA allele. Of 102 patients with follow-up DSA data, 40 patients (39.2%) progressed. Kaplan-Meier curve estimates indicated a higher incidence of ischaemic stroke in the progression group during follow-up (p=0.035). Younger age (p=0.041), RNF213 p.R4810K GA genotype (p=0.037) and poor collateral compensation from the middle cerebral artery (MCA) to ACA (p<0.001) were risk factors of ACA-occlusive MMD progression to typical MMD. CONCLUSIONS Cognitive decline and TIA might be the main manifestations of ACA-occlusive MMD. Isolated ACA occlusion may be an early signal of MMD. The initial lesion site of MMD is not strictly confined to the terminal portion of the internal carotid artery. Younger patients, patients with RNF213 p.R4810K GA genotype or those with inadequate MCA-to-ACA compensation are more likely to develop typical MMD.
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Affiliation(s)
- Si-Meng Liu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Gan Gao
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Fang-Bin Hao
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Shi-Tong Liu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Ri-Miao Yang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hou-di Zhang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Min-Jie Wang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Zheng-Xing Zou
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qing-Bao Guo
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Xiao-Peng Wang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - He-Guan Fu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jing-Jie Li
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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