Acute therapeutic management of M1-middle cerebral artery occlusion with underlying intracranial atherosclerotic disease: is mechanical thrombectomy the right first-line choice?

Background Acute occlusions of the anterior circulation with an underlying intracranial atheromatous disease (ICAD) represent a diagnostic and therapeutic challenge. The aim of this study was to compare the results of the endovascular treatment (EVT) ± intravenous thrombolysis (IVT) and the best medical treatment (BMT ± IVT) as first-line approach in a cohort of patients with certain diagnosis of M1-Middle Cerebral Artery (M1-MCA) occlusions and underlying ICAD. Methods Patients with M1-MCA and a certain diagnosis of underlying ICAD were included in this retrospective, monocentric analysis between 2018 and April 2023. Baseline, procedural and clinico-neuroradiological follow-up data were collected. EVT ± IVT and BMT ± IVT were the two study groups. An independent core lab assessed the imaging data. The primary outcome was the rate of functional independence at 3 months (mRS0-2); secondary outcomes included the extension of the ischemic lesion (∆baseline-24 hours volume), the early neurological deterioration (END), the rate of symptomatic intracranial haemorrhages (sICH). Results Thirty-four patients were included in the study (65,7 ± 16,5 y.o.; males: 52,8%), 23 were treated by EVT ± IVT and 11 with BMT ± IVT. Functional independence was less frequent in the EVT ± IVT group compared to the BMT ± IVT (26%vs81,8%, p = 0,003). The increase of ∆ volume, the rate of END and sICH were significantly lower in the BMT ± IVT group. Conclusions EVT ± IVT (only MT) was associated with worse clinical and neuroimaging outcomes compared to BMT ± IVT. Nevertheless, a beneficial effect of primary angioplasty ± stenting should be taken in account and future studies will be necessary to investigate this therapeutic option.