Intracranial Atherosclerotic Disease in Acute Ischemic Stroke: Clinical Predictors, Imaging Profiles, and Treatment

BackgroundIntracranial atherosclerotic disease (ICAD) is a leading cause of ischemic stroke worldwide, with a significant prevalence in specific populations. This study aims to compare the clinical characteristics, imaging profiles, and outcomes of stroke patients with large vessel occlusion (LVO) caused by ICAD versus non-ICAD etiologies, particularly in those transferred for endovascular treatment (EVT). MethodsA retrospective analysis was conducted using data from the Riyadh Thrombectomy Registry, including 219 patients with acute ischemic stroke who underwent EVT between January 2019 and March 2024. Clinical, demographic, and imaging data were collected and compared between ICAD and non-ICAD groups. Imaging modalities included computed tomography perfusion (CTP) and angiography, with key metrics such as the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index evaluated for prognostic utility. ResultsPatients with ICAD were older and demonstrated a higher prevalence of vascular risk factors. ICAD patients presented with better ASPECTS scores, smaller ischemic core volumes, and higher mismatch ratios, reflecting better collateral circulation. However, despite favorable imaging profiles, ICAD patients exhibited higher mortality rates, particularly in cases involving basilar artery occlusion. HIR and CBV indices demonstrated modest diagnostic performance in distinguishing ICAD from non-ICAD, with an area under the curve (AUC) of 0.62 for HIR and 0.57 for CBV. ConclusionsICAD patients undergoing EVT showed distinct clinical and imaging characteristics compared to non-ICAD patients. Despite better collateral circulation, ICAD is associated with higher mortality, especially in posterior circulation strokes. Further research is required to optimize EVT strategies and explore adjunctive therapies tailored to this challenging patient population.