Revascularization treatments within 4.5 h after onset in acute ischemic stroke with isolated extracranial artery occlusion

Introduction: The optimal revascularization treatment in patients with acute ischemic stroke (AIS) and isolated extracranial artery occlusion remains uncertain. We aimed to compare outcomes between endovascular treatment (EVT) and intravenous thrombolysis (IVT) alone in patients with AIS and isolated extracranial artery occlusion without concomitant ipsilateral large intracranial occlusion treated ≤ 4.5 h of onset. Methods: We retrospectively analyzed prospectively collected data from two multicenter registries (IRETAS for EVT and SITS-ISTR for IVT). Primary efficacy endpoints were 3-month modified Rankin Scale (mRS) score 0–1 and 0–2. Primary safety endpoints were symptomatic intracranial hemorrhage (sICH) and 3-month mortality. Multivariable logistic regression was used to adjust for imbalances in demographics, clinical variables, stroke etiology data, and procedure data. Results: A total of 793 patients were included in the study (EVT, n = 358; IVT alone, n = 389; control angiography, n = 46), of whom 633 with extracranial internal carotid artery (ICA) occlusion and 160 with extracranial vertebral artery (VA) occlusion. In the isolated extracranial ICA or VA occlusions, EVT was associated with lower rates of mRS 0–1 (aOR: 0.45, 95% CI: 0.29–0.71) and mRS 0–2 (aOR: 0.42, 95% CI: 0.27–0.66), higher rate of mortality (aOR: 2.91, 95% CI: 1.62–5.24). In the isolated extracranial ICA occlusion, IVT was associated with higher rates of mRS 0–2 (aOR: 2.63, 95% CI: 1.13–6.08) compared with control angiography. Conclusions: Our data support IVT ≤ 4.5 h after onset as first-line therapy in eligible patients with AIS and isolated extracranial artery occlusion whereas the benefit of EVT appears limited and warrants further investigation in RCTs.