New research emerges on LVOs
Experts explain paradigm shift in treatment strategies.
Acritical challenge in stroke treatment is gaining renewed attention: intracranial atherosclerotic disease (ICAD) and its role in large vessel occlusions. ICAD accounts for 10% to 30% of large vessel occlusion (LVO) cases, making it a significant contributor to stroke risk. Yet, unlike embolic occlusions, ICAD-related LVOs are a significant contributor to stroke risk and are notoriously difficult to treat.
Rami Morsi, MD, delivers fresh insight into the challenge during his presentation, “Cracking the Code: The Pathophysiology of ICAD in LVO and Patient Outcomes.” Morsi’s presentation is part of a broader American Heart Association session on Wednesday, “Hard to Crack: Comprehensive Strategies for Diagnosing and Treating Acute LVO Due to Intracranial Atherosclerotic Disease” (Bench to Bedside). Morsi is a neuroendovascular surgery fellow at the University of Chicago.
“Patients often experience reocclusion after thrombectomy, driven by unstable plaque, persistent inflammation and severe vessel narrowing. These patients represent the highest-risk phenotype for strokes,” Morsi said, noting that advanced age, race/ethnicity, smoking, diabetes and hypertension are key risk factors.
The session will explore why ICAD-related strokes have worse outcomes, including higher mortality, bleeding rates and dependency compared with non-ICAD cases. Pathophysiology plays a major role: Plaque rupture and thrombus formation lead to acute occlusion, while residual stenosis and inflammation increase the likelihood of reocclusion — sometimes to as high as 50%-75%.
Technical challenges in ICAD-related LVOS compound the problem, Morsi said. Thrombectomy procedures are longer, catheter navigation is harder, and stenting in emergent settings remains controversial.
“There’s no standardized approach,” hesaid, citing potential risks associated with stent placement and prolonged blood thinner use, which can trigger hemorrhagic complications.
Morsi reminds clinicians that ICAD-related LVOs cannot be ignored. Mild symptoms can mask severe disease, so early suspicion is crucial, and neurologists should expect technical challenges and plan for adjunctive interventions.
Finally, he said aggressive secondary prevention — lipid control, smoking cessation and other risk factor management — is essential.
“ICAD-related LVOs demand tailored management, early suspicion and proactive prevention. Treating the acute event is not enough — long-term risk reduction is essential,” he said.
Morsi said he expects future research to include refining imaging techniques, identifying blood-based markers for plaque instability and conducting randomized trials on stenting versus medical management.
Within that same “bench to bedside” session on Wednesday, Kazutaka Uchida, MD, PhD, will present “Real-World Lessons: Selecting the Right EVT Candidates.” Uchida, an associate professor of neurosurgery at Hyogo Medical University in Nishinomiya, Japan, will discuss new research that calls for tailored stroke treatment.
Emerging evidence from a multicenter, registry analyses in Japan is reshaping how clinicians approach LVO strokes caused by atherosclerotic disease, Uchida said. Atherothrombotic (AT) and intracranial atherosclerotic strokes require a fundamentally different treatment mindset compared with embolic LVO cases.
Research findings underscore several critical points, Uchida said, including that early neurological deterioration matters. Patients with initially mild symptoms who worsen rapidly face significantly poorer outcomes, prompting a shift away from “wait-and-see” approaches to timely endovascular therapy (EVT), he said.
Additionally, up to 15% of patients with AT-LVO experience vessel reocclusion within 90 days, often leading to recurrent strokes and poor prognosis. Preventing early reocclusion is now a top priority, he said. Uchida advocates for pathophysiology-driven EVT strategies, moving beyond time-based algorithms. Real-world patient selection should integrate dynamic neurological changes, angiographic features and collateral circulation status rather than relying solely on initial severity scores.
“ICAD-LVO patients often present with good collateral circulation and smaller infarct cores, which may allow a wider treatment window,” he said, but noted that neurological instability should override clock-based hesitation.”
In short, Uchida said because reocclusion after EVT is strongly associated with recurrent stroke, symptomatic ICH and death, centers should be prepared for early post-procedural surveillance and rapid rescue strategies..
Ultimately, this paradigm shift could improve outcomes for stroke patients as clinicians adopt more nuanced, individualized treatment strategies, he said.
