This study examines the clinical outcomes of endovascular reperfusion therapy and emergent intracranial stenting based on the angiographically defined occlusion location of the middle cerebral artery (MCA).

We reviewed consecutive patients with acute MCA infarct associated with intracranial atherosclerotic stenosis (ICAS) who underwent rescue intracranial stenting and balloon angioplasty after initial mechanical thrombectomy. We compared patient demographics, baseline characteristics, clinical outcomes, and periprocedural complications, including in-stent thrombosis and re-occlusion, according to the MCA occlusion location. The occlusion location was categorized based on the presence of the proximal MCA stump in enrolled ICAS patients.

Of 47 patients, 30 (63.8%) were classified as having a stump group. The initial NIHSS was more severe in the without-stump group compared to the with-stump group (13.0 [8.0–16.0] vs. 8.0 [8.0–13.0] p = 0.078). There were no significant differences in procedure time, technique, and devices. However, the successful revascularization rate was significantly lower in the without-stump group (64.7% vs. 100%, p = 0.002). Additionally, the immediate re-occlusion rate after the first endovascular reperfusion therapy tended to be higher in the without-stump group (76.5% vs. 36.7%, p = 0.02). No significant association was found between periprocedural complications, including intracerebral hemorrhage and mortality.

Angiographically presented MCA occlusion without a stump in acute large vessel occlusion underlying ICAS predicts more complicated intracranial stenting and poorer clinical outcomes than patients with a stump.