Primary angioplasty/stenting versus mechanical thrombectomy as the initial approach for underlying ICAD-LVO: a multicenter retrospective cohort study

Objective Intracranial atherosclerotic disease-related large vessel occlusion (ICAD-LVO) is a prevalent stroke subtype among Asian populations. Characterized by dynamic intraprocedural reocclusion and underlying stenotic pathology, this condition poses distinct challenges for acute endovascular management. Contemporary guidelines universally recommend mechanical thrombectomy (MT) as first-line recanalization therapy for large vessel occlusion (LVO); however such recommendations derive predominantly from studies without etiological stratification. Consequently, optimal initial endovascular strategies for ICAD-LVO remain undefined despite its epidemiological significance in Asian cohorts. Methods In this multicenter retrospective cohort study, 161 patients with underlying ICAD-LVO who underwent endovascular therapy (June 2022–December 2024) were stratified by initial strategy: angioplasty/stenting (AS group, n = 94) or mechanical thrombectomy (MT group, n = 67). The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] score 0–2). Secondary outcomes included successful recanalization (mTICI 2b–3), symptomatic intracranial hemorrhage (SICH), and mortality. Results Among 161 included patients (94 AS vs. 67 MT), baseline characteristics were balanced except for a higher prevalence of hyperlipidemia ( p = 0.041), progressive stroke ( p < 0.001), and tirofiban administration ( p = 0.043) in the AS group. The initial AS approach achieved significantly higher rates of functional independence (63.8% vs. 47.8%; adjusted OR = 2.886, 95% CI: 1.290–6.736, p = 0.011) and reduced the need for rescue therapy (24.5% vs. 55.2%). Rates of successful recanalization (96.8% vs. 91.0%, p = 0.155), SICH (13.8% vs. 13.4%, p = 0.985), and 90-day mortality (14.9% vs. 13.4%, p = 0.784) did not differ significantly. Conclusion In this multicenter retrospective cohort study, primary angioplasty/stenting was associated with superior clinical efficacy compared to mechanical thrombectomy as the initial approach for underlying ICAD-LVO. This approach showed higher rates of 90-day functional independence while maintaining a comparable safety profile. These findings support the concept of etiology-specific endovascular strategies; however, this approach requires confirmation in prospective randomized controlled trials.