Acute Ischemic Stroke: Significance of Multimodal Pre-operative Prediction of Intracranial Atherosclerosis-related Large Vessel Occlusion

When large-vessel occlusion (LVO) occurs in acute ischemic stroke, accurate differentiation of intracranial atherosclerosis-related occlusion (ICAD-O) from embolism-related occlusion (EMB-O) is critical for guiding treatment decisions. This review focuses on the preoperative prediction of ICAD-O and emphasizes the practical clinical and imaging factors. ICAD-O is often associated with younger age, male sex, and vascular risk factors, such as hypertension and diabetes, and the absence of atrial fibrillation is a key characteristic of its differentiation. Imaging findings, including truncal-type occlusion and non-culprit stenosis, further aid in the identification of ICAD-O. Predictive scales integrating clinical and imaging data, such as the ISAT, REMIT, ABC²D, and ATHE scores, provide structured approaches for distinguishing ICAD-O from EMB-O. By reviewing these predictive tools and findings, this review aims to enhance the accuracy and efficiency of the preoperative diagnosis, supporting better-informed clinical decision-making for stroke patients with LVO.