Endovascular therapy for symptomatic non-acute middle cerebral artery occlusion: impact on Lenticulostriate arteries reperfusion and clinical safety

Non-acute middle cerebral artery occlusion (NAMCAO) is a significant cause of ischemic stroke, often resulting in persistent neurological deficits and a high risk of recurrence. Endovascular therapy (EVT) shows potential benefit but faces challenges related to microvascular reperfusion and procedural safety, particularly in the perforator territories supplied by Lenticulostriate arteries (LSAs). A retrospective cohort of 112 consecutive patients with symptomatic NAMCAO treated by EVT at three centers was analyzed. Clinical assessments included NIHSS and modified Rankin Scale (mRS) scores at baseline and 6 months. Imaging evaluation included digital subtraction angiography to grade LSA reperfusion and CT perfusion parameters. Statistical analyses included logistic and ordinal regression analyses to identify predictors of outcomes and complications. The technical success rate of EVT was 91.1%, demonstrating an acceptable safety profile with a low periprocedural complication rate of 7.1%. Frequent reappearance of Lateral lenticulostriate arteries (LLSAs) was observed after middle cerebral artery (MCA) occlusion recanalization, indicating improved microvascular perfusion. Importantly, no significant differences in complication rates were observed across LLSA reappearance grades, underscoring the protective role of collateral compensation among perforating arteries. Significant neurological recovery was demonstrated by reductions in NIHSS and mRS scores from baseline to 6-month follow-up (p < 0.001). Postprocedural perfusion status (mTICI) was significantly associated with successful reperfusion, further supporting the benefit of EVT in restoring cerebral perfusion. Endovascular therapy in symptomatic NAMCAO is safe and effective, significantly improving microvascular reperfusion and neurological outcomes without increasing perforator-related complications. Careful patient selection and collateral status evaluation optimize procedural success. Prospective studies using advanced imaging biomarkers are needed to refine therapeutic strategies.