Effect of First-Pass Reperfusion on Outcome After Endovascular Treatment for Ischemic Stroke

Impact of obesity-related indicators on first-pass effect in patients with ischemic stroke receiving mechanical thrombectomy

PURPOSE

The first-pass effect (FPE), defined as complete revascularization after a single thrombectomy pass in large vessel occlusion, is a predictor of good prognosis in patients with acute ischemic stroke (AIS) receiving mechanical thrombectomy (MT). We aimed to evaluate obesity-related indicators if possible be predictors of FPE.

METHODS

We consecutively enrolled patients with AIS who were treated with MT between January 2019 and December 2021 at our institution. Baseline characteristics, procedure-related data, and laboratory test results were retrospectively analyzed. A multivariable logistic regression analysis was performed to evaluate the independent predictors of FPE.

RESULTS

A total of 151 patients were included in this study, of whom 47 (31.1%) had FPE. After adjusting for confounding factors, the independent predictors of achieving FPE were low levels of body mass index (BMI) (OR 0.85, 95% CI 0.748 to 0.971), non-intracranial atherosclerotic stenosis (OR 4.038, 95% CI 1.46 to 11.14), and non-internal carotid artery occlusion (OR 13.14, 95% CI 2.394 to 72.11). Patients with lower total cholesterol (TC) (< 3.11 mmol/L) were more likely to develop FPE than those with higher TC (≥ 4.63 mmol/L) (OR 4.280; 95% CI 1.24 to 14.74) CONCLUSION: Lower BMI, non-intracranial atherosclerotic stenosis, non-internal carotid artery occlusion, and lower TC levels were independently associated with increased rates of FPE in patients with AIS who received MT therapy. FPE was correlated with better clinical outcomes after MT.

Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when?

BACKGROUND

Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined.

OBJECTIVE

To evaluate the association between early changes to the EVT approach and reperfusion.

METHODS

Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c-3, following the second and third passes.

RESULTS

Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c-3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c-3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c-3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c-3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar.

CONCLUSIONS

Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.

Impact of Procedure Time on First Pass Effect in Mechanical Thrombectomy for Anterior Circulation Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT).

METHODS

A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation.

RESULTS

A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable.

CONCLUSION

FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.

First pass effect of mechanical thrombectomy for acute vertebrobasilar artery occlusion: data from the ANGEL-ACT registry

BACKGROUND

To explore the incidence, predictors, and association of first pass effect (FPE) on clinical outcomes of mechanical thrombectomy (MT) for acute vertebrobasilar artery occlusion (VBAO) in the Asian population.

METHODS

We selected patients from the ANGEL-ACT registry. We defined FPE as complete recanalization after one MT attempt without rescue treatment, multiple pass effect (MPE) as complete recanalization after >1 MT attempt or after one MT attempt with rescue treatment, and incomplete recanalization (ICR) as a modified Thrombolysis in Cerebral Ischemia score of 2b, independent of the number of MT attempts. We conducted multivariable logistic analyses to identify the independent predictors of FPE and to compare the outcomes, including favorable outcome, mortality within 90 days, and intracranial hemorrhage (ICH) among the FPE, MPE, and ICR groups.

RESULTS

Two hundred and seventy-nine patients, 68 with FPE (24.4%), 114 with MPE (40.9%), and 83 with ICR (29.7%), were included. Underlying intracranial atherosclerosis disease (ICAD) (adjusted OR (aOR) 0.16, 95% CI 0.08 to 0.34, P<0.001) was independently associated with a low chance of FPE. Furthermore, FPE was associated with a favorable outcome compared with MPE and ICR (MPE vs FPE, aOR 0.49, 95% CI 0.25 to 0.97, P=0.040; ICR vs FPE, aOR 0.38, 95% CI 0.18 to 0.81, P=0.012), and decreased mortality (MPE vs FPE, aOR 2.57, 95% CI 1.04 to 6.36, P=0.041) compared with MPE but similar mortality to ICR (P=0.374). No difference was found for ICH among the three groups (P>0.05).

CONCLUSIONS

FPE occurred in 24.4% of patients with VBAO in our cohort, which was associated with improved clinical outcomes compared with MPE and ICR. VBAO with underlying ICAD was less likely to achieve FPE.

TRIAL REGISTRATION NUMBER

NCT03370939.

Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke

STAIR XII (12th Stroke Treatment Academy Industry Roundtable) included a workshop to discuss the priorities for advancements in neuroimaging in the diagnostic workup of acute ischemic stroke. The workshop brought together representatives from academia, industry, and government. The participants identified 10 critical areas of priority for the advancement of acute stroke imaging. These include enhancing imaging capabilities at primary and comprehensive stroke centers, refining the analysis and characterization of clots, establishing imaging criteria that can predict the response to reperfusion, optimizing the Thrombolysis in Cerebral Infarction scale, predicting first-pass reperfusion outcomes, improving imaging techniques post-reperfusion therapy, detecting early ischemia on noncontrast computed tomography, enhancing cone beam computed tomography, advancing mobile stroke units, and leveraging high-resolution vessel wall imaging to gain deeper insights into pathology. Imaging in acute ischemic stroke treatment has advanced significantly, but important challenges remain that need to be addressed. A combined effort from academic investigators, industry, and regulators is needed to improve imaging technologies and, ultimately, patient outcomes.

Clinical Benefit of First-Pass Recanalization Is Time-Dependent in Endovascular Treatment of Acute Ischemic Stroke

Clinical benefit can be time-dependent even after first-pass recanalization (FPR) in endovascular treatment of acute stroke. This study aimed to evaluate the association between favorable outcome and FPR under a specific time frame. Patients who underwent mechanical thrombectomy were retrospectively reviewed. Recanalization status was categorized into four groups based on FPR and dichotomized time from groin puncture to recanalization (P-to-R time). Favorable outcomes were compared between groups. A total of 458 patients were included. As the cutoff of P-to-R time for favorable outcome was 30 min, recanalization status was categorized into FPR (+) with a P-to-R time ≤ 30 min (Group 1), FPR (-) with a P-to-R time ≤ 30 min (Group 2), FPR (+) with a P-to-R time > 30 min (Group 3), and FPR (-) with a P-to-R time > 30 min (Group 4). Favorable outcomes in Group 3 (37.5%) were significantly less frequent than those in Group 1 (60.4%, p = 0.029) and Group 2 (59.5%, p = 0.033) but were not significantly different from those in Group 4 (35.7%, p = 0.903). Compared to Group 1, Group 3 (adjusted odds ratio, 0.30 [95% confidence interval, 0.12-0.76]; p = 0.011) and Group 4 (0.25 [0.14-0.48]; p < 0.001) were adversely associated with favorable outcomes. FPR was associated with functional outcome in a time-dependent manner. Even for patients who have achieved FPR, their functional outcome might not be favorable if the P-to-R time is >30 min.

Modified treatment in cerebral ischemia 1 versus modified treatment in cerebral ischemia 0 before endovascular stroke treatment in middle cerebral artery’s M1-occlusion: Predictor for revascularization success and outcome?

Background

Little is known about the implications for revascularization success of target vessel occlusions (TVOs) with persisting antegrade perfusion before initiation of endovascular stroke treatment (EST) (modified treatment in cerebral ischemia (mTICI 1)) compared to a complete occlusion (mTICI 0). Here, we compared these two states of TVO.

Methods

Retrospective, single-center analysis of patients treated for M1-segment middle cerebral artery (MCA) occlusion with EST from January 2015 until May 2020 in a tertiary stroke center. Primary study endpoint was successful recanalization (mTICI 2c-3) after one thrombectomy attempt. Secondary endpoints were clinical outcome (modified Rankin Scale (mRS) 90 days after stroke onset), complication rate, and rate of underlying atherosclerotic disease. The two study groups were compared in univariate analysis including patient characteristics and procedural details.

Results

In this study, 422/581 patients (72.6%) presented with complete M1-occlusion compared to 159/581 (27.4%) with incomplete M1-occlusion. Neither did the recanalization success rate differ between the study groups nor the rate of complications (mTICI 0: 2.4%, mTICI 1: 0.6%, p = 0.304) or underlying atherosclerotic disease. Patients with incomplete initial occlusion showed a lower mRS at discharge (median interquartile range (IQR) mTICI 0: 4 (3–5) vs. mTICI 1: 3 (2–6), p = 0.014), but a comparable mRS 90 days after stroke onset (mTICI 0: 3 (2–6) vs. mTICI 1: 4 (2–6), p = 0.479).

Conclusion

Complete M1-occlusions (mTICI 0) and incomplete occlusions (mTICI 1) show the same recanalization success, comparable complication rate, and clinical outcome as well as the same rate of underlying atherosclerotic disease. Thus, incomplete M1-occlusions do not allow for an individualized interventional approach.

First-Pass Recanalization with EmboTrap II in Acute Ischemic Stroke (FREE-AIS): A Multicenter Prospective Study

OBJECTIVE

We aimed to evaluate the efficacy of EmboTrap II in terms of first-pass recanalization and to determine whether it could yield favorable outcomes.

MATERIALS AND METHODS

In this multicenter, prospective study, we consecutively enrolled patients who underwent mechanical thrombectomy using EmboTrap II as a front-line device. The primary outcome was the first pass effect (FPE) rate defined by modified Thrombolysis In Cerebral Infarction (mTICI) grade 2c or 3 by the first pass of EmboTrap II. In addition, modified FPE (mFPE; mTICI grade 2b-3 by the first pass of EmboTrap II), successful recanalization (final mTICI grade 2b-3), and clinical outcomes were assessed. We also analyzed the effect of FPE on a modified Rankin Scale (mRS) score of 0-2 at 3 months.

RESULTS

Two hundred-ten patients (mean age ± standard deviation, 73.3 ± 11.4 years; male, 55.7%) were included. Ninety-nine patients (47.1%) had FPE, and mFPE was achieved in 150 (71.4%) patients. Successful recanalization was achieved in 191 (91.0%) patients. Among them, 164 (85.9%) patients underwent successful recanalization by exclusively using EmboTrap II. The time from groin puncture to FPE was 25.0 minutes (interquartile range, 17.0-35.0 minutes). Procedure-related complications were observed in seven (3.3%) patients. Symptomatic intracranial hemorrhage developed in 14 (6.7%) patients. One hundred twenty-three (58.9% of 209 completely followed) patients had an mRS score of 0-2. Sixteen (7.7% of 209) patients died during the follow-up period. Patients who had successful recanalization with FPE were four times more likely to have an mRS score of 0-2 than those who had successful recanalization without FPE (adjusted odds ratio, 4.13; 95% confidence interval, 1.59-10.8; p = 0.004).

CONCLUSION

Mechanical thrombectomy using the front-line EmboTrap II is effective and safe. In particular, FPE rates were high. Achieving FPE was important for an mRS score of 0-2, even in patients with successful recanalization.

Successful reperfusion in relation to the number of passes: comparing outcomes of first pass expanded Treatment In Cerebral Ischemia (eTICI) 2B with multiple-pass eTICI 3

BACKGROUND

Higher expanded Treatment In Cerebral Ischemia (eTICI) reperfusion scores after endovascular treatment (EVT) are associated with better outcomes. However, the influence of the number of passes on this association is unclear. We aimed to compare outcomes of single-pass good reperfusion (eTICI 2B) with multiple-pass excellent/complete reperfusion (eTICI 2C/3) in daily clinical practice.

METHODS

We compared outcomes of patients in the MR CLEAN Registry with good reperfusion (eTICI 2B) in a single pass to those with excellent/complete reperfusion (eTICI 2C/3) in multiple passes. Regression models were used to investigate the association of single-pass eTICI 2B versus multiple-pass eTICI 2C/3 reperfusion with 90-day functional outcome (modified Rankin Scale (mRS)), functional independence (mRS 0-2), per-procedural complications and safety outcomes.

RESULTS

We included 699 patients: 178 patients with single-pass eTICI 2B, and 242 and 279 patients with eTICI 2C/3 after 2 and ≥3 passes, respectively. Patients with eTICI 2C/3 after 2 or ≥3 passes did not achieve significantly better functional outcomes compared with patients with single-pass eTICI 2B (adjusted common OR (acOR) 1.06, 95% CI 0.75 to 1.50 and acOR 0.88, 95% CI 0.74 to 1.05 for 90-day mRS, and adjusted OR (aOR) 1.24, 95% CI 0.78 to 1.97 and aOR 0.79, 95% CI 0.52 to 1.22 for functional independence).

CONCLUSIONS

Our results did not show better outcomes for patients who achieved eTICI 2C/3 in multiple, that is, two or more, passes when compared with patients with single-pass eTICI 2B. However, this concerns observational data. Further research is necessary to investigate the per-pass effect in relation to reperfusion and functional outcome.

Influence of the interventionist's experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry

BACKGROUND

The relationship between the interventionist's experience and outcomes of endovascular thrombectomy (EVT) for acute ischemic stroke of the anterior circulation, is unclear.

OBJECTIVE

To assess the effect of the interventionist's level of experience on clinical, imaging, and workflow outcomes. Secondly, to determine which of the three experience definitions is most strongly associated with these outcome measures.

METHODS

We analysed data from 2700 patients, included in the MR CLEAN Registry. We defined interventionist's experience as the number of procedures performed in the year preceding the intervention (EXPfreq), total number of procedures performed (EXPno), and years of experience (EXPyears). Our outcomes were the baseline-adjusted National Institutes of Health Stroke Scale (NIHSS) score at 24-48 hours post-EVT, recanalization (extended Thrombolysis in Cerebral Infarction (eTICI) score ≥2B), and procedural duration. We used multilevel regression models with interventionists as random intercept. For EXPfreq and EXPno results were expressed per 10 procedures.

RESULTS

Increased EXPfreq was associated with lower 24-48 hour NIHSS scores (adjusted (a)β:-0.46, 95% CI -0.70 to -0.21). EXPno and EXPyears were not associated with short-term neurological outcomes. Increased EXPfreq and EXPno were both associated with recanalization (aOR=1.20, 95% CI 1.11 to 1.31 and aOR=1.08, 95% CI 1.04 to 1.12, respectively), and increased EXPfreq, EXPno, and EXPyears were all associated with shorter procedure times (aβ:-3.08, 95% CI-4.32 to -1.84; aβ:-1.34, 95% CI-1.84 to -0.85; and aβ:-0.79, 95% CI-1.45 to -0.13, respectively).

CONCLUSIONS

Higher levels of interventionist's experience are associated with better outcomes after EVT, in particular when experience is defined as the number of patients treated in the preceding year. Every 20 procedures more per year is associated with approximately one NIHSS score point decrease, an increased probability for recanalization (aOR=1.44), and a 6-minute shorter procedure time.

[Neurothrombectomy 2022-Extension of indications and technical innovations]

For advanced territorial ischemia numerous retrospective and prospective studies have shown a positive effect of mechanical thrombectomy (MT) compared to best medicinal treatment alone. For patients with minor stroke (NIHSS < 6) there is currently a lack of evidence for MT. Appropriate study protocols must differentiate between patients with large vessel occlusion with disproportionately mild symptoms and more distal vascular occlusion and therefore correspondingly fewer clinical symptoms. The role of intravenous lysis treatment before MT as bridging lysis also currently retains its general recommendation, as large studies could not show a uniform noninferiority of MT alone. In addition, the use of intra-arterial lysis after successful MT offers a promising approach, which still needs to be evaluated. Novel aspiration catheters and stent-retrievers as well as competing thrombectomy techniques can be compared by the first pass effect, the successful recanalization with only one attempt at thrombectomy. Contact aspiration and stent-retriever thrombectomy under aspiration are equivalent and established thrombectomy procedures. For the latter, several detailed maneuver tactics are described for improvement of thrombectomy success. Also, in retrospective studies the combination with a balloon-guided catheter promises a further improvement of recanalization results. In the case of failure of supra-aortic vessel probing with inguinal access, radial access and direct carotid puncture are alternative access routes. Recent studies on ICA stenting with tandem occlusions showed a benefit of stents without an increased risk for symptomatic intracranial hemorrhage. The retrograde approach, to first treat the intracranial vessel occlusion and then the carotid stenosis, seems to be advantageous.

Comparison of stent retriever thrombectomy using 3-dimensional patient-specific models of intracranial circulation with actual middle cerebral artery occlusion thrombectomy cases

BACKGROUND AND PURPOSE

Stent retriever (SR) thrombectomy is commonly used for the treatment of emergent large vessel occlusion (ELVO) in acute ischemic stroke. Clot imaging parameters such as clot length, diameter, distance to the internal carotid artery terminus, and vessel angle where the SR is deployed may predict the likelihood of achieving first pass effect (FPE). Most of the proposed factors that seem to affect recanalization success have been studied individually, and conflicting data derived from clinical versus in vitro studies using 3-dimensional printed models of intracranial circulation currently exist.

METHODS

Using patient-specific 3-dimensional phantoms of the cervical and intracranial circulation, we simulated middle cerebral arteries (MCA) M1 and M2 occlusions treated with SR thrombectomy using Solitaire (Medtronic) or Trevo (Styker). Our primary outcome was FPE, defined as Thrombolysis in Cerebral Infarction score of 2c-3 achieved after a single thrombectomy attempt. We also performed retrospective analysis of same clot imaging characteristics of consecutive cases of MCA occlusion and its association with FPE matching the 3-dimensional in vitro experiments. Analysis was conducted using IBM SPSS Statistics Version 25 (IBM Corp., Armonk, NY). Chi-square tests and bivariate logistic regressions were the main statistical tests used in analysis. A p-value of less than .05 was considered to indicate statistical significance. Ninety-five confidence intervals (95% CI) were generated.

RESULTS

We compared 41 thrombectomy experiments performed using patient-specific 3-dimensional in vitro models with a retrospective cohort of 41 patients treated with SR thrombectomy. We found that in the in vitro cohort, higher MCA angulation was associated with a lower likelihood of FPE (odds ratio [OR] = 0.967, 95% CI = 0.944-0.991, p = .008). Meanwhile in the in vivo cohort, higher MCA angulation was associated with a higher likelihood of FPE (OR = 1.039, 95% CI = 1.003-1.077, p = .033). Neither clot length nor location of clot (M1 vs. M2) was associated with a difference in FPE rates in either cohort.

DISCUSSION

Comparison of SR thrombectomy performed during actual MCA occlusion cases versus patient-specific 3-dimensional replicas revealed MCA angulation as an independent predictor of procedure success or failure. However, the opposite direction of effect was observed between the two studied environments, indicating potential limitations of studying SR thrombectomy using 3-dimensional models of LVO.

Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry

BACKGROUND

Pre-stroke dependent patients (modified Rankin Scale score (mRS) ≥3) were excluded from most trials on endovascular treatment (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Therefore, little evidence exists for EVT in those patients. We aimed to investigate the safety and benefit of EVT in pre-stroke patients with mRS score 3.

METHODS

We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in the Netherlands (MR CLEAN) Registry. All patients treated with EVT for anterior circulation AIS with pre-stroke mRS 3 were included. We assessed causes for dependence and compared patients with successful reperfusion (defined as expanded Thrombolysis in Cerebral Ischemia scale (eTICI) 2b-3) to patients without successful reperfusion. We used regression analyses with pre-specified adjustments. Our primary outcome was 90-day mRS 0-3 (functional improvement or return to baseline).

RESULTS

A total of 192 patients were included, of whom 82 (43%) had eTICI <2b and 108 (56%) eTICI ≥2b. The median age was 80 years (IQR 73-87). Fifty-one of the 192 patients (27%) suffered from previous stroke and 36/192 (19%) had cardiopulmonary disease. Patients with eTICI ≥2b more often returned to their baseline functional state or improved (n=26 (26%) vs n=15 (19%); adjusted odds ratio (aOR) 2.91 (95% CI 1.08 to 7.82)) and had lower mortality rates (n=49 (49%) vs n=50 (64%); aOR 0.42 (95% CI 0.19 to 0.93)) compared with patients with eTICI <2b.

CONCLUSIONS

Although patients with AIS with pre-stroke mRS 3 comprise a heterogenous group of disability causes, we observed improved outcomes when patients achieved successful reperfusion after EVT.

Stentrievers : An engineering review

The advent of endovascular therapy for acute large vessel occlusion has revolutionized stroke treatment. Timely access to endovascular therapy, and the ability to restore intracranial flow in a safe, efficient, and efficacious manner has been critical to the success of the thrombectomy procedure. The stentriever has been a mainstay of endovascular stroke therapy, and current guidelines recommend the usage of stentrievers in the treatment of large vessel occlusion stroke. Despite the success of existing stentrievers, there continues to be significant development in the field, with newer stentrievers attempting to improve on each of the three key aspects of the thrombectomy procedure. Here, we elucidate the technical requirements that a stentriever must fulfill. We then review the basic variables of stent design, including the raw material and its form, fabrication method, geometric configuration, and further additions. Lastly, a selection of stentrievers from successive generations are reviewed using these engineering parameters, and clinical data is presented. Further avenues of stentriever development and testing are also presented.

First-line Double Stentriever Thrombectomy for M1/TICA Occlusions : Initial Experiences

BACKGROUND

Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large-vessel occlusion; however, mechanical thrombectomy fails to achieve adequate recanalization in nearly one third of these cases. Rescue therapy using two stentrievers simultaneously yields good results in clots refractory to single stentriever treatment. We aimed to determine the safety and efficacy of first-line double stentriever thrombectomy for acute occlusion of the M1 segment of the middle cerebral artery and/or terminal internal carotid artery (TICA).

METHODS

This single-center study prospectively enrolled consecutive patients with a single M1/TICA occlusion to undergo double stentriever thrombectomy between May and October 2020. Outcomes included successful recanalization (modified thrombolysis in cerebral infarction, TICI 2b/3), first-pass effect, procedure times, number of device passes, symptomatic intracerebral hemorrhage, National Institutes of Health Stroke Scale Score (NIHSS) at discharge, 90-day functional independence (modified Rankin scale 0-2), and 90-day mortality.

RESULTS

We analyzed 39 patients median age 79 years (range 42-96 years); 23 (58.9%) female; 19 (48.7%) with TICA occlusions; 5 (12.8%) with mRS 3-5 at admission; mean NIHSS at admission, 17 ± 4.39). Mean time from symptom onset to final angiogram was 238.0 ± 94.6 min; mean intervention duration was 36.0 ± 24.2 min. The mean number of device passes was 1.5 ± 1.07. All patients had final TICI 2b/3, and 27 (69%) had TICI 2c/3 after the first pass. We observed 3 (7.9%) cases of intracerebral symptomatic hemorrhages. At 90 days, 16 (41%) patients were functionally independent and 9 (23%) had died. The percentage of patients with good clinical outcome at 90 days was 55.5% in the first-pass subgroup.

CONCLUSION

Our findings suggest that first-line double stentriever thrombectomy is safe and effective for M1/TICA occlusions.

Aspiration Versus Stent Retriever Thrombectomy for Posterior Circulation Stroke

BACKGROUND AND PURPOSE

Whereas a clear benefit of endovascular treatment for anterior circulation stroke has been established, randomized trials assessing the posterior circulation have failed to show efficacy. Previous studies in anterior circulation stroke suggest that advanced thrombectomy devices were of great importance in achieving clinical benefit. Little is known about the effect of thrombectomy techniques on outcomes in posterior circulation stroke. In this study, we compare first-line strategy of direct aspiration to stent retriever thrombectomy for posterior circulation stroke.

METHODS

We analyzed data of patients with a posterior circulation stroke who were included in the Multicentre Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry between March 2014 and December 2018, a prospective, nationwide study, in which data were collected from consecutive patients who underwent endovascular treatment for ischemic stroke in the Netherlands. We compared patients who underwent first-line aspiration versus stent retriever thrombectomy. Primary outcome was functional outcome according to the modified Rankin Scale. Secondary outcomes were reperfusion grade, complication rate, and procedure duration. Associations between thrombectomy technique and outcome measures were estimated with multivariable ordinal logistic regression analyses.

RESULTS

Overall, 71 of 205 patients (35%) were treated with aspiration, and 134 (65%) with stent retriever thrombectomy. Patients in the aspiration group had a lower pc-ASPECTS on baseline computed tomography, and general anesthesia was more often applied in this group. First-line aspiration was associated with better functional outcome compared with stent retriever thrombectomy (adjusted common odds ratio for a 1-point improvement on the modified Rankin Scale 1.94 [95% CI, 1.03-3.65]). Successful reperfusion (extended Thrombolysis in Cerebral Infarction ≥2B) was achieved more often with aspiration (87% versus 73%, P=0.03). Symptomatic hemorrhage rates were comparable (3% versus 4%). Procedure times were shorter in the aspiration group (49 versus 69 minutes P<0.001).

CONCLUSIONS

In this retrospective nonrandomized cohort study, our findings suggest that first-line aspiration is associated with a shorter procedure time, better reperfusion, and better clinical outcome than stent retriever thrombectomy in patients with ischemic stroke based on large vessel occlusion in the posterior circulation.

Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke

Background

First pass reperfusion (FPR), that is, excellent reperfusion (expanded treatment in cerebral ischemia (eTICI) 2C-3) in one pass, after endovascular treatment (EVT) of an occluded artery in the anterior circulation, is associated with favorable clinical outcome, even when compared with multiple pass excellent reperfusion (MPR). In patients with posterior circulation ischemic stroke (PCS), the same association is expected, but currently unknown. We aimed to assess characteristics associated with FPR and the influence of FPR versus MPR on outcomes in patients with PCS.

Methods

We used data from the MR CLEAN Registry, a prospective observational study. The effect of FPR on 24-hour National Institutes of Health Stroke Scale (NIHSS) score, as percentage reduction, and on modified Rankin Scale (mRS) scores at 3 months, was tested with linear and ordinal logistic regression models.

Results

Of 224 patients with PCS, 45 patients had FPR, 47 had MPR, and 90 had no excellent reperfusion (eTICI <2C). We did not find an association between any of the patient, imaging, or treatment characteristics and FPR. FPR was associated with better NIHSS (−45% (95% CI: −65% to −12%)) and better mRS scores (adjusted common odds ratio (acOR): 2.16 (95% CI: 1.23 to 3.79)) compared with no FPR. Outcomes after FPR were also more favorable compared with MPR, but the effect was smaller and not statistically significant (NIHSS: −14% (95% CI: −51% to 49%), mRS acOR: 1.50 (95% CI: 0.75 to 3.00)).

Conclusions

FPR in patients with PCS is associated with favorable clinical outcome in comparison with no FPR. In comparison with MPR, the effect of FPR was no longer statistically significant. Nevertheless, our data support the notion that FPR should be the treatment target to pursue in every patient treated with EVT.

Effect of First-Pass Reperfusion on Outcome After Endovascular Treatment for Ischemic Stroke

Background

First‐pass reperfusion (FPR) is associated with favorable outcome after endovascular treatment. It is unknown whether this effect is independent of patient characteristics and whether FPR has better outcomes compared with excellent reperfusion (Expanded Thrombolysis in Cerebral Infarction [eTICI] 2C‐3) after multiple‐passes reperfusion. We aimed to evaluate the association between FPR and outcome with adjustment for patient, imaging, and treatment characteristics to single out the contribution of FPR.

Methods and Results

FPR was defined as eTICI 2C‐3 after 1 pass. Multivariable regression models were used to investigate characteristics associated with FPR and to investigate the effect of FPR on outcomes. We included 2686 patients of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Factors associated with FPR were as follows: history of hyperlipidemia (adjusted odds ratio [OR], 1.05; 95% CI, 1.01–1.10), middle cerebral artery versus intracranial carotid artery occlusion (adjusted OR, 1.11; 95% CI, 1.06–1.16), and aspiration versus stent thrombectomy (adjusted OR, 1.07; 95% CI, 1.03–1.11). Interventionist experience increased the likelihood of FPR (adjusted OR, 1.03 per 50 patients previously treated; 95% CI, 1.01–1.06). Adjusted for patient, imaging, and treatment characteristics, FPR remained associated with a better 24‐hour National Institutes of Health Stroke Scale (NIHSS) score (−37%; 95% CI, −43% to −31%) and a better modified Rankin Scale (mRS) score at 3 months (adjusted common OR, 2.16; 95% CI, 1.83–2.54) compared with no FPR (multiple‐passes reperfusion+no excellent reperfusion), and compared with multiple‐passes reperfusion alone (24‐hour NIHSS score, (−23%; 95% CI, −31% to −14%), and mRS score (adjusted common OR, 1.45; 95% CI, 1.19–1.78)).

Conclusions

FPR compared with multiple‐passes reperfusion is associated with favorable outcome, independently of patient, imaging, and treatment characteristics. Factors associated with FPR were the experience of the interventionist, history of hyperlipidemia, location of occluded artery, and use of an aspiration device compared with stent thrombectomy.