Mechanical thrombectomy with second-generation devices for acute cerebral middle artery M2 segment occlusion: A meta-analysis

Mechanical thrombectomy for middle cerebral artery M2 occlusions

BACKGROUND

The safety and efficacy of mechanical thrombectomy (MT) for proximal large vessel occlusion after acute ischemic stroke (AIS) have been demonstrated. Clinical investigations of endovascular approaches for treating AIS due to M2 occlusions have been ongoing.

PURPOSE

To assess the outcomes of M2 occlusions according to treatment modality and anatomical division.

METHODS

A total of 113 consecutive M2 occlusions treated with endovascular treatment (EVT) at our tertiary stroke center between January 2019 and December 2022 were retrospectively analyzed. Patients were divided into three groups: mechanical thrombectomy (MT); intravenous thrombolysis plus MT (IVT + MT); and IVT alone. The primary outcomes were good prognosis (mRS = 0-2) and mortality (mRS = 6) on day 90. The secondary outcome was to determine the differences in outcomes between lesions in the superior and inferior branches of M2.

RESULTS

In total, 55 (48.7%) patients underwent MT. In 42 (37.2%) patients, bridging IVT was performed with MT, and IVT alone was applied in 16 (14.2%) patients. Neither the prognosis at 90 days nor the mortality rate significantly differed among the groups. The outcomes did not significantly differ between occlusions in the superior and inferior branches of M2.

CONCLUSION

MT was found to be safe and effective for treating M2 occlusions in this series.

Aspiration thrombectomy of M2 middle cerebral artery occlusion to treat acute ischemic stroke: A core lab–adjudicated subset analysis from the COMPLETE registry and literature review

Background

Although the benefits of aspiration thrombectomy for treating acute ischemic stroke caused by proximal large vessel occlusion have been established, fewer data are available for evaluating aspiration thrombectomy of distal occlusion. The objective of this study was to evaluate, by means of prospectively collected data, the safety and efficacy of aspiration thrombectomy in patients with M2 middle cerebral artery (MCA) occlusion.

Methods

This study is a subset analysis of a global prospective multicenter observational registry that included patients who presented with either anterior or posterior large vessel occlusion and were eligible for mechanical thrombectomy using the Penumbra System including the Penumbra 3D Revascularization Device. For this analysis, all patients in the registry with M2 MCA occlusion were included.

Results

Of the 650 patients in the registry, 113 (17.4%) had M2 MCA occlusion. The rate of a modified treatment in cerebral infarction score of 2b to 3 after the procedure was 79.6% (90/113), the rate of a modified Rankin Scale score of 0–2 at 90 days was 72.5% (79/109), and the all-cause mortality rate at 90 days was 8.8% (10/113). Device-related serious adverse events occurred in one patient (0.9%) within 24 h and in two patients (1.8%) overall. Procedure-related serious adverse events occurred in four patients (3.5%) within 24 h and in six patients (5.3%) overall (nine events).

Conclusion

For appropriately selected patients, aspiration thrombectomy for acute ischemic stroke due to M2 MCA occlusion was safe and effective, with high rates of technical success and good functional outcome.

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke

BACKGROUND

Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT.

METHODS

We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0-2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups.

RESULTS

The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group (p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group (p < 0.05).

CONCLUSION

The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

Comparing data from thrombectomy in m2 occlusion and proximal middle cerebral artery

INTRODUCTION

Mechanical thrombectomy for large vessel occlusion in the anterior circulation has been shown to be beneficial. The question of whether this technique is safe and effective in the distal vasculature remains unanswered. We wanted to compare outcome data from mechanical thrombectomy of M2 branches of the middle cerebral artery (MCA) with those of the M1 segment, and better understand the clinical predictors of these M2 occlusions.

METHODS

A retrospective analysis was performed of data prospectively collected between January 2017 and July 2021 from patients with acute ischemic stroke undergoing mechanical thrombectomy of isolated M1 or M2 branches of the MCA.

RESULTS

350 patients were identified, 287 with M1 and 63 with M2 occlusions. Mean age was 70.71 ± 12.55 and 75.21 ± 10.21 years, respectively (p = 0.0083). Baseline Alberta Stroke Program Computed Tomography (ASPECT) score was worse in the M1 cohort (7.68 ± 1.73 vs. 8.32 ± 1.54; p = 0.0079), while there was no significant difference in National Institutes of Health Stroke Scale (NIHSS) scores. No statistical disparity existed in mean procedure duration for each cohort; fewer thrombectomy attempts were required in the M2 cohort (2.01 vs. 1.63; p = 0.0478). There was no statistical difference in total time to recanalization (559.19 vs. 629.97, p = 0.2506). Similar rates of successful reperfusion were observed (Thrombolysis in Ischaemic Stroke score [TICI] ≥ 2b 80.84% vs. 71.43% p = 0.1221). Good outcome (modified Rankin scale ≤ 2) was 56.10 in M1 occlusions and 63.49% on M2 groups. Intracranial haemorrhage rates were similar.

CONCLUSIONS

M2 thrombectomy is safe and a significant proportion of patients achieve a good clinical outcome. Advanced age, atrial fibrillation and previous treatment with anticoagulants were predictors for poor outcome. Good outcome was achieved when effective recanalization was obtained.

Survival and functional outcome following endovascular thrombectomy for anterior circulation acute ischemic stroke caused by large vessel occlusion in Sweden 2017-2019-a nationwide, prospective, observational study

BACKGROUND

Endovascular thrombectomy (EVT) is standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), but data on nationwide performance in routine healthcare are sparse. The study aims were to describe EVT patients with LVO AIS, analyze mortality and functional outcome, and compare results with randomized controlled trials (RCTs).

METHODS

Data from the Riksstroke and the Swedish Endovascular Treatment of Acute Stroke Registry (RSEVAS) on pre-stroke independent patients, with LVO AIS in 2017-2019, defined as occlusion of the intracranial internal carotid artery, or the M1 or M2 segments of the middle cerebral artery, and groin puncture <6 h of onset, were compared to aggregated HERMES collaboration RCT data. We assessed 90-day survival and function, defined by the modified Rankin Scale. Specific analyzes were stratified by occlusion location.

RESULTS

In all, 1011/2560 of RSEVAS patients matched RCT inclusion criteria. Compared with RCT data, patients were older (73 vs. 68), fewer received intravenous thrombolysis (63.1% vs. 83%), and M2 occlusions were more common (24.5% vs. 8%). 90-day survival in RSEVAS was 85.3%, 42.8% achieved good outcome and 5% had symptomatic intracerebral hemorrhage (sICH). Corresponding outcomes in RCT data were 84.7% survival, 46% good outcome, and 4.4% sICH. Functional outcome was most favorable following M2 occlusions.

CONCLUSIONS

EVT patients from our large real-world national dataset differed from RCT patients in several baseline factors including distribution of vascular occlusion site. However, the overall outcome of EVT in our Swedish cohort appeared to well match the pivotal trial findings.

Endovascular treatment for acute M2 occlusion stroke within 6 hours-a retrospective real-world evidence

Background

We compared the efficacy and safety of endovascular therapy (EVT), intravenous (IV) thrombolysis and conservative treatment in M2 segment occlusion stroke based on a real-world database.

Methods

We retrospectively analyzed the database of admitted patients with M2 segment occlusion between January 2018 and December 2020. The patients who were eligible for reperfusion treatment were assigned to EVT, IV thrombolysis or conservative treatment according to the exact management proceeding. The primary outcome was a score of 0 and 1 on the modified Rankin scale (mRS) at 90 days. The odds ratio (OR) for the primary outcome was adjusted for age, baseline National Institute of Health Stroke Scale score, and door-to-treatment time. The secondary outcomes were based on a mRS score from 0 to 2 at 90 days and the safety outcomes including symptomatic intracranial hemorrhage, and all-cause mortality. The data were analyzed by the logistical regression model, including baseline adjustments.

Results

A total of 109 patients were included. Among them, 42 (38.5%) patients received EVT, 45 (42.5%) received IV thrombolysis and 22 (20.8%) received conservative treatment. The primary outcome based on a mRS score of 0 and 1, occurred in 66.7% of patients in the EVT group and 40% in the IV thrombolysis group (adjusted OR, 1.79; 95% confidence interval [CI], 1.19-2.68; P = 0.01). Symptomatic intracranial hemorrhage occurred in 1 patient (2.3%) in the EVT group and in 2 patients (4.4%) in the IV thrombolysis group (adjusted OR = 0.71, 95% CI: 0.13-4.07).

Conclusion

EVT showed better functional outcomes than IV thrombolysis and conservative treatment in moderate to severe acute stoke patients with M2 occlusion. There was no significant difference in the three groups concerning the incidence of symptomatic intracranial hemorrhage.

Intravenous Thrombolysis Combined with Arterial Thrombolysis (Bridging Therapy) Effectively Improves Vascular Recanalization Rate in Patients with Cerebral Infarction

Objective

To explore the efficacy of intravenous thrombolysis combined with arterial thrombolysis (bridging therapy) in patients with acute cerebral infarction and its effect on serum inflammatory factors.

Methods

The case data of 138 patients with acute cerebral infarction admitted to our hospital from February 2019 to February 2021 were retrospectively analyzed. According to the treatment plan they received, patients were assigned to two groups, namely, an observation group (n = 71) treated with bridging therapy and a control group (n = 67) treated with intravenous thrombolysis alone. The following indexes were recorded and compared between the two groups: treatment efficacy, National Institutes of Health Stroke Scale (NIHSS) score, activities of daily living, incidence rates of vascular recanalization, intracranial hemorrhage and reembolization after treatment, levels of inflammatory factors before and after treatment, levels of prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen (FIB) before and 1 week after treatment, and modified Rankin Scale scores 1, 3, and 6 months after treatment.

Results

Compared with the control group, the therapeutic efficacy, neurological function, activities of daily living, and vascular recanalization were markedly better in the observation group (P > 0.05). In addition, the incidence of intracranial hemorrhage and reembolization was statistically lower in the observation group (P < 0.05). No marked difference was found between the two groups in terms of pretreatment serum inflammatory factors and coagulation function (P > 0.05), while the above indicators improved statistically after treatment in both groups, with comparatively more obvious improvement in the observation group. It was also observed that, compared with the control group, the modified Rankin Scale score in the observation group was significantly better at 3 and 6 months after treatment (P < 0.05).

Conclusion

Bridging therapy can improve the vascular recanalization rate among patients suffering from acute cerebral infarction, reduce the incidence of intracranial hemorrhage and reembolization, and improve the prognosis and neurological function of patients, which is worthy of clinical application.

First-line contact aspiration versus first-line stent retriever for acute ischemic stroke with M2 occlusion: A systematic review and meta-analysis

OBJECTIVE

Mechanical thrombectomy is widely used for acute ischemic stroke caused by middle cerebral artery M2 segment occlusion. However, the comparison between contact aspiration (CA) and stent retriever (SR) used as first-line techniques for acute M2 occlusion is still unclear. We aimed to perform a systematic review and meta-analysis on this issue.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was followed. Three databases (Pubmed, Embase, and Cochrane) were searched. The Newcastle-Ottawa scale was used to assess the risk of bias for the included studies. We focused on two main outcomes, the final successful reperfusion (modified Thrombolysis in Cerebral Infarction mTICI 2b/3) and 90-day functional independence (modified Rankin Scale score 0-2). The meta-analyses were performed using the random-effects models.

RESULTS

Seven observational studies were included for systematic review. Only one study indicated a superiority of first-line SR in achieving final successful reperfusion, while the other six studies did not show significant difference between these two techniques. And all the seven studies showed comparable proportion of 90-day functional independence. Five studies were available for meta-analysis with 601 patients (239 received first-line CA, 362 received first-line SR). The pooled results also suggested that the proportion of final successful reperfusion (OR=1.18, 95%CI 0.72-1.93, I2 =0%) and 90-day functional independence (OR=1.18, 95%CI 0.82-1.68, I2 =0%) were comparable between these two strategies.

CONCLUSION

For patients with acute M2 occlusion, first-line CA and SR techniques could achieve similar final reperfusion outcomes and 90-day clinical prognosis. Further studies with randomized controlled design are needed.

Meta-Analysis of the Effectiveness and Safety of Intravenous Thrombolysis in Patients with Acute Cerebral Infarction

In this paper, a meta-analysis of the effectiveness and safety of intravenous thrombolysis in patients with acute cerebral infarction was carried out, the original literature inclusion criteria and retrieval strategies were developed, and the collection deadline was about new oral anticoagulants and other methods for the antithrombotic intravenous thrombolytic treatment of patients with acute cerebral infarction for the relevant literature on the safety and effectiveness comparison. First, the quality of the literature is evaluated according to whether the included studies are randomized controlled trials, whether there is randomized concealment, whether blinding is used, and whether they are withdrawn or lost to follow-up, and the RevMan 5.2 software is used for meta-analysis. At the same time, grey literature databases such as dissertations were experimentally searched, and all randomized controlled studies (RCT), nonrandomized controlled studies, case-controlled studies, cohort studies, case series reports, etc. of Wingspan in the treatment of intracranial atherosclerotic stenosis were collected. In the prevention of myocardial infarction in patients with acute cerebral infarction, the difference between the two was not statistically significant (RR = 0.82, 95% CI (0.57, 1.17), P = 0.27). Compared with other methods, it can significantly reduce the all-cause mortality of patients with nonvalvular venous thrombolysis, and the difference is statistically significant (RR = 0.90, 95% CI (0.85, 0.96), P = 0.001). Experimental results show that in terms of safety, the new oral anticoagulant is better than other methods in reducing minor bleeding in patients with acute cerebral infarction, and the difference is statistically significant (RR = 0.87, 95% CI (0.76, 0 99), P = 0.03); the effect is better than other methods in reducing the incidence of serious bleeding events, and the difference is statistically significant (RR = 0.79, 95% CI (0.74, 0.85), P < 0.00001).

Stent-retriever alone versus combined use of stent-retriever and contact aspiration technique for middle cerebral artery M2 occlusions: a propensity score analysis

BACKGROUND

The optimal endovascular treatment (EVT) technique for middle cerebral artery (MCA) M2 segment occlusions remains unknown. We aim to analyze whether reperfusion rate, procedure times, procedure-related complications, and clinical outcome differed between patients with isolated M2 occlusions who underwent stent-retriever (SR) alone versus combined SR and contact aspiration (CA) as a front-line EVT.

METHODS

Patients who underwent EVT for isolated MCA-M2 occlusion were recruited from the prospectively ongoing ROSSETTI registry. Patients were divided regarding the EVT approach into SR alone versus SR+CA and propensity score matching was used to achieve baseline balance. Demographic, procedural, safety, and clinical outcomes were compared between groups. Multivariable logistic regression analysis was performed to identify independent predictors of first-pass effect (FPE) and 90-day modified Rankin scale (mRS) 0-2.

RESULTS

214 patients underwent EVT for M2 occlusion, 125 treated with SR alone and 89 with SR+CA. Propensity score matchnig analysis selected 134 matched patients. The rates of FPE (42% vs 40%, p=1.000) and 90-day mRS 0-2 (60% vs 51%, p=0.281) were comparable between groups. Patients treated with SR alone had lower need of rescue therapy (p=0.006), faster times to reperfusion (p<0.001), and lower procedure-related complications (p=0.031). Higher initial Alberta Stroke Program Early CT Score was an independent predictor of FPE. Age, baseline National Institutes of Health Stroke Scale score, and procedure duration were significant predictors of good clinical outcome at 3 months.

CONCLUSIONS

As front-line modality in M2 occlusions, the SR alone approach results in similar rates of reperfusion and good clinical outcomes to combined SR+CA and might be advantageous due to faster reperfusion times and fewer adverse events.

Endovascular reperfusion of M2 occlusions in acute ischemic stroke reduced disability and mortality: ETIS Registry results

BACKGROUND

The predictors of successful reperfusion and the effect of reperfusion after endovascular treatment (EVT) for M2 occlusions have not been well studied. We aimed to identify predictors of successful reperfusion and the effect of reperfusion on outcomes of EVT for M2 occlusions in current practice.

METHODS

Patients with acute ischemic stroke due to isolated M2 occlusions who were enrolled in the prospective multicenter Endovascular Treatment in Ischemic Stroke (ETIS) Registry in France between January 2015 and March 2020 were included. The primary outcome was a favorable outcome, defined as modified Rankin Scale (mRS) score of 0-2 at 90 days. Successful reperfusion was defined as an improvement of ≥1 points in the modified Thrombolysis In Cerebral Infarction score between the first and the last intracranial angiogram.

RESULTS

A total of 458 patients were included (median National Institutes of Health Stroke Scale (NIHSS) score 14; 61.4% received prior intravenous thrombolysis). Compared with the non-reperfused patients, reperfused patients had an increased rate of excellent outcome (OR 2.3, 95% CI 0.98 to 5.36; p=0.053), favorable outcome (OR 2.79, 95% CI 1.31 to 5.93; p=0.007), and reduced 90-day mortality (OR 0.39, 95% CI 0.19 to 0.79; p<0.01). Admission NIHSS score was the only predictor of successful reperfusion. First-line strategy was not a predictor of successful reperfusion or favorable outcome, but the use of a stent retriever, alone or with an aspiration catheter, was associated with higher rates of procedural complications and 90-day mortality.

CONCLUSIONS

Successful reperfusion of M2 occlusions reduced disability and mortality. However, safety is a concern, especially if the procedure failed.

Endovascular treatment versus intravenous thrombolysis alone in isolated M2 occlusion: a meta-analysis

BACKGROUND

Optimal reperfusion strategies for M2 occlusion are still uncertain, with previous studies questioning benefit of mechanical thrombectomy (MT) over intravenous thrombolysis alone (IVT). Here we systematically reviewed and meta-analyzed data from studies comparing IVT alone vs MT with/without previous IVT, to define risk/benefit profile of each paradigm.

METHODS

The study followed PRISMA guidelines. PubMed, EMBASE, and Cochrane Central were searched only for RCTs comparing MT with or without IVT vs IVT alone in adults with acute ischemic stroke and M2 occlusion. Primary endpoint was functional independence at 90 days (modified Rankin Scale<3); secondary endpoints were represented by symptomatic intracranial hemorrhage (sICH) and good recanalization (TICI>2a). Odds ratios for endpoints were pooled with meta-analysis and compared between reperfusion strategies.

RESULTS

Seven studies (n=779) were included, all of high quality. Rate of good functional outcome was similar for MT and IVT (62.4% vs 66.3%; OR=0.73; 95%CI: 0.38-1.41; p_{heterogeneity}=0.008) (Fig. 1).sICH was significantly more frequent in the MT group (8.5%) vs IVT group (3%) (OR 2.76, 95%CI 1.19-6.36, p_{heterogeneity}=0.14). Good recanalization (TICI>2a) rate was higher in MT group vs IVT alone group (81.2% vs 51.4%; OR 3.99; 95%CI: 1.98-8.94; p_{heterogeneity}=0.80).

CONCLUSIONS

IVT alone provides similar clinical benefit compared to MT with/without IVT in cases of M2 occlusion. MT quadruplicates rates of good recanalization, but triplicates risk of sICH. Further trials are needed to define if MT confers any advantage over IVT for M2 occlusion.

Iatrogenic intracranial vessel dissection during mechanical thrombectomy rescued by emergent stenting: 2 case reports

Intracranial vessel dissection is a procedural complication associated with endovascular treatment. However, there have been few reports on its potential causes and management during mechanical thrombectomy. In approximately 250 cases of mechanical thrombectomy over the past 5 years at our institution, iatrogenic intracranial dissection occurred in 2 patients (0.8%). In this report, we described these 2 cases that were rescued through emergent stenting. Mechanical thrombectomy, using both a stent retriever and an aspiration catheter, was performed for acute middle cerebral artery M2 occlusion in Patient 1 (a 69-year-old man) and for distal M1 occlusion in Patient 2 (an 83-year-old woman). In both cases, recanalization was achieved with the procedure, but irregular stenosis developed at the initially nonoccluded, but mildly arteriosclerotic, M1, after recanalization. During the thrombectomy procedure, the aspiration catheter sifted up to the arteriosclerotic M1. In both cases, the lesions were considered vessel dissection, due to a shift of the aspiration catheter tip into the arteriosclerotic vessel wall. Repeated percutaneous angiography with antithrombotic therapy failed to improve the lesions and to maintain the antegrade blood flow. Finally, lesions in each patient were successfully rescued through the use of emergent stenting. A drug-eluting stent for coronary use was deployed in Patient 1, and an Enterprise stent was applied in Patient 2. Inadvertent shift of the aspiration catheter into arteriosclerotic vessels can cause a serious intracranial vessel dissection. When performing mechanical thrombectomy, intracranial stents need to be available as rescue treatment devices to manage refractory iatrogenic intracranial vessel dissection.

Benefit of endovascular thrombectomy for M2 middle cerebral artery occlusion in the ARISE II study

Background

The benefit of endovascular thrombectomy for acute ischemic stroke with M2 segment middle cerebral artery occlusion remains controversial, with uncertainty and paucity of data specific to this population.

Objective

To compare outcomes between M1 and M2 occlusions in the Analysis of Revascularization in Ischemic Stroke with EmboTrap (ARISE II) trial.

Methods

We performed a prespecified analysis of the ARISE II trial with the primary outcome of 90-day modified Rankin Scale score of 0–2, which we termed good outcome. Secondary outcomes included reperfusion rates and major adverse events. The primary predictor was M2 occlusion, which we compared with M1 occlusion.

Results

We included 183 patients, of whom 126 (69%) had M1 occlusion and 57 (31%) had M2 occlusion. There was no difference in the reperfusion rates or adverse events between M2 and M1 occlusions. The rate of good outcome was not different in M2 versus M1 occlusions (70.2% vs 69.7%, p=0.946). In a logistic regression model adjusted for age, sex, and baseline National Institutes of Health Stroke Scale score, M2 occlusions did not have a significantly different odds of good outcome compared with M1 occlusions (OR 0.94, 95% CI 0.47 to 1.88, p=0.87).

Conclusion

In ARISE II, M2 occlusions achieved a 70.2% rate of good outcome at 90 days, which is above published rates for untreated M2 occlusions and superior to prior reports of M2 occlusions treated with endovascular thrombectomy. We also report similar rates of good outcome, successful reperfusion, death, and other adverse events when comparing the M1 and M2 occlusions.