Early reocclusion after successful mechanical thrombectomy for large artery occlusion-related stroke

Association of CT perfusion parameters with outcomes in patients with medium vessel occlusion undergoing endovascular thrombectomy

Background

Imaging biomarkers obtained on computed tomography perfusion (CTP) have proven effective in predicting outcomes after endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke. However, the association of CTP imaging biomarkers with outcomes in medium-size vessel occlusion (MeVO) stroke patients remains unknown.

Objectives

Therefore, we aimed to explore whether CTP parameters can be used for selection of a subset of MeVO patients that are more likely to benefit from EVT.

Methods

Consecutively enrolled acute MeVO stroke patients treated with EVT were included. All patients underwent CTP on admission and follow-up noncontrast CT 24 h post-EVT. CTP parameters including core and penumbra volumes were obtained. Excellent outcome, defined as a modified Rankin score of 0-1 at 90 days poststroke was the primary outcome, and survival at 90 days was the safety outcome. Regression analyses were performed to examine the associations between different CTP parameters and outcomes.

Results

Overall, 70 patients with MeVO were included (47% male, median age 75), and 66 (94%) had long-term follow-up data. Of those included, 26 patients (39%) had excellent outcomes and 2 (3%) had symptomatic intracerebral hemorrhage. On regression analysis, hypoperfused volumes on CTP were associated with excellent outcomes (adjusted odds ratio (aOR) 1.02, 95% confidence intervals (CI) 1.001-1.037), whereas core volume was not. Other factors associated with excellent outcome included admission National Institutes of Health Stroke Scale score (aOR 0.85, 95% CI 0.73-0.98) and lack of hypertension (aOR 0.07, 95% CI 0.07-0.62). Core or penumbral volumes were not associated with survival.

Conclusion

Higher volumes of hypoperfused tissue on CTP are associated with a higher likelihood of excellent outcome. Core and penumbral volumes are not associated with increased mortality in patients with MeVO that undergo EVT.

Recurrent Large Vessel Occlusion After Successful Recanalization From Mechanical Thrombectomy: Risk Factors and Outcomes After Repeat Mechanical Thrombectomy

BACKGROUND AND OBJECTIVES

Mechanical thrombectomy (MT) is the standard of care in patients with large vessel occlusion (LVO). Despite successful recanalization, about 5% of patients are at risk for developing recurrent LVO. Our study identifies predictors of recurrent LVO and outcomes after repeat MT.

METHODS

This was a retrospective multicenter study of patients who underwent MT for LVO. Cases were patients who developed recurrent LVO after successful recanalization (thrombolysis in cerebral infarction ≥2b) and controls were patients who did not develop recurrent LVO. Descriptive statistics and univariate analyses were used to compare both cohorts.

RESULTS

Six hundred twenty nine patients achieved successful recanalization after MT. A total of 13 patients developed recurrent LVO. On univariate analysis, age (odds ratio [OR]: 0.96, 95% CI: 0.93-0.99), initiation of antithrombotics (OR: 0.09, 95% CI: 0.03-0.30), number of attempts (OR: 0.97, 95% CI: 0.96-0.99; P < .05), and postoperative statin use (OR: 0.21, 95% CI: 0.06-0.70) were significantly associated with decreased odds of recurrent LVO. Presence of underlying disease in target vessel (OR: 3.23, 95% CI: 1.03-10.06) and thrombolysis in cerebral infarction 3 revascularization (OR: 5.08, 95% CI: 1.54-16.71) were associated with increased odds of recurrent LVO. Ten patients (76.9%) who developed recurrent LVO had a thrombus in the same vessel as the initial occlusion. Most patients developed reocclusion within 24 hours of the initial MT (n = 8, 61.5%). Five patients (38.5%) were functionally independent on discharge (modified Rankin Score 0-2).

CONCLUSION

Our study identified predictors of recurrent LVO after successful recanalization from MT. Further validation of risk factors of recurrent LVO could help cater antithrombotic regimen in this cohort.

Clinical impact of occlusion location in the middle cerebral artery during endovascular reperfusion therapy for acute ischemic stroke with underlying intracranial atherosclerotic stenosis

BACKGROUND AND PURPOSE

This study examines the clinical outcomes of endovascular reperfusion therapy and emergent intracranial stenting based on the angiographically defined occlusion location of the middle cerebral artery (MCA).

MATERIALS AND METHODS

We reviewed consecutive patients with acute MCA infarct associated with intracranial atherosclerotic stenosis (ICAS) who underwent rescue intracranial stenting and balloon angioplasty after initial mechanical thrombectomy. We compared patient demographics, baseline characteristics, clinical outcomes, and periprocedural complications, including in-stent thrombosis and re-occlusion, according to the MCA occlusion location. The occlusion location was categorized based on the presence of the proximal MCA stump in enrolled ICAS patients.

RESULTS

Of 47 patients, 30 (63.8 %) were classified as having a stump group. The initial NIHSS was more severe in the without-stump group compared to the with-stump group (13.0 [8.0-16.0] vs. 8.0 [8.0-13.0] p = 0.078). There were no significant differences in procedure time, technique, and devices. However, the successful revascularization rate was significantly lower in the without-stump group (64.7 % vs. 100 %, p = 0.002). Additionally, the immediate re-occlusion rate after the first endovascular reperfusion therapy tended to be higher in the without-stump group (76.5 % vs. 36.7 %, p = 0.02). No significant association was found between periprocedural complications, including intracerebral hemorrhage and mortality.

CONCLUSIONS

Angiographically presented MCA occlusion without a stump in acute large vessel occlusion underlying ICAS predicts more complicated intracranial stenting and poorer clinical outcomes than patients with a stump.

Risk Factors and Clinical Outcomes of Arterial Re-Occlusion After Successful Mechanical Thrombectomy for Emergent Intracranial Large Vessel Occlusion

Background: Re-occlusion of initially recanalized arteries after thrombectomy is a significant concern that may lead to poor outcomes. This study aimed to identify the risk factors and evaluate the prognosis of arterial re-occlusion following successful thrombectomy in patients diagnosed with emergent large-vessel occlusion (ELVO). Methods: We retrospectively analyzed data from 155 consecutive patients with ELVO who underwent mechanical thrombectomy (MT). Patients were classified into two groups according to whether the initial recanalized artery was re-occluded within 7 days after successful thrombectomy: re-occlusion and non-occlusion groups. Multivariate analysis was performed for potentially associated variables with p < 0.20 in the univariate analysis to identify the independent risk factors of re-occlusion. Differences in clinical outcomes were also assessed in these two groups. Results: Re-occlusion occurred in 10.3% of patients (16/155). Multivariate analysis demonstrated that large artery atherosclerosis (odds ratio [OR]: 3.942, 95% confidence interval [CI]: 1.247-12.464; p = 0.020), the number of device passes (OR: 2.509, 95% CI: 1.352-4.654; p = 0.004), and residual thrombus/stenosis (OR: 4.123, 95% CI: 1.267-13.415; p = 0.019) were independently associated with re-occlusion. Patients with re-occlusion had significantly worse NIHSS scores at discharge and lower opportunities for achieving functional independence at 3 months after MT than patients without re-occlusion. Conclusions: Large artery atherosclerosis, a high number of thrombectomy device passes, and residual thrombus/stenosis seemed to promote re-occlusion after successful recanalization. Timely identification and proper treatment strategies to prevent re-occlusion are warranted to improve clinical outcomes, especially among high-risk patients.

Impact of prodromal symptoms on the prognosis of patients with basilar artery occlusion treated with mechanical thrombectomy

INTRODUCTION

Even with reperfusion therapies, the prognosis of patients with basilar artery occlusion (BAO) related stroke remains poor. We aimed to test the hypothesis that the presence of prodromal symptoms, an easily available anamnestic data, is a key determinant of poor functional outcome.

PATIENTS AND METHODS

Data from patients with BAO treated in Lille, France, with mechanical thrombectomy (MT) between 2015 and 2021 were prospectively collected. The presence of prodromal symptoms was defined by previous transient neurological deficit or gradual progressive clinical worsening preceding a secondary sudden clinical worsening. We compared the characteristics of patients with and without prodromal symptoms. We built multivariate logistic regression models to study the association between the presence of prodromal symptoms and functional (mRS 0-3 and mortality), and procedural (successful recanalization and early reocclusion) outcomes.

RESULTS

Among the 180 patients, 63 (35%) had prodromal symptoms, most frequently a vertigo. Large artery atherosclerosis was the predominant cause of stroke (41.3%). The presence of prodromal symptoms was an independent predictor of worse 90-day functional outcome (mRS 0-3: 25.4% vs 47.0%, odds ratio (OR) 0.39; 95% confidence interval (CI) 0.16-0.86) and 90-day mortality (OR 2.17; 95% CI 1.02-4.65). Despite similar successful recanalization rate, the proportion of early basilar artery reocclusion was higher in patients with prodromal symptoms (23.8% vs 5.6%, p = 0.002).

DISCUSSION AND CONCLUSION

More than one third of BAO patients treated with MT had prodromal symptoms, especially patients with large-artery atherosclerosis. Clinicians should systematically screen for prodromal symptoms given the poor related functional outcome and increased risk of early basilar artery reocclusion.

Mechanical Thrombectomy in Stroke-Retrospective Comparison of Methods: Aspiration vs. Stent Retrievers vs. Combined Method-Is Aspiration the Best Starting Point?

Background: There are three main methods of mechanical thrombectomy (MT): using a stent retriever (SR) only (SO), aspiration catheter (AC) only (AO) and the combined method (CM) using both the SR and AC. This paper describes a real-life, single-center experience using SO, AO and CM during 276 consecutive MTs. Methods: The primary endpoint was the frequency of first-pass complete (FPE TICI3). The secondary endpoints were final mTICI 2b-3, procedure duration, clinical outcome and the total number of device passes. The third aim of this study was to test the association between the clinical outcomes in patients treated with each method and various factors. Results: There was a significant difference (p = 0.016) between the groups' FPE TICI3 rates with 46% mTICI 3 in the AO group, 41% in the CM group and 21% in the SO group. AO resulted in procedure time shortening to a mean duration of 43 min, and the scores were 56 min for CM and 63 min for SO (p < 0.0001). There were no significant differences in clinical outcomes or in-hospital mortality. The analysis showed a correlation between good clinical outcomes and the administration of IVT: OR 1.71 (1.03-2.84) p = 0.039. Patients ≥66 years old had higher odds of a bad outcome compared to younger patients in general (OR, 1.99 95% CI, 1.17-3.38; p = 0.011). FPE TICI3 was associated with good functional outcomes in the whole treated cohort (OR, 1.98; 95% CI, 1.21-3.25; p = 0.006). Conclusions: In our series, AO proved to be the best starting point in most cases. It demonstrates good technical efficacy regarding FPE, it is fast and clinical outcomes seem to be the least age- and FPE TICI3-dependent. It can be easily converted into the combined method, which had the second-best outcomes in our cohort.

Incidence, severity and impact on functional outcome of persistent hypoperfusion despite large-vessel recanalization, a potential marker of impaired microvascular reperfusion: Systematic review of the clinical literature

The reported incidence of persistent hypoperfusion despite complete recanalization as surrogate for impaired microvascular reperfusion (IMR) has varied widely among clinical studies, possibly due to differences in i) definition of complete recanalization, with only recent Thrombolysis in Cerebral Infarction (TICI) grading schemes allowing distinction between complete (TICI3) and partial recanalization with distal occlusions (TICI2c); ii) operational definition of IMR; and iii) consideration of potential alternative causes for hypoperfusion, notably carotid stenosis, re-occlusion and post-thrombectomy hemorrhage. We performed a systematic review to identify clinical studies that carried out brain perfusion imaging within 72 hrs post-thrombectomy for anterior circulation stroke and reported hypoperfusion rates separately for TICI3 and TICI2c grades. Authors were contacted if this data was missing. We identified eight eligible articles, altogether reporting 636 patients. The incidence of IMR after complete recanalization (i.e., TICI3) tended to decrease with the number of considered alternative causes of hypoperfusion: range 12.5-42.9%, 0-31.6% and 0-9.1% in articles that considered none, two or all three causes, respectively. No study reported the impact of IMR on functional outcome separately for TICI-3 patients. Based on this systematic review, IMR in true complete recanalization appears relatively rare, and reported incidence highly depends on definition used and consideration of confounding factors.