More than five stentriever passes: real benefit or futile recanalization?

Introducing the Futile Recanalization Prediction Score (FRPS): A Novel Approach to Predict and Mitigate Ineffective Recanalization after Endovascular Treatment of Acute Ischemic Stroke

Objective: This study aims to develop and validate the Futile Recanalization Prediction Score (FRPS), a novel tool designed to predict the severity risk of FR and aid in pre- and post-EVT risk assessments. Methods: The FRPS was developed using a rigorous process involving the selection of predictor variables based on clinical relevance and potential impact. Initial equations were derived from previous meta-analyses and refined using various statistical techniques. We employed machine learning algorithms, specifically random forest regression, to capture nonlinear relationships and enhance model performance. Cross-validation with five folds was used to assess generalizability and model fit. Results: The final FRPS model included variables such as age, sex, atrial fibrillation (AF), hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, cognitive impairment, pre-stroke modified Rankin Scale (mRS), systolic blood pressure (SBP), onset-to-puncture time, sICH, and NIHSS score. The random forest model achieved a mean R-squared value of approximately 0.992. Severity ranges for FRPS scores were defined as mild (FRPS < 66), moderate (FRPS 66-80), and severe (FRPS > 80). Conclusions: The FRPS provides valuable insights for treatment planning and patient management by predicting the severity risk of FR. This tool may improve the identification of candidates most likely to benefit from EVT and enhance prognostic accuracy post-EVT. Further clinical validation in diverse settings is warranted to assess its effectiveness and reliability.

First-Pass Effect Predicts Clinical Outcome and Infarct Growth After Thrombectomy for Distal Medium Vessel Occlusions

BACKGROUND

The first-pass effect in endovascular thrombectomy (EVT) has been associated with better clinical outcomes and decreased stroke progression in large vessel occlusion but has not been evaluated in distal, medium vessel occlusions (DMVOs).

OBJECTIVE

To assess the impact on clinical outcome and stroke progression of the modified first-pass effect (defined as a successful first-pass [modified Thrombolysis In Cerebral Infarction 2b/2c/3] revascularization) in patients who underwent EVT for a primary DMVOs.

METHODS

We collected data from consecutive patients who underwent EVT for a primary DMVO at a single large academic center. We compared the rate of good clinical outcome (modified Rankin Scale of 0-2 at 3 months) and stroke progression between patients who demonstrated modified first-pass effect (mFPE) vs those who did not (no-mFPE).

RESULTS

Between January 2018 and January 2021, we included 60 patients who underwent EVT for an acute ischemic stroke with a primary DMVO. Overall, mFPE was achieved in 32% (19/60) of EVTs. The mFPE was associated with a higher rate of good clinical outcome compared with no-mFPE (89% vs 46%, odds ratio = 16.04 [2.23-115.39], P = .006 in multivariate analysis). Final stroke volume was less among mFPE patients (6.9 mL [4.7-13.6] vs 23 mL [14.6-47], P = .001) as was stroke progression (6.8 mL [4-12.1] vs 17.8 mL [8.1-34.9], P = .016). The mFPE was still associated with higher rates of good clinical outcome when compared with patients reaching an modified Thrombolysis In Cerebral Infarction score ≥2b in more than 1 pass (89% vs 53%; odds ratio = 7.37 [1.43-38.08], P = .017).

CONCLUSION

The mFPE may be associated with better clinical outcomes and lower stroke progression in DMVO.

Per-pass analysis of recanalization and good neurological outcome in thrombectomy for stroke: Systematic review and meta-analysis

BACKGROUND AND AIM

First pass effect (FPE) is defined as achieving a complete recanalization with a single thrombectomy device pass. Although clinically desired, FPE is reached in less than 30% of thrombectomy procedures. Multiple device passes are often necessary to achieve successful or complete recanalization. We performed a systematic review and meta-analysis to determine the recanalization rate after each pass of mechanical thrombectomy and its association with good neurological outcome.

METHODS

A literature search was performed for studies reporting the number of device passes required for either successful (mTICI 2b or higher) or complete (mTICI 2c or higher) recanalization. Using random-effect meta-analysis, we evaluated the likelihood of recanalization and good neurological outcome (measured with the modified Rankin Score <2 at 90 days) after each device pass.

RESULTS

Thirteen studies comprising 4197 patients were included. Among cases with failed first pass, 24% of them achieved final complete recanalization and 45% of them achieved final successful recanalization. Independently to the total number of previously failed attempts, the likelihood of achieving successful recanalization was 30% per pass, and the likelihood to achieve complete recanalization was about 20% per pass. The likelihood of good neurological outcome in patients with final successful recanalization decreased after each device pass: 55% after the first pass, 48% after the second pass, 42% after the third pass, 36% after the fourth pass, and 26% for 5 passes or more.

CONCLUSION

Each pass is associated with a stable likelihood of recanalization but a decreased likelihood of good neurological outcome.

Influence of single pass recanalization in acute ischemic stroke with large vessel occlusion in patients of Asian ethnicity

BACKGROUND AND PURPOSE

A previous report revealed single pass recanalization was associated with better functional outcome for patients with acute ischemic stroke with large vessel occlusion in real-world settings. However, the effect of single pass recanalization in acute large vessel occlusion based on the largest registry in real-world settings in Asian population are not well scrutinized.

MATERIALS AND METHODS

RESCUE-Japan Registry-2 was a physician-initiated prospective multicenter registry that enrolled consecutive patients with acute large vessel occlusion who were admitted within 24 h of onset. We compared patients who underwent endovascular therapy and achieved good recanalization in single or multiple device passes (single-pass group and multiple-passes group, respectively) in terms of the good outcome defined as modified Rankin Scale of 0-2 at 90 days after onset. We estimated the odds ratios, safety and mortality adjusting for confounders.

RESULTS

Among 2420 patients registered, 1281 patients treated with endovascular therapy. 829 patients were analyzed (557 patients in single-pass and 272 patients in multiple-passes group). Patient characteristics were almost similar between two groups. The good outcome was more observed of patients in the single groups (51.5% vs 39.3%). The adjusted odds ratio of single pass of good outcome was 1.92 (95% confidence interval, 1.37-2.69). The frequencies of symptomatic intracranial hemorrhage were similar between the two groups.

CONCLUSION

Single pass recanalization was associated with good clinical outcome on real-world settings in Asian population.

Nomogram to Predict the Number of Thrombectomy Device Passes for Acute Ischemic Stroke with Endovascular Thrombectomy

Purpose

This study aimed to determine the risk factors associated with the number of thrombectomy device passes and establish a nomogram for predicting the number of device pass attempts in patients with successful endovascular thrombectomy (EVT).

Methods

We enrolled patients from a signal comprehensive stroke center (CSC) who underwent EVT because of large vessel occlusion stroke. Multivariate logistic regression analysis was used to develop the best-fit nomogram for predicting the number of thrombectomy device passes. The discrimination and calibration of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC-ROC) and a calibration plot with a bootstrap of 1000 resamples. A decision curve analysis (DCA) was used to measure the availability and effect of this predictive tool.

Results

In total, 130 patients (mean age 64.9 ± 11.1 years; 83 males) were included in the final analysis. Age (odds ratio [OR], 1.085; 95% confidence interval [CI], 1.005-1.172; p = 0.036), baseline Alberta Stroke Program Early computed tomography (ASPECTS) score (OR, 0.237; 95% CI, 0.115-0.486; p < 0.001), and homocysteine level (OR, 1.090; 95% CI, 1.028-1.155; p = 0.004) were independent predictors of device pass number and were thus incorporated into the nomogram. The AUC-ROC determined the discrimination ability of the nomogram, which was 0.921 (95% CI, 0.860-0.980), which indicated good predictive power. Moreover, the calibration plot revealed good predictive accuracy of the nomogram. The DCA demonstrated that when the threshold probabilities of the cohort ranged between 5.0% and 98.0%, the use of the nomogram to predict a device pass number > 3 provided greater net benefit than did "treat all" or "treat none" strategies.

Conclusion

The nomogram comprised age, baseline ASPECTS score, and homocysteine level, can predict a device pass number >3 in acute ischemic stroke (AIS) patients who are undergoing EVT.

Local Intra-arterial Thrombolysis during Mechanical Thrombectomy for Refractory Large-Vessel Occlusion: Adjunctive Chemical Enhancer of Thrombectomy

BACKGROUND AND PURPOSE

Data on adjunctive intra-arterial thrombolysis during mechanical thrombectomy for refractory thrombus are sparse. The aim of this study was to evaluate the efficacy and safety of local intra-arterial urokinase as an adjunct to mechanical thrombectomy for refractory large-vessel occlusion.

MATERIALS AND METHODS

We retrospectively evaluated patients with acute ischemic stroke who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion between January 2016 and December 2019. Patients were divided into 2 groups based on the use of intra-arterial urokinase as an adjunctive therapy during mechanical thrombectomy for refractory thrombus: the urokinase and nonurokinase groups. Herein, refractory thrombus was defined as the target occlusion with minimal reperfusion (TICI 0 or 1) despite >3 attempts with conventional mechanical thrombectomy. The baseline characteristics, procedural outcomes, and clinical outcome were compared between the 2 groups.

RESULTS

One hundred fourteen cases of refractory thrombus were identified. A total of 45 and 69 patients were in the urokinase and the nonurokinase groups, respectively. The urokinase group compared with the nonurokinase group showed a higher rate of successful reperfusion (82.2% versus 63.8%, P = .034), with lower procedural times (54 versus 69 minutes, P = .137). The rates of good clinical outcome, distal embolism, and symptomatic intracranial hemorrhage were similar between the 2 groups. The use of intra-arterial urokinase (OR = 3.682; 95% CI, 1.156-11.730; P = .027) was an independent predictor of successful reperfusion.

CONCLUSIONS

The use of local intra-arterial urokinase as an adjunct to mechanical thrombectomy may be an effective and safe method that provides better recanalization than the conventional mechanical thrombectomy for refractory thrombus in patients with embolic large-vessel occlusion.