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Kniep H, Meyer L, Broocks G, Faizy TD, Bechstein M, Brekenfeld C, Flottmann F, van Horn N, Geest V, Winkelmeier L, Alegiani A, Deb-Chatterji M, Hanning U, Thomalla G, Fiehler J, Gellissen S. Thrombectomy in M2 occlusion compared to M1 occlusion: treatment effects of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 recanalization on functional outcome. J Neurointerv Surg 2023; 15:e438-e445. [PMID: 36990689 PMCID: PMC10803999 DOI: 10.1136/jnis-2022-019898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Emerging data suggest that mechanical thrombectomy (MT) might also be safe and efficient for medium and distal occlusions. This study aims to compare average treatment effects on functional outcome of different degrees of recanalization after MT in patients with M2 occlusion and M1 occlusion. METHODS All patients enrolled in the German Stroke Registry (GSR) between June 2015 and December 2021 were analyzed. Inclusion criteria were stroke with primary M1 occlusion or M2 occlusion, and availability of relevant clinical data. 4259 patients were included, thereof 1353 with M2 occlusion and 2906 with M1 occlusion. Treatment effects were analyzed using double-robust inverse-probability-weighted regression-adjustment (IPWRA) estimators to control for confounding covariates. Binarized endpoint metrics were defined as good outcome with modified Rankin Scale (mRS) ≤2 at 90 days, and linearized endpoint metrics were defined as mRS shift pre-stroke to 90 days. Effects were evaluated for near complete recanalization (Thrombolysis In Cerebral Infarction scale (TICI) 2b) and complete recanalization (TICI 3). RESULTS Treatment effect estimation for TICI ≥2b versus TICI <2b in M2 occlusions showed an increase in the probability of a good outcome from 27% to 47% with a number-needed-to-treat (NNT) of 5. For M1 occlusions the probability of a good outcome increased from 16% to 38% with NNT 4.5. TICI 3 versus TICI 2b increased the probability of a good outcome by 7 percentage points in M1 occlusions; for M2 occlusions the beneficial effect was not significant. CONCLUSIONS Results suggest that successful recanalization with TICI ≥2b versus TICI <2b after MT in M2 occlusions provides significant patient benefit with treatment effects comparable to M1 occlusions. The probability of functional independence increased by 20 percentage points (NNT 5) and stroke-related mRS increase was reduced by 0.9 mRS points. In contrast to M1 occlusions, complete recanalization TICI 3 versus TICI 2b had lower additional beneficial effect.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kniep H, Meyer L, Broocks G, Bechstein M, Guerreiro H, Winkelmeier L, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellißen S. Predictors of functional outcome after thrombectomy for M2 occlusions: a large scale experience from clinical practice. Sci Rep 2023; 13:18740. [PMID: 37907482 PMCID: PMC10618211 DOI: 10.1038/s41598-023-45232-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023] Open
Abstract
Mechanical thrombectomy (MT) for acute ischemic stroke with medium vessel occlusions is still a matter of debate. We sought to identify factors associated with clinical outcome after MT for M2-occlusions based on data from the German Stroke Registry-Endovascular Treatment (GSR-ET). All patients prospectively enrolled in the GSR-ET from 05/2015 to 12/2021 were analyzed (NCT03356392). Inclusion criteria were primary M2-occlusions and availability of relevant clinical data. Factors associated with excellent/good outcome (modified Rankin scale mRS 0-1/0-2), poor outcome/death (mRS 5-6) and mRS-increase pre-stroke to day 90 were determined in multivariable logistic regression. 1348 patients were included. 1128(84%) had successful recanalization, 595(44%) achieved good outcome, 402 (30%) had poor outcome. Successful recanalization (odds ratio [OR] 4.27 [95% confidence interval 3.12-5.91], p < 0.001), higher Alberta stroke program early CT score (OR 1.25 [1.18-1.32], p < 0.001) and i.v. thrombolysis (OR 1.28 [1.07-1.54], p < 0.01) increased probability of good outcome, while age (OR 0.95 [0.94-0.95], p < 0.001), higher pre-stroke-mRS (OR 0.36 [0.31-0.40], p < 0.001), higher baseline NIHSS (OR 0.89 [0.88-0.91], p < 0.001), diabetes (OR 0.52 [0.42-0.64], p < 0.001), higher number of passes (OR 0.75 [0.70-0.80], p < 0.001) and intracranial hemorrhage (OR 0.26 [0.14-0.46], p < 0.001) decreased the probability of good outcome. Additional predictors of mRS-increase pre-stroke to 90d were dissections, perforations (OR 1.59 [1.11-2.29], p < 0.05) and clot migration, embolization (OR 1.67 [1.21-2.30], p < 0.01). Corresponding to large-vessel-occlusions, younger age, low pre-stroke-mRS, low severity of acute clinical disability, i.v. thrombolysis and successful recanalization were associated with good outcome while diabetes and higher number of passes decreased probability of good outcome after MT in M2 occlusions. Treatment related complications increased probability of mRS increase pre-stroke to 90d.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Liyis BGD, Surya SC, Tedyanto EH, Pramana NAK, Widyadharma IPE. Mechanical thrombectomy in M1 and M2 segments of middle cerebral arteries: A meta-analysis of prospective cohort studies. Clin Neurol Neurosurg 2023; 231:107823. [PMID: 37301003 DOI: 10.1016/j.clineuro.2023.107823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/22/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Recent studies indicate that endovascular therapy is superior to intravenous thrombolysis in treating M1 segment MCA occlusions, however, the effectiveness of mechanical thrombectomy in MI vs. M2 segment occlusions is unclear. METHODS The meta-analysis was conducted by searching databases from January 2016 to January 2023, without language constraints. The quality of the studies was assessed using the Newcastle-Ottawa Scale. Pooled data analysis of outcomes, pre-existing medical comorbidities, and baseline scores were performed. RESULTS Six prospective cohort studies with 6356 patients were included (4405 vs. 1638). Patients with M2 occlusion had a significantly lower mean baseline NIHSS at admission (MD: -2.14; 95 %CI: -3.48 to -0.81; p = 0.002). Conversely, patients with M1 occlusion had a lower ASPECTS at admission score (MD: 0.29; 95 %CI: 0.00-0.59; p = 0.05). No significant difference was found between segments in terms of pre-existing medical comorbidities (OR: 0.96; 95 %CI: 0.87-1.05; p = 0.36), mortality rate at 90 days (OR: 0.88; 95 %CI: 0.76-1.02; p = 0.10), and hemorrhage occurrence within 24-hours (OR: 1.06; 95 %CI: 0.89-1.25; p = 0.53). Patients with M2 occlusion were more likely to have good outcomes after therapy (OR: 1.18; 95 %CI: 1.05-1.32; p = 0.006). Successful recanalization rates were comparatively higher among patients with an M1 occlusion (OR: 0.79; 95 %CI: 0.68-0.92; p = 0.003). Functional outcomes at 90 days are better in M2 occlusion patients, while successful recanalization rates are higher in M1 occlusion patients. No significant differences were found in mortality rates or hemorrhage incidence. CONCLUSIONS These results suggest that mechanical thrombectomy is a safe and effective treatment for MCA occlusions in both M1 and M2 segments.
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Toh KZX, Koh MY, Loh EDW, Kwok GYR, Teo YH, Teo YN, Goh CXY, Syn NLX, Ho AFW, Sia CH, Brouwer PA, Andersson T, Meyer L, Fiehler J, Bhogal P, Sharma VK, Tan BYQ, Yeo LLL. Distal medium vessel occlusions in acute ischaemic stroke - Stent retriever versus direct aspiration: A systematic review and meta-analysis. Eur Stroke J 2023; 8:434-447. [PMID: 37231692 PMCID: PMC10334182 DOI: 10.1177/23969873231151262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/28/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Acute ischaemic stroke due to distal medium vessel occlusion (AIS-DMVO) causes significant morbidity. Endovascular thrombectomy advancement has made treating AIS-DMVO with stent retrievers (SR) and aspiration catheters (AC) possible, however the optimal technique remains unknown. We performed a systematic review and meta-analysis to investigate the efficacy and safety of SR use compared to purely AC use in patients with AIS-DMVO. METHODS We systematically searched PubMed, Cochrane Library and EMBASE, from inception to 2nd September 2022, for studies comparing SR or primary combined (SR/PC) against AC in AIS-DMVO. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (modified Rankin Scale (mRS) 0-2 at 90 days), first pass effect (modified Thrombolysis in Cerebral Infarction scale (mTICI) 2c-3 or expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2c-3 at first pass), successful final recanalisation (mTICI or eTICI 2b-3), and excellent final recanalisation (mTICI or eTICI 2c-3). Safety outcomes were symptomatic intracranial haemorrhage (sICH) and 90-day mortality. RESULTS 12 cohort studies and 1 randomised-controlled trial were included, involving 1881 patients with 1274 receiving SR/PC and 607 receiving AC only. SR/PC achieved higher odds of functional independence (odds ratio (OR) 1.33, 95% confidence interval (CI) 1.06-1.67) and lower odds of mortality (OR 0.69, 95% CI 0.50-0.94) than AC. Odds of successful/excellent recanalisation and sICH were similar between both groups. Stratified to compare only SR and only AC, the use of only SR, achieved significantly higher odds of successful recanalisation as compared to only AC (OR 1.80, 95% CI 1.17-2.78). CONCLUSION There is potential for efficacy and safety benefits in SR/PC use as compared to AC only in AIS-DMVO. Further trials are necessary to validate the efficacy and safety of SR use in AIS-DMVO.
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Affiliation(s)
- Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Xin Yi Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Li Xun Syn
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Andrew Fu Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Program, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Patrick A Brouwer
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
| | | | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin YQ Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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Fifi JT, Yaeger K, Matsoukas S, Hassan AE, Yoo A, Sheth S, Zaidat OO. 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. Front Neurol 2023; 14:1076754. [PMID: 37064191 PMCID: PMC10100586 DOI: 10.3389/fneur.2023.1076754] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/06/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundAlthough 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.MethodsThis 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.ResultsOf 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).ConclusionFor 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.
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Affiliation(s)
- Johanna T. Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Johanna T. Fifi
| | - Kurt Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ameer E. Hassan
- Valley Baptist Medical Center, Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Albert Yoo
- Texas Stroke Institute, Dallas, TX, United States
| | - Sunil Sheth
- UTHealth McGovern Medical School, Houston, TX, United States
| | - Osama O. Zaidat
- Department of Endovascular Neurosurgery, Mercy Health St. Vincent Medical Center, Toledo, OH, United States
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6
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Endovascular treatment achieves better outcomes than best medical management in patients with M2 occlusion and high stroke severity: a meta-analysis. J Neurol 2023; 270:2924-2937. [PMID: 36862149 DOI: 10.1007/s00415-023-11653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for patients with M2 occlusion. This study aims to compare the efficacy and safety of endovascular treatment (EVT) with best medical management (BMM) in patients with M2 occlusion, and to investigate whether the optimal treatment varies according to stroke severity. METHODS Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT and BMM. According to stroke severity, the study population were classified into those with moderate-severe stroke and those with mild stroke. National Institute of Health Stroke Scale (NIHSS) scores ≥ 6 was defined as moderate-severe stroke, and NIHSS scores 0-5 as mild stroke. Random-effects meta-analyses were performed to measure the symptomatic intracranial hemorrhage (sICH) within 72 h, and the modified Rankin Scale (mRS) scores 0-2 and the mortality at 90 days. RESULTS Totally, 20 studies were identified, including 4358 patients. In the moderate-severe stroke population, the EVT had 82% higher odds for mRS scores 0-2 (OR 1.82, 95% CI 1.34-2.49) and a 43% lower odds for mortality (OR 0.57, 95% CI 0.39-0.82) compared with the BMM. However, no difference was found in the sICH rate (OR 0.88, 95% CI 0.44-1.77). In the mild stroke population, no differences were observed in the mRS scores 0-2 (OR 0.81, 95% CI 0.59-1.10) or mortality (OR 1.23, 95% CI 0.72-2.10) between EVT and BMM, whereas EVT was associated with higher sICH rate (OR 4.21, 95% CI 1.86-9.49). CONCLUSION EVT may be only beneficial for patients with M2 occlusion and high stroke severity, but not for those with NIHSS scores 0-5.
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7
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Delgado Acosta F, Jiménez Gómez E, Bravo Rey I, Romero Saucedo V, Valverde Moyano R, Oteros Fernández R. Comparing data from thrombectomy in m2 occlusion and proximal middle cerebral artery. Interv Neuroradiol 2023; 29:102-107. [PMID: 35043725 PMCID: PMC9893234 DOI: 10.1177/15910199221074881] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/26/2021] [Accepted: 01/04/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Adusumilli G, Kobeissi H, Ghozy S, Kallmes KM, Brinjikji W, Kallmes DF, Heit JJ. Comparing Tigertriever 13 to other thrombectomy devices for distal medium vessel occlusion: A systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231152510. [PMID: 36655307 DOI: 10.1177/15910199231152510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND There is limited evidence on the optimal endovascular strategy for treatment of distal medium-vessel occlusions (DMVO). The low-profile Tigertriever 13 stent-triever shows early promise as an adaptable device that can navigate the distal vasculature without increasing complication risk in DMVO. METHODS Using Nested Knowledge, we screened literature for RCTs and cohort studies on the endovascular treatment of DMVO. The primary outcome was reperfusion success, as measured by thrombolysis in cerebral infarction (TICI) ≥ 2b and secondary outcomes included rate of symptomatic intracranial hemorrhage (sICH), mortality at 90 days, and modified Rankin scale (mRS) scores 0-2 at 90 days. A random-effects model was used to compute pooled prevalence rates and their corresponding 95% confidence intervals (CI). RESULTS Eleven studies with 1402 patients, 167 patients treated by Tigertriever 13 and 1235 patients treated by other devices, were included in the meta-analysis. The rate of reperfusion success was similar in patients treated by Tigertriever 13 (83.2% [95% CI: 71.5-96.7%]) versus other devices (81.6% [95% CI: 75.3-88.4%], p > 0.05). The rate of sICH was also similar in patients treated by Tigertriever 13 (7.2% [95% CI: 4.1-12.5%]) versus other devices (6.9% [95% CI: 5.5-8.8%]). There was significant heterogeneity in the reporting of mortality and mRS. CONCLUSIONS Tigertriever 13 had similar rates of reperfusion success and sICH as other devices used for the treatment of DMVO. Heterogeneity in data element reporting prevented further analyses. Further studies evaluating Tigertriever 13 and other potential devices in DMVO should attempt to harmonize data element reporting.
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Affiliation(s)
| | - Hassan Kobeissi
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Sherief Ghozy
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | | | | | - David F Kallmes
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
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9
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Zhai G, Song J, Yu N, Guo C, Liu S, Yue C, Yang D, Xie D, Liu X, Yu S, Lei L. Predictors of Mechanical Thrombectomy for Anterior Circulation Emergent Large-Vessel Occlusion in the Older Adults. Clin Appl Thromb Hemost 2023; 29:10760296231184219. [PMID: 37386776 DOI: 10.1177/10760296231184219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Few studies have reported the clinical outcomes of older adult patients with acute anterior circulation large-vessel occlusion (LVO) who underwent mechanical thrombectomy (MT). Therefore, we investigated the safety, functional outcomes, and predictors of MT for anterior circulation LVO in older adults. We enrolled patients with acute anterior circulation LVO from May 2018 to October 2021 in this retrospective study. Patients were divided into older (≥80 years) and young (<80 years) groups. Multivariable logistic regression analyses determined the safety, functional outcomes, and predictors of MT for anterior circulation LVO. We divided 1182 patients with acute ischemic stroke into young (18-79 years; 1028 patients) and older (≥80 years; 154 patients) groups. Compared with the young group, the older group had more unfavorable functional outcomes and increased mortality (P = .003). In the older adult patients, lower initial NIHSS score and higher ASPECTS were correlated with good outcomes. On the contrary, higher initial NIHSS score and lower ASPECTS were related to increased mortality. No difference was detected in symptomatic intracranial hemorrhage within 48 h between two groups. Increasing age was associated with lower rates of favorable functional outcomes and higher mortality rates. The lower initial NIHSS score combined with the higher ASPECTS may predict functional outcomes post-thrombectomy in older adults.
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Affiliation(s)
- Guojie Zhai
- Department of Neurology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Nizhen Yu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuye Yu
- Department of Neurology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Lei Lei
- Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang, China
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10
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Bilgin C, Hardy N, Hutchison K, Pederson JM, Mebane A, Olaniran P, Kobeissi H, Kallmes KM, Fiorella D, Kallmes DF, Brinjikji W. First-line thrombectomy strategy for distal and medium vessel occlusions: a systematic review. J Neurointerv Surg 2022; 15:539-546. [PMID: 36223996 DOI: 10.1136/jnis-2022-019344] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The benefit of mechanical thrombectomy (MT) and efficacy of different first-line MT techniques remain unclear for distal and medium vessel occlusions (DMVOs). In this systematic review, we aimed to compare the performance of three first-line MT techniques in DMVOs. METHODS The PubMed database was searched for studies examining the utility of MT in DMVOs (middle cerebral artery M2-3-4, anterior cerebral artery, and posterior cerebral artery). Studies providing data for aspiration thrombectomy (ASP), stent retriever thrombectomy (SR), and combined SR+ASP technique were included. Non-comparative studies were excluded. Safety and efficacy data were collected for each technique. The Nested Knowledge AutoLit platform was utilized for literature search, screening, and data extraction. Pooled data were presented as descriptive statistics. RESULTS 13 studies comprising 2422 MT procedures were identified. The overall successful recanalization rate was 77.0% (1513/1964) for DMVOs. SR+ASP had a successful recanalization rate of 83.7% (297/355), SR had a 75.6% rate (638/844), while ASP alone had a 74.2% rate (386/520). The overall functional independence rate was 51.3% (851/1659) among DMVOs. The ASP alone group had a functional independence rate of 46.9% (219/467), while functional independence rates of the SR and SR+ASP groups were 51.5% (372/723) and 61.7% (174/282), respectively. Finally, the subarachnoid hemorrhage rates were 1.8% (4/217) for the ASP group, 9.3% (26/281) for the SR group, and 11.9% (41/344) for the SR+ASP group. CONCLUSIONS Our systematic review supports the proposition that MT is a safe and effective treatment option for DMVOs. Additionally, while the SR+ASP group had consistently high rates of clot clearance and good neurological outcomes, the SR and SR+ASP groups also had higher rates of subarachnoid hemorrhage, highlighting the need for improved DMVO treatment devices.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicole Hardy
- Nested Knowledge, Inc, Saint Paul, Minnesota, USA
| | | | - John Michael Pederson
- Nested Knowledge, Inc, Saint Paul, Minnesota, USA.,Superior Medical Experts, Inc, St. Paul, Minnesota, USA
| | | | | | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | | | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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11
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Wen X, Ye G, Li Z, Wang H, Wang D, Pan Z, Chen M. First-line contact aspiration versus first-line stent retriever for acute ischemic stroke with M2 occlusion: A systematic review and meta-analysis. Clin Neurol Neurosurg 2022; 216:107215. [PMID: 35349856 DOI: 10.1016/j.clineuro.2022.107215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Xuebin Wen
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China
| | - Gengfan Ye
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China
| | - Zhenqiang Li
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China
| | - Hongcai Wang
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China
| | - Dongfeng Wang
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China
| | - Zhihao Pan
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China.
| | - Maosong Chen
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, Zhejiang, China.
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12
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Predictors of Good Clinical Outcome after Thrombectomy for Distal Medium Vessel Occlusions. World Neurosurg 2022; 160:e566-e572. [PMID: 35077884 DOI: 10.1016/j.wneu.2022.01.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Good clinical outcome predictors have been emphasized in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) with large vessel occlusion (LVO). MT for distal, medium vessel occlusions (DMVO) is still debated. We sought to assess the factors associated with clinical outcome after MT for DMVO. METHODS We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center and aimed to identify the baseline clinical, imaging and MT factors associated with good clinical outcome (defined as modified Rankin scale [mRS] of 0-2) at 3 months. RESULTS Between January 2018 and January 2021, 61 patients underwent a MT for an AIS with a primary DMVO. Overall, good clinical outcome was achieved in 56% (34/61) of our patients. In multivariate analysis, an older age (ODDS ratio 0.89 [0.83-0.96], p=0.003), longer puncture to recanalization time (ODDS ratio 0.97 [0.93-0.99], p=0.033), and higher baseline core volume (ODDS ratio 0.84 [0.75-0.94], p=0.003) decreased the probability of good clinical outcomes, while a final complete (or near-) recanalization (mTICI 2c-3) increased the probability of good outcome (ODDS ratio 14.19 [1.99-101.4], p=0.008). CONCLUSION An older age, a longer puncture to recanalization time and a higher baseline core volume decreased the probability of good clinical outcomes, while successful recanalization (mTICI 2c-3) was associated with better outcomes after MT for DMVO.
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13
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Negida A, Ghaith HS, Gabra MD, Aziz MA, Elfil M, Al-Shami H, Bahbah EI, Kanmounye US, Esene I, Raslan AM. Should the direct aspiration first pass technique be advocated over the stent-retriever technique for acute ischemic stroke? A systematic review and meta-analysis of 7692 patients. Surg Neurol Int 2022; 12:597. [PMID: 34992914 PMCID: PMC8720438 DOI: 10.25259/sni_903_2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/09/2021] [Indexed: 01/02/2023] Open
Abstract
Background: The present meta-analysis aimed to synthesize evidence from all published studies with head-to-head data on the outcomes of a direct aspiration first pass technique (ADAPT) and the stent-retriever (SR) in acute ischemic stroke (AIS) patients. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Laird. Results: Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), embolus in a new territory (ENT), hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage, or procedural complications (all P > 0.05). Conclusion: Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients.
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Affiliation(s)
- Ahmed Negida
- Faculty of Medicine, Zagazig University, Zagazig University, Zagazig, Sharkia, Egypt
| | | | | | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, Egypt
| | - Haider Al-Shami
- Department of Neurosurgery, National Bank Hospital, Cairo, Egypt
| | - Eshak I Bahbah
- Faculty of Medicine, Al-Azhar University, New Damietta, Egypt
| | - Ulrick Sidney Kanmounye
- Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon, Africa
| | - Ignatius Esene
- Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon, Africa
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, United States
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14
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Pérez-García C, Rosati S, Gómez-Escalonilla C, Arrazola J, López-Frías A, González E, Fondevila J, Vega P, Murias E, Jimenez-Gomez E, Bravo Rey I, Macho J, San Roman L, Rodriguez Caamaño I, Paipa AJ, Remollo S, Aguilar Tejedor Y, Bermúdez-Coronel I, Moliner S, Pumar JM, Bashir S, Puig J, López-Rueda A, Blasco J, Nogueira RG, Moreu M. Stent-retriever alone versus combined use of stent-retriever and contact aspiration technique for middle cerebral artery M2 occlusions: a propensity score analysis. J Neurointerv Surg 2021; 14:1062-1067. [PMID: 34750112 DOI: 10.1136/neurintsurg-2021-017987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/15/2021] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
| | - Santiago Rosati
- Interventional Neuroradiology, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Juan Arrazola
- Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Eva González
- Interventional Neuroradiology, Hospital Universitario de Cruces, Bilbao, Spain
| | - Jon Fondevila
- Interventional Neuroradiology, Hospital Universitario de Cruces, Bilbao, Spain
| | - Pedro Vega
- Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Eduardo Murias
- Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Elvira Jimenez-Gomez
- Interventional Neuroradiology, Hospital Universitario Reina Sofía, Cordoba, Spain
| | - Isabel Bravo Rey
- Interventional Neuroradiology, Hospital Universitario Reina Sofía, Cordoba, Spain
| | - Juan Macho
- Interventional Neuroradiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Luis San Roman
- Interventional Neuroradiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Isabel Rodriguez Caamaño
- Interventional Neuroradiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Andres Julián Paipa
- Neurology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Sebastian Remollo
- Interventional Neuroradiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Yeray Aguilar Tejedor
- Interventional Radiology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | - Sarai Moliner
- Interventional Neuroradiology, Hospital General Universitario de Alicante, Alicante, Spain
| | - José Manuel Pumar
- Interventional Neuroradiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Saima Bashir
- Neurology, University Hospital Dr Josep Trueta, Girona, Spain
| | - Josep Puig
- Radiology, University Hospital Dr Josep Trueta, Girona, Spain
| | - Antonio López-Rueda
- Interventional Neuroradiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Jordi Blasco
- Interventional Neuroradiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Raul G Nogueira
- Neurology and Interventional Radiology, Grady Memorial Hospital, Chickasha, Oklahoma, USA
| | - Manuel Moreu
- Interventional Neuroradiology, Hospital Clínico San Carlos, Madrid, Spain
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15
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Renieri L, Valente I, Dmytriw AA, Puri AS, Singh J, Nappini S, Nencini P, Kaliaev A, Abdalkader M, Alexandre A, Garignano G, Vivekanandan S, Fong RP, Parra-Fariñas C, Spears J, Gomez-Paz S, Ogilvy C, Regenhardt RW, Alotaibi N, Beer-Furlan A, Joshi KC, Walker M, Vicenty-Padilla J, Darcourt J, Foreman P, Kuhn AL, Nguyen TN, Griessenauer CJ, Marotta TR, Thomas A, Patel AB, Leslie-Mazwi TM, Chen M, Levitt MR, Chen K, Cognard C, Pedicelli A, Limbucci N. Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions. J Neurointerv Surg 2021; 14:546-550. [PMID: 34226193 DOI: 10.1136/neurintsurg-2021-017425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/16/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND M2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking. METHODS A retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques. RESULTS There were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1-6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9-44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1-24.3)) and combined technique (OR 4.6 (1.1-20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome. CONCLUSION Stent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.
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Affiliation(s)
- Leonardo Renieri
- Interventional Neuroravascular Unit, University Hospital Careggi, Firenze, Italy
| | - Iacopo Valente
- UOC Radiologia e Neuroradiologia, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Adam A Dmytriw
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ajit S Puri
- Division of Neuroradiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jasmeet Singh
- Division of Neuroradiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sergio Nappini
- Neurovascular Interventional Unit, University Hospital Careggi, Firenze, Italy
| | | | - Artem Kaliaev
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Andrea Alexandre
- UOC Radiologia e Neuroradiologia, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Giuseppe Garignano
- UOC Radiologia e Neuroradiologia, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Sheela Vivekanandan
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Reginald P Fong
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Carmen Parra-Fariñas
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Santiago Gomez-Paz
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Naif Alotaibi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - André Beer-Furlan
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Krishna C Joshi
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Melanie Walker
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Juan Vicenty-Padilla
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jean Darcourt
- Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Paul Foreman
- Department of Neurosurgery, Orlando Health Corp, Orlando, Florida, USA
| | - Anna L Kuhn
- Division of Neuroradiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Thomas R Marotta
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ajith Thomas
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Michael Chen
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Karen Chen
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Alessandro Pedicelli
- UOC Radiologia e Neuroradiologia, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Nicola Limbucci
- Interventional Neuroravascular Unit, University Hospital Careggi, Firenze, Italy
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16
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Jia B, Ren Z, Mokin M, Burgin WS, Bauer CT, Fiehler J, Mo D, Ma N, Gao F, Huo X, Luo G, Wang A, Pan Y, Song L, Sun X, Zhang X, Gui L, Song C, Peng Y, Wu J, Zhao S, Zhao J, Zhou Z, Li Y, Jing P, Yang L, Liu Y, Zhao Q, Liu Y, Peng X, Gao Q, Guo Z, Chen W, Li W, Cheng X, Xu Y, Zhang Y, Zhang G, Lu Y, Lu X, Wang D, Wang Y, Li H, Ling L, Peng G, Zhang J, Zhang K, Li S, Qi Z, Xu H, Tong X, Ma G, Liu R, Guo X, Deng Y, Leng X, Leung TW, Liebeskind DS, Wang Y, Wang Y, Miao Z. Current Status of Endovascular Treatment for Acute Large Vessel Occlusion in China: A Real-World Nationwide Registry. Stroke 2021; 52:1203-1212. [PMID: 33596674 DOI: 10.1161/strokeaha.120.031869] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE The benefit of endovascular treatment (EVT) for large vessel occlusion in clinical practice in developing countries like China needs to be confirmed. The aim of the study was to determine whether the benefit of EVT for acute ischemic stroke in randomized trials could be generalized to clinical practice in Chinese population. METHODS We conducted a prospective registry of EVT at 111 centers in China. Patients with acute ischemic stroke caused by imaging-confirmed intracranial large vessel occlusion and receiving EVT were included. The primary outcome was functional independence at 90 days defined as a modified Rankin Scale score of 0 to 2. Outcomes of specific subgroups in the anterior circulation were reported and logistic regression was performed to predict the primary outcome. RESULTS Among the 1793 enrolled patients, 1396 (77.9%) had anterior circulation large vessel occlusion (median age, 66 [56-73] years) and 397 (22.1%) had posterior circulation large vessel occlusion (median age, 64 [55-72] years). Functional independence at 90 days was reached in 45% and 44% in anterior and posterior circulation groups, respectively. For anterior circulation population, underlying intracranial atherosclerotic disease was identified in 29% of patients, with higher functional independence at 90 days (52% versus 44%; P=0.0122) than patients without intracranial atherosclerotic disease. In the anterior circulation population, after adjusting for baseline characteristics, procedure details, and early outcomes, the independent predictors for functional independence at 90 days were age <66 years (odds ratio [OR], 1.733 [95% CI, 1.213-2.476]), time from onset to puncture >6 hours (OR, 1.536 [95% CI, 1.065-2.216]), local anesthesia (OR, 2.194 [95% CI, 1.325-3.633]), final modified Thrombolysis in Cerebral Infarction 2b/3 (OR, 2.052 [95% CI, 1.085-3.878]), puncture-to-reperfusion time ≤1.5 hours (OR, 1.628 [95% CI, 1.098-2.413]), and National Institutes of Health Stroke Scale score 24 hours after the procedure <11 (OR, 9.126 [95% CI, 6.222-13.385]). CONCLUSIONS Despite distinct characteristics in the Chinese population, favorable outcome of EVT can be achieved in clinical practice in China. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.
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Affiliation(s)
- Baixue Jia
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Zeguang Ren
- Department of Neurosurgery, University of South Florida (Z.R., M.M., W.S.B., C.T.B.)
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida (Z.R., M.M., W.S.B., C.T.B.)
| | - W Scott Burgin
- Department of Neurosurgery, University of South Florida (Z.R., M.M., W.S.B., C.T.B.)
| | - Clayton T Bauer
- Department of Neurosurgery, University of South Florida (Z.R., M.M., W.S.B., C.T.B.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Dapeng Mo
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Ning Ma
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Feng Gao
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Xiaochuan Huo
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Gang Luo
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases (A.W., Y. Pan), Beijing Tiantan Hospital, Capital Medical University
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases (A.W., Y. Pan), Beijing Tiantan Hospital, Capital Medical University
| | - Ligang Song
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Xuan Sun
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Xuelei Zhang
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Liqiang Gui
- Department of Interventional Neuroradiology, Langfang Changzheng Hospital, China (L.G.)
| | - Cunfeng Song
- Department of Interventional Neuroradiology, Liaocheng Third People's Hospital, China (C.S.)
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, China (Y. Peng)
| | - Jin Wu
- Department of Neurology, Second Affiliated Hospital of Nanjing Medical University, China (J.W.)
| | - Shijun Zhao
- Department of Interventional Radiology, Fengrun District People's Hospital of Tangshan City, China (S.Z.)
| | - Junfeng Zhao
- Department of Neurology, SiPing Central People's Hospital, China (J. Zhao)
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, China (Z.Z.)
| | - Yongli Li
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, China (Y. Li)
| | - Ping Jing
- Department of Neurology, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, China (P.J.)
| | - Lei Yang
- Department of Neurosurgery, The First Hospital of Shijiazhuang, China (L.Y.)
| | - Yajie Liu
- Department of Neurology, Shenzhen Hospital of Southern Medical University, China (Yajie Liu)
| | - Qingshi Zhao
- Department of Neurology, The People's Hospital of Longhua, China (Q.Z.)
| | - Yan Liu
- Department of Neurology, Jingjiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, China (Yan Liu)
| | - Xiaoxiang Peng
- Department of Neurology, Hubei Third People's Hospital, China (X.P.)
| | - Qingchun Gao
- Department of Neurology, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, China (Q.G.)
| | - Zaiyu Guo
- Department of Neurosurgery, Tianjin TEDA Hospital, China (Z.G.)
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, China (W.C.)
| | - Weirong Li
- Department of Neurology, Taiyuan Central Hospital, China (W.L.)
| | - Xiaojiang Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, China (X.C.)
| | - Yun Xu
- Department of Neurology, Affiliated Drum Tower Hospital of Nanjing University Medical School, China (Y.X.)
| | - Yongqiang Zhang
- Department of Neurosurgery, Wenling First People's Hospital, China (Y.Z.)
| | - Guilian Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, China (G.Z.)
| | - Yijiu Lu
- Department of Internal Neurology, The First People's Hospital of Yulin, China (Y. Lu)
| | - Xinyu Lu
- Department of Neurosurgery, Zhenjiang First People's Hospital, China (X. Lu)
| | - Dengxiang Wang
- Department of Neurology, Qitaihe Coal General Hospital, China (D.W.)
| | - Yan Wang
- Stroke Center, People's Hospital of Tangshan City, China (Yan Wang)
| | - Hao Li
- Department of Neurology, Affiliated Hospital Guilin Medical University, China (H.L.)
| | - Li Ling
- Department of Neurology, The Affiliated Hospital of Hebei University, China (L.L.)
| | - Guangge Peng
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Jingyu Zhang
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Kai Zhang
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Shuo Li
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Zhongqi Qi
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Haifeng Xu
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Xu Tong
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Gaoting Ma
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Raynald Liu
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Xu Guo
- Department of Neurointervetion, Beijing Anzhen Hospital, Capital Medical University, China (X.G.)
| | - Yiming Deng
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, China (X. Leng, T.W.L.)
| | - Thomas W Leung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, China (X. Leng, T.W.L.)
| | | | - Yilong Wang
- Department of Neurology, China National Clinical Research Center for Neurological Diseases, Tiantan Clinical Trial and Research Center for Stroke (Yilong Wang), Beijing Tiantan Hospital, Capital Medical University
- Beijing Tiantan Hospital, Capital Medical University, China (Yongjun Wang)
| | | | - Zhongrong Miao
- Interventional Neuroradiology Center (B.J., D.M., N.M., F.G., X.H., G.L., L.S., X.S., X.Z., G.P., J. Zhang, K.Z., S.L., Z.Q., H.X., X.T., G.M., R.L., Y.D., Z.M.), Beijing Tiantan Hospital, Capital Medical University
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17
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Hirano Y, Ono H, Inoue T, Mitani T, Tanishima T, Tamura A, Saito I. Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery. Surg Neurol Int 2020; 11:420. [PMID: 33365183 PMCID: PMC7749952 DOI: 10.25259/sni_627_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past. Case Description: A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit. Conclusion: Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center, Shinagawa
| | - Tomohiro Mitani
- Department of Neurosurgery, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Takeo Tanishima
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Akira Tamura
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Isamu Saito
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
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18
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Texakalidis P, Giannopoulos S, Karasavvidis T, Rangel-Castilla L, Rivet DJ, Reavey-Cantwell J. Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis of Stent Retrievers vs Direct Aspiration vs a Combined Approach. Neurosurgery 2020; 86:464-477. [PMID: 31313819 DOI: 10.1093/neuros/nyz258] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke due to a large vessel occlusion. OBJECTIVE To compare the safety and efficacy profile of the different mechanical thrombectomy strategies. METHODS A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS Nineteen studies with a total of 2449 patients were included. No differences were identified between the stent retrieval and direct aspiration groups in terms of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 and mTICI 3 recanalization rates, and favorable outcomes (modified Rankin Scale [mRS] ≤ 2). Adverse event rates, including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH), were similar between the stent retrieval and direct aspiration groups. The use of the stent retrieval was associated with a higher risk of vasospasm (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.10-8.09; I2: 0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.47; 95% CI: 1.02-2.12; I2: 0%) and mTICI 3 recanalization (OR: 3.65; 95% CI: 1.56-8.54), although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32). CONCLUSION Stent retrieval thrombectomy and direct aspiration did not show significant differences. Current available evidence is not sufficient to draw conclusions on the best surgical approach. The combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates, although with a higher risk of 24-h SAH, when compared with direct aspiration.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia
| | | | | | | | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
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19
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Boisseau W, Escalard S, Fahed R, Lapergue B, Smajda S, Maier B, Desilles JP, Delvoye F, Ciccio G, Redjem H, Hebert S, Ben Maacha M, Walker G, Gory B, Richard S, Mazighi M, Piotin M, Blanc R. Direct aspiration stroke thrombectomy: a comprehensive review. J Neurointerv Surg 2020; 12:1099-1106. [PMID: 32532857 DOI: 10.1136/neurintsurg-2019-015508] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 01/22/2023]
Abstract
Mechanical thrombectomy is now the standard of care for acute ischemic stroke patients with large vessel occlusions, and can be performed with several devices and techniques. One of these techniques, direct aspiration (DA), consists of navigating a large-bore catheter up to the face of the clot and initiating forceful suction. This comprehensive review has three objectives: (1) to describe the direct aspiration technique; (2) to present the available evidence regarding predictive factors of DA success and performance compared with other techniques; and (3) to discuss the forthcoming improvements in distal aspiration.
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Affiliation(s)
- William Boisseau
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Simon Escalard
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Robert Fahed
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Department of Medicine - Division of Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Stanislas Smajda
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Benjamin Maier
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - Jean Philippe Desilles
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - François Delvoye
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Gabriele Ciccio
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Hocine Redjem
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Solène Hebert
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Malek Ben Maacha
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Gregory Walker
- Department of Medicine - Division of Neurology, Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine - Division of Neurology, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Mikael Mazighi
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - Michel Piotin
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - Raphaël Blanc
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France .,Université de Paris, Paris, Île-de-France, France
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20
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Zafar M, Mussa M, Memon RS, Nadeem S, Usman MS, Siddiqi J, Norbash A, Khosa F, Figueredo VM, Krasuski R, Khan MS. Aspiration Thrombectomy Versus Stent Retriever Thrombectomy Alone for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e8380. [PMID: 32626624 PMCID: PMC7328696 DOI: 10.7759/cureus.8380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction This meta-analysis was conducted to assess the safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy for acute ischemic stroke (AIS). Methods We queried online databases for original studies comparing aspiration thrombectomy with stent retriever thrombectomy in patients with AIS. After article selection, data were extracted on multiple baseline characteristics and prespecified endpoints. Dichotomous data were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs); continuous data as mean differences and 95% CIs. The data were pooled using a random-effects model. Subgroup analysis was conducted based on study type, site of occlusion, and age. Results We shortlisted nine relevant studies (n=1453 patients; n=690 receiving aspiration thrombectomy and n=763 receiving stent retriever thrombectomy). Meta-analysis demonstrated no significant difference between the two groups in the rates of successful recanalization (RR: 0.96 [0.87, 1.06]; p=0.42), excellent functional outcome (RR: 0.90 [0.80, 1.01]; p=0.06), or procedure time (weighted mean difference (WMD): -5.39 minutes [-11.81, 1.04]; p=0.10). However, when removing the study by Nishi et al., sensitivity analysis resulted in a significant reduction in procedure time with aspiration (WMD: -11.01 [-15.54, -6.49]; p<0.0001). No significant difference was observed in safety outcomes, including all-cause mortality (RR: 0.82 [0.57, 1.19]; p=0.30), intracranial hemorrhage (RR: 0.93 [0.55, 1.59]; p=0.80), symptomatic intracranial hemorrhage (RR: 0.72[0.42, 1.21]; p=0.57), or embolization to new territory (RR: 0.71 [0.42, 1.19]; p=0.19). Subgroup analysis revealed that aspiration thrombectomy led to significantly better outcomes in patients with a mean age ≤65 (RR: 1.15 [1.03, 1.29]; p=0.001), and stent retriever thrombectomy led to increased recanalization success in patients with a mean age >65 (RR: 0.89 [0.80, 1.00]; p=0.05). Conclusions Our updated meta-analysis reveals that both aspiration and stent retriever thrombectomy are comparably effective in the management of AIS. Shorter procedure times may potentially be attained with aspiration thrombectomy, and outcomes with each procedure may be age-dependent.
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Affiliation(s)
- Marium Zafar
- Internal Medicine, Dow Medical College, Pakistan, Karachi, PAK
| | - Muhammad Mussa
- Internal Medicine, Dow Medical College, Dow University of Health Sciences (DUHS), Karachi, PAK
| | - Roha S Memon
- Internal Medicine, Dow University of Health Sciences (DUHS), Karachi, PAK
| | - Shahrukh Nadeem
- Medicine, Dow University of Health Sciences (DUHS), Karachi, PAK
| | - Muhammad S Usman
- Internal Medicine, Civil Hospital Karachi, Dow University of Health Sciences (DUHS), Karachi, PAK
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA.,Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA.,Neurosurgery, Arrowhead Regional Medical Center, Colton, USA.,Neurosurgery, California University of Science and Medicine, Colton, USA
| | - Alexander Norbash
- Radiology, Neuroradiology, Interventional Radiology, University of California, San Diego, USA
| | - Faisal Khosa
- Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, CAN
| | | | - Richard Krasuski
- Cardiovascular Medicine, Duke University Health System, Durham, USA
| | - Muhammad S Khan
- Internal Medicine, John H Stroger J. Hospital of Cook County, Chicago, USA
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21
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Findakly S, Maingard J, Phan K, Barras CD, Jhamb A, Chandra R, Thijs V, Brooks M, Asadi H. Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis. Intern Med J 2020; 50:530-541. [DOI: 10.1111/imj.14333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/17/2019] [Accepted: 04/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Julian Maingard
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
- School of MedicineDeakin University Geelong Victoria Australia
- Interventional Neuroradiology UnitMonash Imaging, Monash Health Melbourne Victoria Australia
| | - Kevin Phan
- NeuroSpine Surgery Research GroupPrince of Wales Private Hospital Sydney New South Wales Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Ashu Jhamb
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
| | - Ronil Chandra
- Interventional Neuroradiology UnitMonash Imaging, Monash Health Melbourne Victoria Australia
- Department of ImagingMonash University Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke DivisionFlorey Institute of Neuroscience and Mental Health, University of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Mark Brooks
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
- School of MedicineDeakin University Geelong Victoria Australia
| | - Hamed Asadi
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
- School of MedicineDeakin University Geelong Victoria Australia
- Interventional Neuroradiology UnitMonash Imaging, Monash Health Melbourne Victoria Australia
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22
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Harsany J, Haring J, Hoferica M, Mako M, Janega P, Krastev G, Klepanec A. Aspiration thrombectomy as the first-line treatment of M2 occlusions. Interv Neuroradiol 2020; 26:383-388. [PMID: 32397859 DOI: 10.1177/1591019920925678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The aim of the present study was (i) to evaluate the safety and efficacy of aspiration thrombectomy in patients with M2 occlusions and (ii) to compare outcome of treatment of occlusion of different M2 segments. MATERIALS AND METHODS Between March 2016 and June 2019, 82 patients with acute ischemic stroke and isolated M2 occlusions were treated in cerebrovascular stroke center with aspiration thrombectomy as the first-line treatment. Functional outcomes of patients with different types of M2 occlusions were statistically compared. Multivariable logistic regression analysis was performed to determine the factors associated with good clinical outcome. RESULTS The mean age was 71.9 ± 13.4 years, 47.6% were men. Aspiration thrombectomy alone was utilized in 72.5% of patients, with 27.5% of patients being treated with a combination of aspiration thrombectomy and stent retriever. At the three-month follow-up, there was no statistically significant difference in functional outcome between different types of M2 occlusions (p = 0.662), however in the underpowered analysis because of the small sample size of patients, with good clinical outcome mRS 0-2 in 50% of all treated patients. Symptomatic intracranial hemorrhage was found in 6.1% of patients. Lower age (OR 0.932, 95% CI 0.878-0.988) and lower NIHSS score upon admission (OR 0.893, 95% CI 0.805-0.991) were independent predictors of good clinical outcome. CONCLUSION Aspiration thrombectomy appeared to be a safe and effective first-line treatment option for patients with M2 occlusion, being the first-line option for almost three-quarters of patients.
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Affiliation(s)
- Jan Harsany
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Jozef Haring
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Matus Hoferica
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Miroslav Mako
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Pavol Janega
- Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Georgi Krastev
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Andrej Klepanec
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
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23
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Goebel J, Stenzel E, Wanke I, Paech D, Koehrmann M, Kleinschnitz C, Forsting M, Radbruch A, Moenninghoff C. Effectiveness of Endovascular Recanalization Treatment for M2 Segment Occlusion: Comparison Between Intracranial ICA, M1, and M2 Segment Thrombectomy. Acad Radiol 2019; 26:e298-e304. [PMID: 30587388 DOI: 10.1016/j.acra.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/26/2018] [Accepted: 11/29/2018] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES Mechanical thrombectomy is common practice in proximal anterior vessel occlusion. However, it remains unclear whether peripheral artery occlusions should be treated as well. This retrospective study aimed to prove the effectiveness of endovascular recanalization treatment for the M2 segment by comparison of intracranial internal carotid artery (ICA), M1 segment, and M2 segment thrombectomy. MATERIALS AND METHODS All patients who received endovascular treatment for distal ICA, M1, or M2 segment occlusions between January 2010 and July 2017 at our center were re-analyzed with respect to reperfusion success, interventional and clinical parameters. Statistical analysis was performed by Mann Whitney test, Chi square test, and Spearman correlation analysis. RESULTS A total of 261 patients (median age, 72 years), 100 with ICA, 137 with M1, and 24 with M2 segment occlusion, were included. Duration of endovascular treatment was significantly longer in ICA occlusions (median, 83 minutes, p < 0.001) compared to M1 (56 minutes) or M2 segment occlusions (49 minutes). Recanalization and reperfusion success and rate of endovascular complications did not differ between occlusion sites (AOL, p = 0.071; mTICI, p = 0.540; complications, p = 0.064). No significant difference in revascularization success was found between the different thrombectomy devices (direct thrombus aspiration, stent retrieving, or a sequential combined approach; p = 0.112). Successful M2 recanalization (mTICI 2b-3) correlated significantly with stronger posttherapeutic NIHSS reduction (r = 0.691, p < 0.001). CONCLUSION We found endovascular treatment of M2 segment occlusions as safe and successful as endovascular therapy of the ICA or M1 segment, with stronger posttherapeutic NIHSS reduction after successful compared to insufficient M2 recanalization.
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Affiliation(s)
- Juliane Goebel
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany.
| | - Elena Stenzel
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Isabel Wanke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Daniel Paech
- Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | | | | | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Alexander Radbruch
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Christoph Moenninghoff
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
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24
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Miura M, Shindo S, Nakajima M, Namitome S, Wada K, Nagao Y, Sugimura Y, Terasaki T, Ando Y. Stent Retriever-Assisted Continuous Aspiration for Distal Intracranial Vessel Embolectomy: The Distal Combined Technique. World Neurosurg 2019; 131:e495-e502. [PMID: 31382073 DOI: 10.1016/j.wneu.2019.07.202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/26/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We investigated the efficacy of a combined approach with stent retriever-assisted aspiration catheter for distal intracranial vessel occlusion (distal combined technique [DCT]). METHODS We evaluated consecutive patients with acute ischemic stroke with distal occlusion in anterior circulation, including occlusions of the M2/M3 or A2/A3 segments, who received endovascular therapy (EVT) in a single center. Modified Thrombolysis in Cerebral Infraction (mTICI) score including TICI 2C category, processing time from puncture to reperfusion, proportion of a favorable clinical outcome at discharge (modified Rankin Scale [mRS] score ≤2), and incidence of symptomatic intracranial hemorrhage (sICH) were compared between the DCT and single device approach technique (non-DCT) groups. RESULTS Of 65 patients, 28 were treated with EVT using the DCT and 37 were treated with EVT with a single device approach (non-DCT). In the DCT group, a higher reperfusion rate at the first pass (mTICI score ≥2B, 92% vs. 54%; P = 0.0008; mTICI score ≥2C, 71% vs. 16%; P < 0.0001; mTICI score 3, 57% vs. 14%; P = 0.0004) and shorter time from puncture to successful reperfusion (median, 31 vs. 43 minutes; P = 0.0006) were achieved, respectively. The final successful reperfusion rate was also higher in the DCT group than in the non-DCT group (mTICI score ≥2C, 85% vs. 51%; P = 0.004; mTICI score 3, 75% vs. 43%; P = 0.012), respectively. sICH occurred in 2 patients in the non-DCT group. Patients with mRS score ≤2 at discharge were more prevalent in the DCT than in the non-DCT group (57% vs. 27%, respectively; P = 0.021). CONCLUSIONS This retrospective analysis indicated that the DCT is a useful and safe strategy for patients with distal anterior intracranial vessel occlusion.
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Affiliation(s)
- Masatomo Miura
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan; Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seigo Shindo
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Namitome
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kuniyasu Wada
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yoichiro Nagao
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yusuke Sugimura
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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25
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Technical and Clinical Outcomes After Thrombectomy for the Various Segments of the Middle Cerebral Artery. World Neurosurg 2019; 128:e445-e453. [DOI: 10.1016/j.wneu.2019.04.175] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/19/2019] [Accepted: 04/20/2019] [Indexed: 11/19/2022]
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26
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Nakano T, Shigeta K, Ota T, Amano T, Ueda M, Matsumaru Y, Shiokawa Y, Hirano T. Efficacy and Safety of Mechanical Thrombectomy for Occlusion of the Second Segment of the Middle Cerebral Artery. Clin Neuroradiol 2019; 30:481-487. [DOI: 10.1007/s00062-019-00810-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
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27
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Ren Z, Mokin M, Bauer CT, Miao Z, Burgin WS, Wang Y. Indications for Mechanical Thrombectomy—Too Wide or Too Narrow? World Neurosurg 2019; 127:492-499. [DOI: 10.1016/j.wneu.2019.04.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
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28
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Munich SA, Vakharia K, Levy EI. Left M2 Occlusion With Thrombolysis in Cerebral Infarction (TICI) 2b Recanalization Using "Solumbra" Technique: Video Case. Neurosurgery 2019; 85:S68-S69. [PMID: 31197339 DOI: 10.1093/neuros/nyz082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/18/2019] [Indexed: 11/12/2022] Open
Abstract
Mechanical thrombectomy has become the accepted standard of care in patients with large-vessel occlusions; however, the management of more distal occlusions is more variable. Although often less clinically severe than proximal occlusions, M2 occlusions can cause significant disability, particularly when they occur in the dominant cerebral hemisphere. Recanalization of M2 occlusions with intravenous recombinant tissue plasminogen activator has been reported to be unreliable (only successful in 30.8% of cases).1 Reliable recanalization of M2 occlusions (thrombolysis in cerebral infarction [TICI] grade 2b or 3 in 76.9% of cases) using contemporary endovascular techniques has been reported.2 A multi-institutional experience demonstrated similar radiographic and clinical success rates when comparing direct aspiration and primary stent retrieval to treat M2 occlusions.3 In this video, we present the case of a 62-yr-old woman with a left M2 occlusion treated using the "Solumbra" technique.4 This technique utilizes a stent retriever in conjunction with aspiration, which is achieved by advancing the aspiration catheter adjacent to the clot. The small caliber of the M2 segment prohibits the advancement of the large-bore aspiration catheter into this segment. However, as demonstrated in this video, placement of the aspiration catheter at the M2 ostia with deployment of the stent retriever in the M2 clot can provide effective recanalization. It should be noted that care should be taken when advancing a guide catheter into the petrous carotid artery for support as this is an advanced maneuver and may increase the risk of iatrogenic injury in inexperienced hands. Consent was obtained from the patient prior to performing the procedure. Institutional Review Board approval is not required for the report of a single case.
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Affiliation(s)
- Stephan A Munich
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
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29
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Jiang L, Xia WQ, Huang H, Liu KQ, Si XL, Zhao XY, Yin CG. Mechanical Thrombectomy Outcome Predictors in Stroke Patients with M2 Occlusion: A Single-Center Retrospective Study. World Neurosurg 2019; 127:e155-e161. [PMID: 30872195 DOI: 10.1016/j.wneu.2019.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has demonstrated benefit in patients with acute ischemic stroke due to proximal large-vessel occlusion. However, it is unclear whether these results can be extrapolated to patients with an occlusion of the second segment (M2) of the middle cerebral artery (MCA). We sought to study outcomes in patients with M2 occlusion treated with MT and to better understand clinical predictors of these outcomes. METHODS We performed a single-center retrospective analysis of consecutive patients with acute MCA M2 segment occlusion who underwent stent retriever MT. We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. RESULTS Thirty-seven patients were included in the analysis (median admission National Institutes of Health Stroke Scale [NIHSS] score, 15 [12-19], mean age 74 [67-80] years, 48.6% women). Good clinical outcome at 3 months (modified Rankin Scale ≤2) was achieved in 48.6% of patients. Baseline NIHSS was a predictor of clinical outcomes, based on modified Rankin Scale distribution at 3 months after MT (P = 0.015, odds ratio 1.63, 95% confidence interval 1.01-2.43). CONCLUSIONS The results of our single-institution experience suggest that MT-based endovascular therapy for M2 occlusions is safe and effective. Baseline NIHSS was a predictor of outcomes in patients treated with MT for M2 segment occlusion of the MCA.
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Affiliation(s)
- Lin Jiang
- Department of Neurology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wen-Qing Xia
- Department of Neurology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huan Huang
- Department of Neurology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ke-Qin Liu
- Department of Neurology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiao-Li Si
- Department of Neurology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xin-Yi Zhao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University School of Medicine, Hangzhou, China
| | - Cong-Guo Yin
- Department of Neurology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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30
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Miura M, Yoshimura S, Sakai N, Yamagami H, Uchida K, Nagao Y, Morimoto T. Endovascular therapy for middle cerebral artery M2 segment occlusion: subanalyses of RESCUE-Japan Registry 2. J Neurointerv Surg 2019; 11:964-969. [PMID: 30852524 DOI: 10.1136/neurintsurg-2018-014627] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the efficacy of endovascular therapy (EVT) with that of medical treatment in 'real-world 'patients with M2 occlusion. METHODS This was a post hoc analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2. Among 2420 patients in the registry, we evaluated patients with isolated M2 occlusion and those with functional independence before the stroke. Multivariable logistic regression analysis was used to evaluate and compare clinical outcomes between EVT and medical treatment. Additional propensity score-matched (PSM) analyses were performed. We performed subgroup analyses of the primary outcome (modified Rankin Scale score 0-2 at 90 days) using forest plots of treatment effects. RESULTS Overall, 372 patients with M2 occlusion (n=184 EVT; n=188, medical treatment) were evaluated. The EVT group had a higher baseline National Institutes of Health Stroke Scale score (median (IQR), 15 [9-19] vs 10 [5-16]) and earlier onset to hospital door time (110 [50-258] vs 150 [60-343] min) than the medical treatment group. After adjustment, EVT was significantly associated with higher odds of primary outcome (adjusted OR=2.09; 95% CI 1.26 to 3.47) and lower odds of mortality at 90 days (adjusted OR= 0.27; 95% CI 0.08 to 0.93). After PSM analyses (184 patients were 1:1 matched with each group), EVT was effective and safe relative to medical treatment. Effects favoring EVT were present in several subgroups of interest. CONCLUSION In patients with M2 occlusion, our registry suggests that EVT is effective and safe.
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Affiliation(s)
- Masatomo Miura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.,Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe City, Hyogo, Japan
| | | | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoichiro Nagao
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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31
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Comparison of Superior and Inferior Division Occlusions Treated with Endovascular Thrombectomy. Clin Neuroradiol 2019; 30:339-343. [DOI: 10.1007/s00062-019-00767-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/02/2019] [Indexed: 01/01/2023]
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32
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Single-center experience using the 3MAX or 4MAX reperfusion catheter for the treatment of acute ischemic stroke with distal arterial occlusions in patients not eligible for intravenous fibrinolysis. Radiol Med 2018; 124:408-413. [PMID: 30547359 DOI: 10.1007/s11547-018-0965-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/04/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND In acute stroke, distal cerebrovascular occlusions can be linked to severe clinical symptoms, and treatment by mechanical thrombectomy may have an important clinical impact. When intravenous fibrinolytic therapy is firmly contraindicated, it remains the only treatment option. METHODS A total of 42 patients with isolated distal arterial occlusions and absolute contraindication for intravenous fibrinolytic therapy were retrospectively included. Mechanical thrombectomy was performed using Penumbra 4MAX or 3MAX aspiration catheters. When aspiration alone did not result in successful revascularization, a stent retriever was added. RESULTS Direct thromboaspiration was the first treatment option in all patients. 16.7% of cases required the additional use of a stent retriever. A TICI score ≥ 2b reperfusion at the end of the procedure was obtained in 76.2% and a Rankin Score of 2 or less at 90 days in 45.7%. Two hemorrhagic complications were observed. CONCLUSIONS Direct thromboaspiration appears a safe technique in acute isolated distal arterial occlusions. In a cohort of patients with absolute contraindication for intravenous fibrinolytic therapy, a significant percentage achieved good revascularization.
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Tsang COA, Cheung IHW, Lau KK, Brinjikji W, Kallmes DF, Krings T. Outcomes of Stent Retriever versus Aspiration-First Thrombectomy in Ischemic Stroke: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:2070-2076. [PMID: 30337435 DOI: 10.3174/ajnr.a5825] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/16/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is ongoing debate regarding the optimal first-line thrombectomy technique for large-vessel occlusion. PURPOSE We performed a systematic review and meta-analysis of comparative studies on stent retriever-first and aspiration-first thrombectomy. DATA SOURCES We searched Ovid MEDLINE, PubMed, and EMBASE from 2009 to February 2018. STUDY SELECTION Two reviewers independently selected the studies. The primary end point was successful reperfusion (TICI 2b/3). DATA ANALYSIS Random-effects meta-analysis was used for analysis. DATA SYNTHESIS Eighteen studies including 2893 patients were included. There was no significant difference in the rate of final successful reperfusion (83.9% versus 83.3%; OR = 0.87; 95% CI, 0.62%-1.27%) or good functional outcome (mRS 0-2) at 90 days (OR = 1.07; 95% CI, 0.80-1.44) between the stent-retriever thrombectomy and aspiration groups. The stent-retriever thrombectomy-first group achieved a statistically significant higher TICI 2b/3 rate after the first-line device than the aspiration-first group (74.9% versus 66.4%; OR = 1.53; 95% CI, 1.14%-2.05%) and resulted in lower use of a rescue device (19.9% versus 32.5%; OR = 0.36; 95% CI, 0.14%-0.90%). The aspiration-first approach resulted in a statistically shorter groin-to-reperfusion time (weighted mean difference, 7.15 minutes; 95% CI, 1.63-12.67 minutes). There was no difference in the number of passes, symptomatic intracerebral hemorrhage, vessel dissection or perforation, and mortality between groups. LIMITATIONS Most of the included studies were nonrandomized. There was significant heterogeneity in some of the outcome variables. CONCLUSIONS Stent-retriever thrombectomy-first and aspiration-first thrombectomy were associated with comparable final reperfusion rates and functional outcome. Stent-retriever thrombectomy was superior in achieving reperfusion as a stand-alone first-line technique, with lower use of rescue devices but a longer groin-to-reperfusion time.
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Affiliation(s)
- C O A Tsang
- From the Division of Neurosurgery (C.O.A.T.), Department of Surgery .,Department of Medical Imaging (C.O.A.T., W.B., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - I H W Cheung
- Department of Diagnostic Radiology (I.H.W.C.), Queen Mary Hospital, Hong Kong
| | - K K Lau
- Division of Neurology (K.K.L.), Department of Medicine, University of Hong Kong, Hong Kong
| | - W Brinjikji
- Department of Medical Imaging (C.O.A.T., W.B., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Radiology (W.B., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- Department of Radiology (W.B., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - T Krings
- Department of Medical Imaging (C.O.A.T., W.B., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
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Spiotta AM, Fiorella D, Arthur AS, Frei D, Turk AS, Hirsch JA. The semiotics of distal thrombectomy: towards a TICI score for the target vessel. J Neurointerv Surg 2018; 11:213-214. [DOI: 10.1136/neurintsurg-2018-014353] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2018] [Indexed: 12/28/2022]
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35
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Phan K, Maingard J, Kok HK, Dmytriw AA, Goyal S, Chandra R, Brooks DM, Thijs V, Asadi H. Contact Aspiration versus Stent-Retriever Thrombectomy for Distal Middle Cerebral Artery Occlusions in Acute Ischemic Stroke: Meta-Analysis. Neurointervention 2018; 13:100-109. [PMID: 30196680 PMCID: PMC6132031 DOI: 10.5469/neuroint.2018.00997] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The evidence for endovascular therapy and choice of technique in distal middle cerebral artery (MCA) M2 segment occlusions in acute ischemic stroke remains controversial. We aimed to conduct a systematic review and meta-analysis primarily comparing reperfusion rates of stent-retrieval versus contact aspiration for M2 occlusions. MATERIALS AND METHODS Study selection included cohorts of patients with distal MCA occlusions in acute ischemic strokes treated with an endovascular approach including stent-retrieval or contact aspiration. Twelve studies were selected for meta-analysis for a total of 835 cases. Meta-analysis by proportions was conducted on parameters including baseline and procedural characteristics, thrombolysis in cerebral infarction (TICI) 2b-3 outcomes, and 90-day modified Rankin scale (mRS) outcomes. RESULTS Hypertension and hyperlipidemia were more prevalent in stent-retriever patients. Pooled baseline National Institute of Health Stroke Scale scores and Alberta Stroke Program Early Computed Tomography Score imaging scores were similar. Pooled time onset of symptoms to door arrival was higher for the stent-retrieval group (154 vs. 97.4 minutes, P=0.01), as was time to groin puncture (259.9 vs. 156.2 minutes, P=0.02), but there was no difference in procedure time. The TICI 2b-3 recanalization rate was similar (80.5% vs. 86.8%, P=0.168). The frequency of mRS 0-2 at 90-day was also similar (74.5% vs. 59.9%, P=0.120), and an excellent mRS 0-1 was lower for stent-retrievers (39.9% vs. 65.6%, P=0.003). A significant negative correlation was found between onset to groin puncture time and the proportion of patients with a good mRS (r=-0.71, P=0.048). CONCLUSION Both endovascular techniques achieved recanalization rates greater than 80% and 90-day outcomes of minimal disability with similar complication rates. The literature is skewed by aspiration cases being performed sooner after onset of stroke compared to stent-retriever cases.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Randwick, Australia.,Department of Neurosurgery, Prince of Wales Hospital, Randwick, Australia
| | - Julian Maingard
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Heidelberg, Australia.,Department of Radiology, School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - Hong Kuan Kok
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Adam A Dmytriw
- Department of Radiology, University of Toronto, Toronto, Canada
| | - Sourabh Goyal
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Randwick, Australia
| | - Ronil Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Australia
| | - Duncan Mark Brooks
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Heidelberg, Australia.,Department of Radiology, School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia.,Department of Neurology, Austin Health, Heidelberg, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Heidelberg, Australia.,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Australia
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36
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Desai SM, Rocha M, Molyneaux BJ, Starr M, Kenmuir CL, Gross BA, Jankowitz BT, Jovin TG, Jadhav AP. Thrombectomy 6-24 hours after stroke in trial ineligible patients. J Neurointerv Surg 2018; 10:1033-1037. [DOI: 10.1136/neurintsurg-2018-013915] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 11/03/2022]
Abstract
Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.
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37
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Gory B, Lapergue B, Blanc R, Labreuche J, Ben Machaa M, Duhamel A, Marnat G, Saleme S, Costalat V, Bracard S, Desal H, Mazighi M, Consoli A, Piotin M, Redjem H, Ciccio G, Smajda S, Fahed R, Desilles JP, Rodesch G, Coskun O, Maria FD, Bourdain F, Decroix JP, Wang A, Tchikviladze M, Evrard S, Turjman F, Labeyrie PE, Riva R, Mounayer C, Bonafé A, Eker O, Gascou G, Dargazanli C, Tonnelet R, Derelle AL, Anxionnat R, Bourcier R, Daumas-Duport B, Berge J, Barreau X, Djemmane L. Contact Aspiration Versus Stent Retriever in Patients With Acute Ischemic Stroke With M2 Occlusion in the ASTER Randomized Trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). Stroke 2018; 49:461-464. [DOI: 10.1161/strokeaha.117.019598] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Middle cerebral artery M2-segment occlusions represent an important subgroup of patients with acute stroke with large-vessel occlusion. The safety of mechanical thrombectomy, especially contact aspiration (CA), in such distal intracranial occlusions is still under debate. We compared reperfusion, adverse events, neurological recovery, and functional outcome of patients with isolated M2 occlusions according to the first-line strategy mechanical thrombectomy devices (CA versus stent retriever [SR]).
Methods—
This is a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). The primary outcome was successful reperfusion at the end of all endovascular procedures, defined as modified Thrombolysis in Cerebral Infarction (mTICI) scores 2b/3. Secondary outcomes were mTICI 2c/3 and mTICI 3, 90-day functional outcome, assessed with the modified Rankin Scale score. Safety outcomes included 90-day mortality and any symptomatic intracerebral hemorrhage.
Results—
Seventy-nine patients were included: 48 were allocated to the CA group and 31 to the SR group. There were no significant differences between CA and SR groups in reperfusion after all endovascular procedures regarding mTICI 2b/3 (89.6% versus 83.9%;
P
=0.36), mTICI 2c/3 (54.2% versus 54.8%;
P
=0.90), and mTICI 3 (35.4% versus 41.9%;
P
=0.36) rates. There were no significant differences between CA and SR groups in 90-day modified Rankin Scale ≤2 rate (54.4% versus 50.0%;
P
=0.84), 24-hour change in National Institutes of Health Stroke Scale (mean difference, −3.9; 95% confidence interval, −7.9 to 0.01), and Alberta Stroke Program Early Computed Tomography score (mean difference, 0.9; 95% confidence interval, −0.1 to 2.0) scores. Safety parameters were well balanced between the 2 groups except for a higher 90-day mortality rate in the CA group (19.6% versus 3.3%;
P
=0.078).
Conclusions—
First-line mechanical thrombectomy with CA compared with SR did not result in an increased successful revascularization rate in patients with acute stroke with isolated M2 occlusion.
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Affiliation(s)
- Benjamin Gory
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Bertrand Lapergue
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Raphael Blanc
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Julien Labreuche
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Malek Ben Machaa
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Alain Duhamel
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Gautier Marnat
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Suzana Saleme
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Vincent Costalat
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Serge Bracard
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Hubert Desal
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Mikael Mazighi
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Arturo Consoli
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
| | - Michel Piotin
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (B.G., S.B.); IADI, INSERM U947, University of Lorraine, Vandœuvre-lès-Nancy, France (B.G., S.B.); Department of Stroke Center (B.L.) and Department of Neuroradiology (A.C.), Foch Hospital, Suresnes, France; Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (R.B., M.B.M., M.P.); Department of Biostatistics, University Lille, CHU Lille, EA 2694–Santé Publique:
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38
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Saber H, Narayanan S, Palla M, Saver JL, Nogueira RG, Yoo AJ, Sheth SA. Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis. J Neurointerv Surg 2017; 10:620-624. [PMID: 29127196 DOI: 10.1136/neurintsurg-2017-013515] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA). METHODS We conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3. RESULTS A total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0-2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0-2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42). CONCLUSIONS This meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.
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Affiliation(s)
- Hamidreza Saber
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sandra Narayanan
- Departments of Neurosurgery & Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mohan Palla
- Department of Cardiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Sunil A Sheth
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
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39
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Chen CJ, Wang C, Buell TJ, Ding D, Raper DM, Ironside N, Paisan GM, Starke RM, Southerland AM, Liu K, Worrall BB. Endovascular Mechanical Thrombectomy for Acute Middle Cerebral Artery M2 Segment Occlusion: A Systematic Review. World Neurosurg 2017; 107:684-691. [PMID: 28844911 DOI: 10.1016/j.wneu.2017.08.108] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/15/2017] [Accepted: 08/16/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The benefit of endovascular mechanical thrombectomy (EMT) for acute distal occlusions of the middle cerebral artery M2 segment is incompletely defined. The aim of this systematic review is to analyze the recent literature regarding EMT for acute M2 occlusions. METHODS We reviewed the literature to identify all studies of patients with acute M2 occlusions who underwent EMT that were published after January 1, 2015. Excellent and good outcomes were defined as modified Rankin Scale score of 0-1 and 0-2, respectively, at 3 months. Successful reperfusion was defined as modified Thrombolysis In Cerebral Infarction (mTICI) score of 2b-3. RESULTS Eight studies, comprising 630 EMT-treated patients with acute M2 occlusions, were included in the analysis. The median National Institute of Health Stroke Scale score ranged from 10 to 16, and the median Alberta Stroke Program Computed Tomography Score ranged from 9 to 10. Excellent and good outcomes at 3-month follow-up were observed in 40% and 62%, respectively, of patients with acute M2 occlusion who underwent EMT, with a mortality of 11%. Successful reperfusion was achieved in 78% of cases. Postprocedural intracerebral hemorrhage (ICH) occurred in 14% of patients, including a symptomatic ICH rate of 5%. CONCLUSIONS EMT for acute M2 occlusion affords functional independence to most patients, with a modest rate of symptomatic ICH. However, compared with the natural history of distal MCA occlusions, the benefit of M2 thrombectomy using stent retriever or direct aspiration techniques remains unclear.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
| | - Connor Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Daniel M Raper
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Gabriella M Paisan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Andrew M Southerland
- Department of Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kenneth Liu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bradford B Worrall
- Department of Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
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