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Almallouhi E, Findlay MC, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Shaban A, Goyal N, Yoshimura S, Cuellar H, Howard B, Alawieh A, Alaraj A, Ezzeldin M, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Siddiqui F, Osbun J, Crosa R, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Daglioglu E, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry S, Altschul DJ, Spiotta A, Grandhi R. Clinical and radiographic outcomes after mechanical thrombectomy in medium-vessel posterior cerebral artery occlusions: Subgroup analysis from STAR. Interv Neuroradiol 2024:15910199241273839. [PMID: 39140967 DOI: 10.1177/15910199241273839] [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: 08/15/2024] Open
Abstract
BACKGROUND Whereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known. METHODS Using data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments. RESULTS Of the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65). CONCLUSIONS We describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates.
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Affiliation(s)
- Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
- Neurointerventional Surgery, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Matthew C Findlay
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ilko Maier
- Klinik für Neurologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Pascal Jabbour
- Department of Neurosurgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Stacey Quintero Wolfe
- Department of Neurological Surgery, Wake Forest Baptist Health, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Ansaar Rai
- Department of Neuroradiology, West Virginia University, Morgantown, WV, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Health System, Miami, FL, USA
| | - Marios-Nikos Psychogios
- Department of Neurology, Universitätsspital Basel, Clinic and Polyclinic for Neurology, Basel, Switzerland
| | - Amir Shaban
- Department of Neurology, University of Iowa, Iowa City, IA, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center/Semmes Murphey Foundation, Memphis, TN, USA
| | | | - Hugo Cuellar
- Department of Neurosurgery, LSU Health Shreveport, Shreveport, LA, USA
| | - Brian Howard
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, Kingwood, TX, USA
| | - Daniele G Romano
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Isabel Fragata
- Department of Neuroradiology, NOVA Medical School, Universidade Nova de Lisboa, Portugal + Centro Hospitalar Universitário de Lisboa central, Lisboa, Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Fazeel Siddiqui
- Department of Neurosciences, University of Michigan Health West, Wyoming, MI, USA
| | - Joshua Osbun
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Roberto Crosa
- Department of Neurosurgery, Médica Uruguaya, Montevideo, Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Washington, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Mark Moss
- Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, AR, USA
| | - Ergun Daglioglu
- Department of Neurosurgery, Health Science University, Ankara Bilkent City Hospital, Çankaya/Ankara, Turkey
| | - Richard Williamson
- Department of Neurology, Alleghany Hospital Network, Pittsburgh, PA, USA
| | - Pedro Navia
- Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Shakeel Chowdhry
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - David J Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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Dolia JN, Grossberg JA, Martins PN, Tarek MA, Pabaney A, Al-Bayati AR, Nogueira RG, Haussen DC. Reliability assessment of distal occlusion eTICI scoring. Interv Neuroradiol 2024:15910199241262844. [PMID: 39034141 DOI: 10.1177/15910199241262844] [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: 07/23/2024] Open
Abstract
BACKGROUND The eThrombolysis in Cerebral Infarction (eTICI) score has been validated in proximal large artery occlusion (pLAOs). Despite the growing number of distal medium vessel occlusions (DMVOs) mechanical thrombectomies (MT) and the widespread utilization of the eTICI scoring system, its reliability and standardization for more distal occlusions have not been validated. We aim to evaluate the interrater reliability of eTICI scores in primary DMVOs. METHODS This was a retrospective analysis of a prospectively maintained database for consecutive patients with pLAO and DMVO MT at a single comprehensive stroke center from 2015 to 2022. Two fellowship-trained neurointerventionalists blindly/independently assessed digital subtraction angiograms for final eTICI, followed by consensus reads for discrepancies. RESULTS 59 DMVO of 2248 thrombectomies [M3:29(50%)/M4:1(2%)/A1:3(5%)/A2:12(22%)/A3: 5(9%)/P1:7(12%)/P2:1(2%)] and 124 pLAOs of 308 thrombectomies [i-ICA:13(11%)/MCA-M1: 111(90%)] were included. The distribution of final eTICI scores was comparable between pLAO vs DMVOs (p = 0.82). The pLAO final eTICI score assessment between two readers demonstrated moderate reliability with a kappa0.77 (95%CI: 0.67-0.88), while the DMVO eTICI score assessment exhibited almost-perfect agreement with kappa 0.94 (95%CI: 0.90-0.99). The agreement between the consensus read and the original report in DMVOs was 0.86 (95% CI: 0.71-1.00) while for pLAO it was 0.83(95% CI: 0.76-0.90). The performance of eTICI was comparable amongst different DMVO territories as well as for distal vs. very distal occlusions. CONCLUSION eTICI score exhibited comparable performance for DMVO as compared to pLAO strokes. Further studies investigating DMVO eTICI grading and clinical outcomes are warranted.
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Affiliation(s)
- Jaydevsinh N Dolia
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Pedro N Martins
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | | | - Raul G Nogueira
- Department of Neurology, UPMC, Stroke Institute, Pittsburgh, PA, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
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Ash M, Dimisko L, Chalhoub RM, Howard BM, Cawley CM, Matouk C, Pabaney A, Spiotta AM, Jabbour P, Maier I, Wolfe SQ, Rai AT, Kim JT, Psychogios MN, Mascitelli JR, Starke RM, Shaban A, Yoshimura S, De Leacy R, Kan P, Fragata I, Polifka AJ, Arthur AS, Park MS, Crosa RJ, Williamson R, Dumont TM, Levitt MR, Al Kasab S, Tjoumakaris SI, Liman J, Saad H, Samaniego EA, Fargen KM, Grossberg JA, Alawieh A. Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients. J Neurointerv Surg 2023:jnis-2023-020792. [PMID: 37875342 DOI: 10.1136/jnis-2023-020792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT. METHODS This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation. RESULTS Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time. CONCLUSIONS In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.
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Affiliation(s)
- Makenna Ash
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurie Dimisko
- Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA
| | - Reda M Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar T Rai
- Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Joon-Tae Kim
- Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Min S Park
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Richard Williamson
- Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jan Liman
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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