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Huang X, Sun D, Nguyen TN, Pan Y, Wang M, Abdalkader M, Zaidat OO, Ma N, Gao F, Mo D, Miao Z, Huo X, Zhou Z. Impact of first pass effect in endovascular treatment of large core stroke: a post-hoc analysis of the ANGEL-ASPECT trial. J Neurointerv Surg 2024:jnis-2024-021728. [PMID: 38914460 DOI: 10.1136/jnis-2024-021728] [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: 03/15/2024] [Accepted: 05/15/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The first-pass effect (FPE) is linked to better safety and efficacy prognosis in patients with small- to- moderate sized ischemic infarctions. We evaluated the incidence, prognosis, and predictors of FPE in patients with large core infarctions (LCIs). METHODS We conducted a post-hoc analysis of data from the Trial of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT). The FPE was defined as a successful recanalization (expanded Thrombolysis in Cerebral Infarction (eTICI) 2 c/3, and eTICI 2b-3 as modified FPE (mFPE)) after one pass. The primary outcome was clinical functional independence, and the secondary outcomes were independent ambulation, assessed by the modified Rankin Scale (mRS) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) defined by the Heidelberg bleeding classification, any intracranial hemorrhage (ICH), and death within 90 days of stroke onset. RESULTS Of the 226 patients in the study, FPE and mFPE were achieved in 33 (14.6%) and 82 (36.3%) patients, respectively. Patients with FPE exhibited shorter onset-to-puncture times (adjusted odds ratio [OR] 0.915; 95% confidence interval [CI]: 0.84 to 0.996), and patients with mFPE were older (OR 1.039; 95% CI: 1.005 to 1.075). mFPE was significantly associated with favorable outcomes (modified Rankin score [mRS] 0-2: OR 2.64; 95% CI: 1.37 to 5.07; mRS 0-3: OR 3.31; 95% CI: 1.73 to 6.33). FPE tended to improve outcomes (mRS 0-3: OR 2.24; 95% CI: 0.92 to 4.97; p=0.08). ICH rates (OR 0.60; 95% CI: 0.34 to 1.05; p=0.07) and 90-day deaths (OR 0.57; 95% CI: 0.30 to 1.09; p=0.09) tended to decrease in patients who achieved mFPE but not in patients who achieved FPE. CONCLUSIONS In the ANGEL-ASPECT trial, patients who achieved mFPE had a higher rate of independent ambulation and functional independence, and the rates of any ICH and 90-day death tended to decrease.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuesong Pan
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio, USA
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
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Zheng H, Zhai Y, Cao W, Zhang Q, Bai X, Gao J, Kang M, Liu Y, Guo Y, Lu G, Xu X, Wen C. First pass effect in patients undergoing endovascular treatment for posterior circulation acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107640. [PMID: 38387760 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107640] [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: 12/11/2023] [Revised: 01/12/2024] [Accepted: 02/18/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE This study aims to investigate the impact of first pass effect (FPE) on outcomes in the posterior circulation acute ischemic stroke (PC-AIS) and the independent predictors of FPE. METHODS This was a multicenter, retrospective study. PC-AIS patients who underwent endovascular treatment were reviewed. The cohort achieving complete or nearly complete reperfusion (defined as expanded treatment in cerebralischemia [eTICI] ≥ 2c) was categorized into the FPE and multiple pass effect (MPE) groups. FPE was defined as achieving eTICI ≥ 2c with a single pass and without the use of rescue therapy. Modified FPE (mFPE) was defined as meeting the criteria for FPE but with eTICI ≥ 2b. The association of FPE with 90-day clinical outcomes and predictors for FPE were both investigated. RESULTS The study included a total of 328 patients, with 69 patients (21 %) in the FPE group. For primary outcome, FPE had a significant higher favorable outcome (mRS ≤ 3) rate than MPE (65.2 % vs. 44.8 %, p = 0.003). Similar outcomes were observed in the mFPE. Furthermore, FPE was significantly associated with favorable outcome (adjusted OR 2.23, 95 % CI 1.06-4.73, p = 0.036). Positive predictors for FPE included occlusion in the distal basilar artery, the first-line aspiration or combination, and cardioembolic etiology. Negative predictors for FPE included hypertension and general anesthesia. CONCLUSION For PC-AIS patients due to large or medium vessel occlusion, FPE is associated with favorable clinical outcomes. The first-line techniques of aspiration or combination, as well as avoiding general anesthesia, contribute to a better realization of FPE.
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Affiliation(s)
- Haocun Zheng
- Nanyang Central Hospital of Xinxiang Medical University, Nanyang 473000, China
| | - Yuting Zhai
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China
| | - Wenbo Cao
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Zhang
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China
| | - Xuesong Bai
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jun Gao
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China
| | - Meijuan Kang
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China
| | - Yifeng Liu
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China
| | - Yuanzhan Guo
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China
| | - Guangdong Lu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xinjuan Xu
- Department of Neurosurgery, The Affiliated Cardiovascular Hospital of Shanxi Medical University and Shanxi Cardiovascular Hospital (Institute), Taiyuan, 030000, Shanxi, China
| | - Changming Wen
- Neurology Department, Nanyang Central Hospital, Nanyang 473000, China.
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Sun D, Huo X, Raynald, Jia B, Tong X, Wang A, Ma N, Gao F, Mo D, Miao Z. First pass effect of mechanical thrombectomy for acute vertebrobasilar artery occlusion: data from the ANGEL-ACT registry. J Neurointerv Surg 2023; 15:1201-1206. [PMID: 36725361 DOI: 10.1136/jnis-2023-020065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/20/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND To explore the incidence, predictors, and association of first pass effect (FPE) on clinical outcomes of mechanical thrombectomy (MT) for acute vertebrobasilar artery occlusion (VBAO) in the Asian population. METHODS We selected patients from the ANGEL-ACT registry. We defined FPE as complete recanalization after one MT attempt without rescue treatment, multiple pass effect (MPE) as complete recanalization after >1 MT attempt or after one MT attempt with rescue treatment, and incomplete recanalization (ICR) as a modified Thrombolysis in Cerebral Ischemia score of 2b, independent of the number of MT attempts. We conducted multivariable logistic analyses to identify the independent predictors of FPE and to compare the outcomes, including favorable outcome, mortality within 90 days, and intracranial hemorrhage (ICH) among the FPE, MPE, and ICR groups. RESULTS Two hundred and seventy-nine patients, 68 with FPE (24.4%), 114 with MPE (40.9%), and 83 with ICR (29.7%), were included. Underlying intracranial atherosclerosis disease (ICAD) (adjusted OR (aOR) 0.16, 95% CI 0.08 to 0.34, P<0.001) was independently associated with a low chance of FPE. Furthermore, FPE was associated with a favorable outcome compared with MPE and ICR (MPE vs FPE, aOR 0.49, 95% CI 0.25 to 0.97, P=0.040; ICR vs FPE, aOR 0.38, 95% CI 0.18 to 0.81, P=0.012), and decreased mortality (MPE vs FPE, aOR 2.57, 95% CI 1.04 to 6.36, P=0.041) compared with MPE but similar mortality to ICR (P=0.374). No difference was found for ICH among the three groups (P>0.05). CONCLUSIONS FPE occurred in 24.4% of patients with VBAO in our cohort, which was associated with improved clinical outcomes compared with MPE and ICR. VBAO with underlying ICAD was less likely to achieve FPE. TRIAL REGISTRATION NUMBER NCT03370939.
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Affiliation(s)
- Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - BaiXue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Kobeissi H, Adusumilli G, Ghozy S, Dmytriw AA, Senol YC, Orscelik A, Bilgin C, Kadirvel R, Brinjikji W, Kallmes DF. First-pass effect in posterior acute ischemic stroke undergoing endovascular thrombectomy: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107304. [PMID: 37579638 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107304] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023] Open
Abstract
OBJECTIVES First-pass effect (FPE) has been shown to be a predictor of favorable clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Literature regarding FPE for posterior circulation AIS is sparse; we conducted a systematic review and meta-analysis to explore FPE in posterior circulation stroke undergoing EVT. MATERIALS AND METHODS We conducted a systematic review of the English literature in PubMed, Embase, Scopus, and Web of Science. FPE was defined as thrombolysis in cerebral infarction (TICI) 2c-3 and modified FPE (mFPE) was defined as TICI 2b-3 in one pass. Definitions of non-FPE and non-mFPE varied among studies. The primary outcome of interest was modified Rankin Scale (mRS) 0-2. Secondary outcomes of interest were mRS 0-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated odds ratios (OR) and corresponding 95% confidence intervals (CI). Heterogeneity was assessed with Q statistic and I2 test. RESULTS Seven studies with 417 patients in the mFPE group, 942 in the non-mFPE group, 545 in the FPE group, and 1023 in the non-FPE group were included. Overall, FPE was associated with greater rates of 90-day mRS 0-2 (OR= 2.78, 95% CI= 2.11-3.65; P-value< 0.001) and mRS 0-3 (OR= 2.67, 95% CI= 1.98-3.60; P-value< 0.001); however, there was significant heterogeneity among studies for both mRS 0-2 (I2= 69%; P-value< 0.001) and mRS 0-3 (I2= 69%; P-value< 0.001). FPE and non-FPE were associated with similar rates of sICH (OR= 0.65, 95% CI= 0.40-1.07; P-value= 0.09), and no heterogeneity was observed (I2= 0%; P-value= 0.95). FPE was associated with lower rates of mortality (OR= 0.44, 95% CI= 0.33-0.58; P-value< 0.001), although heterogeneity was observed (I2= 58%; P-value= 0.01). CONCLUSIONS FPE is associated with favorable clinical outcomes in patients undergoing EVT for posterior circulation AIS. Future studies should work to further quantify the impact of FPE on outcomes in the posterior circulation.
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Affiliation(s)
- Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; College of Medicine, Central Michigan University, Mount Pleasant, MI, USA.
| | - Gautam Adusumilli
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Huang X, Chen C, Li M, Duan Z, Ji Y, Wu K, Xu J, Xiao L, Xu P, Sun W. First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry. Ther Adv Neurol Disord 2022; 15:17562864221139595. [PMID: 36452411 PMCID: PMC9703483 DOI: 10.1177/17562864221139595] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/01/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Achieving rapid and complete vascular recanalization in patients with acute large vessel occlusion can significantly improve patients' prognosis. OBJECTIVE We aimed to investigate the potential contribution of the first-pass effect (FPE) to the clinical outcome of patients with acute vertebrobasilar artery occlusion (VBAO). METHODS We retrospectively analyzed the data of patients who underwent endovascular thrombectomy (EVT) caused by VBAO in a multicentered retrospective registry dataset. FPE was defined as successful recanalization [modified thrombolysis in cerebral infarction (mTICI) 2b/3 as modified FPE (mFPE); mTICI 3 as true FPE (tFPE)] after one pass of the device without rescue therapy. The baseline characteristics and procedural and clinical outcomes were analyzed. Multivariate analysis was used to explore the predictors of FPE and the relationship between FPE and 90-day prognosis. RESULTS A total of 508 patients (age, 63.7 ± 13.1 years, male, 71.6%) were finally included, 29.9% (152/508) of whom achieved mFPE, and 21.1% (107/508) of whom achieved tFPE. FPE was significantly associated with improved clinical outcomes, regardless of mFPE [odds ratio (OR): 0.601, 95% confidence interval (CI): 0.370-0.977, p = 0.040] and tFPE (OR: 0.547, 95% CI: 0.318-0.940, p = 0.029). The use of contact aspiration, favorable collateral status, cardioembolic etiology, and basilar artery occlusion were statistically significant predictors of mFPE and tFPE, whereas hypertension was a negative predictor. Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) prior to EVT was a positive predictor of mFPE but not of tFPE. CONCLUSION FPE was associated with significantly favorable outcomes in EVT patients with VBAO. The predictors of FPE include infarct etiology, the site of occlusion, collateral status, EVT strategies, and IV rt-PA bridging strategies. TRIAL REGISTRATION NUMBER URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Chu Chen
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Min Li
- Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zuowei Duan
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yachen Ji
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Kangfei Wu
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Junfeng Xu
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Lulu Xiao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Pengfei Xu
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, 26# Jinzhai Road, Hefei 230026, Anhui Province, China
| | - Wen Sun
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, 26# Jinzhai Road, Hefei 230026, Anhui Province, China
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Abstract
One-fifth of strokes occur in the territory of the posterior circulation, but
their management, particularly acute reperfusion therapy and neurointervention
procedures for secondary prevention, has received much less attention than
similar interventions for the anterior circulation. In this review, we overview
the treatment of posterior circulation stroke, including both interventions in
the acute setting and secondary prevention. We focus on areas in which the
management of posterior circulation stroke differs from that of stroke in
general and highlight recent advances. Effectiveness of acute revascularization of posterior circulation strokes remains
in large parts unproven. Thrombolysis seems to have similar benefits and lower
hemorrhage risks than in the anterior circulation. The recent ATTENTION and
BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar
artery occlusion, but its effect on other posterior occlusion sites remains
uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can
benefit from decompressive craniectomy. Secondary prevention of posterior circulation strokes includes aggressive
treatment of cerebrovascular risk factors with both drugs and lifestyle
interventions and short-term dual anti-platelet therapy. Randomized controlled
trial (RCT) data suggest basilar artery stenosis is better treated with medical
therapy than stenting, which has a high peri-procedural risk. Limited data from
RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is
currently best treated with medical therapy alone; the situation for
extracranial stenosis is less clear where stenting for symptomatic stenosis is
an option, particularly for recurrent symptoms; larger RCTs are required in this
area.
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Affiliation(s)
- Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge UK 2152
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
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