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Vandelanotte S, Staessens S, François O, De Wilde M, Desender L, De Sloovere AS, Dewaele T, Tersteeg C, Vanhoorelbeke K, Vanacker P, Andersson T, De Meyer SF. Association between thrombus composition and first-pass recanalization after thrombectomy in acute ischemic stroke. J Thromb Haemost 2024; 22:2555-2561. [PMID: 38897388 DOI: 10.1016/j.jtha.2024.05.034] [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: 04/10/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Achieving first-pass recanalization (FPR) has become the primary procedural objective during thrombectomy in acute ischemic stroke patients as it correlates with the best clinical outcome. Understanding factors contributing to FPR failures is essential to enhance FPR success rates. As the central target of thrombectomy, the thrombus itself may be a significant factor influencing FPR. OBJECTIVES This study aimed to investigate the association between thrombus composition and FPR success rates. METHODS In total, thrombi from 267 ischemic stroke patients were collected in the AZ Groeninge Hospital (Kortrijk, Belgium). Thrombus composition was determined via detailed histologic analysis of red blood cells (RBCs), fibrin, von Willebrand factor, platelets, leukocytes, citrullinated histone 3 (marker for neutrophil extracellular traps), and intracellular and extracellular DNA. FPR was defined as obtaining a modified thrombolysis in cerebral infarction (mTICI) score of 2c/3 after the first pass. RESULTS An mTICI score of 2c/3 was obtained in 180 patients, which was achieved via a successful FPR procedure in 126 cases or after multiple passes in 54 cases. Interestingly, thrombi from FPR cases had a different composition from thrombi that needed multiple passes to obtain an mTICI score of 2c/3. FPR thrombi contained significantly more RBCs (P = .0264), less fibrin (P = .0196), and less extracellular DNA (P = .0457). CONCLUSION Our results indicate that thrombi characterized by lower RBC content, higher fibrin levels, and increased extracellular DNA are less likely to result in an FPR. These results are important to guide future research aiming at improving procedures or technologies to obtain FPR rates in RBC-poor thrombi.
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Affiliation(s)
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Maaike De Wilde
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Tom Dewaele
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Peter Vanacker
- Department of Neurology, AZ Groeninge, Kortrijk, Belgium; Department of Neurology, University Hospitals Antwerp, Antwerp, Belgium; Department of Translational Neuroscience, University of Antwerp, Antwerp, Belgium
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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2
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Pillai P, Bush SJ, Kusuma Y, Churilov L, Dowling RJ, Luu VD, Davis SM, Mitchell PJ, Yan B. Atrial fibrillation is associated with higher first pass effect following thrombectomy for large vessel occlusion. J Neurointerv Surg 2024; 16:652-656. [PMID: 37355258 DOI: 10.1136/jnis-2023-020512] [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: 05/02/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND First pass effect (FPE), defined as single-pass complete or near complete reperfusion during endovascular thrombectomy (EVT) for large vessel occlusion (LVO) strokes, is a critical performance metric. Atrial fibrillation (AF)-related strokes have different clot composition compared with non-AF strokes, which may impact thrombectomy reperfusion results. We compared FPE rates in AF and non-AF stroke patients to evaluate if AF-related strokes had higher FPE rates. METHODS We conducted a post-hoc analysis of the DIRECT-SAFE trial data, including patients with retrievable clots on the initial angiographic run. Patients were categorized into AF and non-AF groups. The primary outcome was the presence or absence of FPE (single-pass, single-device resulting in complete/near complete reperfusion) in AF and non-AF groups. We used multivariable logistic regression to examine the association between FPE and AF, adjusting for thrombolysis pre-thrombectomy and clot location. RESULTS We included 253 patients (67 with AF, 186 without AF). AF patients were older (mean age: 74 years vs 67.5 years, p=0.001), had a higher proportion of females (55% vs 40%, p=0.044), and experienced more severe strokes (median National Institutes of Health Stroke Scale (NIHSS) score: 17 vs 14, p=0.009) than non-AF patients. No differences were observed in thrombolytic agent usage, time metrics, or clot location. AF patients achieved a higher proportion of FPE compared with non-AF patients (55.22% vs 37.3%, adjusted odds ratio 2.00 (95% CI 1.13 to 3.55), p=0.017). CONCLUSIONS AF-related strokes in LVO patients treated with EVT were associated with FPE. This highlights the need for preparedness for multiple passes and potential adjuvant/rescue therapy in non-AF-related strokes.
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Affiliation(s)
- Presaad Pillai
- Department of Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Neurology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | - Steven J Bush
- Department of Radiology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Yohanna Kusuma
- Department of Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Leonid Churilov
- Melbourne Medical School, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Richard J Dowling
- Department of Radiology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Vu Dang Luu
- Radiology Center, Bach Mai Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Stephen M Davis
- Department of Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bernard Yan
- Department of Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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Nogueira RG, Pinheiro A, Brinjikji W, Abbasi M, Al-Bayati AR, Mohammaden MH, Souza Viana L, Ferreira F, Abdelhamid H, Bhatt NR, Kvamme P, Layton KF, Delgado Almandoz JE, Hanel RA, Mendes Pereira V, Almekhlafi MA, Yoo AJ, Jahromi BS, Gounis MJ, Patel B, Arturo Larco JL, Fitzgerald S, Mereuta OM, Doyle K, Savastano LE, Cloft HJ, Thacker IC, Kayan Y, Copelan A, Aghaebrahim A, Sauvageau E, Demchuk AM, Bhuva P, Soomro J, Nazari P, Cantrell DR, Puri AS, Entwistle J, Polley EC, Frankel MR, Kallmes DF, Haussen DC. Clot composition and recanalization outcomes in mechanical thrombectomy. J Neurointerv Surg 2024; 16:466-470. [PMID: 37419694 DOI: 10.1136/jnis-2023-020117] [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: 02/06/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes. METHODS Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes. RESULTS A total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5-23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1-2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots. CONCLUSIONS Despite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.
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Affiliation(s)
| | | | | | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | | - Nirav R Bhatt
- UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Peter Kvamme
- Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Kennith F Layton
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Ricardo A Hanel
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mohammed A Almekhlafi
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Babak S Jahromi
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Biraj Patel
- Radiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | | | | | - Oana Madalina Mereuta
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
- CÚRAM-SFI Research Centre for Medical Devices and Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Karen Doyle
- Physiology, CURAM, National University of Ireland Galway, Galway, Ireland
| | | | | | - Ike C Thacker
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Interventional Neuroradiology, Abbot Northwestern Hospital, 55435, Minnesota, USA
| | - Alexander Copelan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Health System, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
| | - Parita Bhuva
- Neuroendovascular Surgery, Texas Stroke Institute, Plano, Texas, USA
| | - Jazba Soomro
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Pouya Nazari
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Neurosurgery and Radiology, Northwestern University, Chicago, Illinois, USA
| | | | - Ajit S Puri
- Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - John Entwistle
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | | | - Michael R Frankel
- Department of Neurology, Emory University Atlanta, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Diogo C Haussen
- Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Baek JH, Kim BM, Suh SH, Jeon HJ, Ihm EH, Park H, Kim CH, Cha SH, Choi CH, Yi KS, Kim JH, Suh S, Kim B, Chang Y, Kim SY, Oh JS, Heo JH, Kim DJ, Nam HS, Kim YD. First-Pass Recanalization with EmboTrap II in Acute Ischemic Stroke (FREE-AIS): A Multicenter Prospective Study. Korean J Radiol 2023; 24:145-154. [PMID: 36725355 PMCID: PMC9892223 DOI: 10.3348/kjr.2022.0618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/18/2022] [Accepted: 12/11/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the efficacy of EmboTrap II in terms of first-pass recanalization and to determine whether it could yield favorable outcomes. MATERIALS AND METHODS In this multicenter, prospective study, we consecutively enrolled patients who underwent mechanical thrombectomy using EmboTrap II as a front-line device. The primary outcome was the first pass effect (FPE) rate defined by modified Thrombolysis In Cerebral Infarction (mTICI) grade 2c or 3 by the first pass of EmboTrap II. In addition, modified FPE (mFPE; mTICI grade 2b-3 by the first pass of EmboTrap II), successful recanalization (final mTICI grade 2b-3), and clinical outcomes were assessed. We also analyzed the effect of FPE on a modified Rankin Scale (mRS) score of 0-2 at 3 months. RESULTS Two hundred-ten patients (mean age ± standard deviation, 73.3 ± 11.4 years; male, 55.7%) were included. Ninety-nine patients (47.1%) had FPE, and mFPE was achieved in 150 (71.4%) patients. Successful recanalization was achieved in 191 (91.0%) patients. Among them, 164 (85.9%) patients underwent successful recanalization by exclusively using EmboTrap II. The time from groin puncture to FPE was 25.0 minutes (interquartile range, 17.0-35.0 minutes). Procedure-related complications were observed in seven (3.3%) patients. Symptomatic intracranial hemorrhage developed in 14 (6.7%) patients. One hundred twenty-three (58.9% of 209 completely followed) patients had an mRS score of 0-2. Sixteen (7.7% of 209) patients died during the follow-up period. Patients who had successful recanalization with FPE were four times more likely to have an mRS score of 0-2 than those who had successful recanalization without FPE (adjusted odds ratio, 4.13; 95% confidence interval, 1.59-10.8; p = 0.004). CONCLUSION Mechanical thrombectomy using the front-line EmboTrap II is effective and safe. In particular, FPE rates were high. Achieving FPE was important for an mRS score of 0-2, even in patients with successful recanalization.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hong-Jun Jeon
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Eun Hyun Ihm
- Department of Neurosurgery, Andong Hospital, Andong, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sang-Hoon Cha
- Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea.,College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
| | - Chi-Hoon Choi
- Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea.,College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
| | - Kyung Sik Yi
- Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea
| | - Jun-Hwee Kim
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Sangil Suh
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Neurosurgery, International St. Mary’s Hospital, Catholic Kwandong University, Incheon, Korea
| | - Jae Sang Oh
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Cheonan Hospital, Cheonan, Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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5
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Ghozy S, Kacimi SEO, Azzam AY, Farahat RA, Abdelaal A, Kallmes KM, Adusumilli G, Heit JJ, Kadirvel R, Kallmes DF. Successful mechanical thrombectomy in acute ischemic stroke: revascularization grade and functional independence. J Neurointerv Surg 2022; 14:779-782. [PMID: 35022301 DOI: 10.1136/neurintsurg-2021-018436] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/31/2021] [Indexed: 12/18/2022]
Abstract
Most studies define the technical success of endovascular thrombectomy (EVT) as a Thrombolysis in Cerebral Infarction (TICI) revascularization grade of 2b or higher. However, growing evidence suggests that TICI 3 is the best angiographic predictor of improved functional outcomes. To assess the association between successful TICI revascularization grades and functional independence at 90 days, we performed a systematic review and network meta-analysis of thrombectomy studies that reported TICI scores and functional outcomes, measured by the modified Rankin Scale, using the semi-automated AutoLit software platform. Forty studies with 8691 patients were included in the quantitative synthesis. Across TICI, modified TICI (mTICI), and expanded TICI (eTICI), the highest rate of good functional outcomes was observed in patients with TICI 3 recanalization, followed by those with TICI 2c and TICI 2b recanalization, respectively. Rates of good functional outcomes were similar among patients with either TICI 2c or TICI 3 grades. On further sensitivity analysis of the eTICI scale, the rates of good functional outcomes were equivalent between eTICI 2b50 and eTICI 2b67 (OR 0.81, 95% CI 0.52 to 1.25). We conclude that near complete or complete revascularization (TICI 2c/3) is associated with higher rates of functional outcomes after EVT.
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Affiliation(s)
- Sherief Ghozy
- Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ahmed Y Azzam
- Faculty of Medicine, October 6 University, Giza, Egypt
| | | | - Abdelaziz Abdelaal
- Postgraduate Medical Education, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin M Kallmes
- Nested Knowledge, St. Paul, Minnesota, USA.,Superior Medical Experts, St. Paul, Minnesota, USA
| | - Gautam Adusumilli
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Jeremy J Heit
- Department of Neuroradiology and Neurosurgery, Stanford University, Palo Alto, California, USA
| | | | - David F Kallmes
- Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
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