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

First pass effect in patients with large core infarcts undergoing mechanical thrombectomy: subgroup analysis of the prospective international ASSIST registry

BACKGROUND

Studies have described a first pass effect (FPE) where patients with successful recanalization after one pass experience better outcomes. Few studies have evaluated this in patients with large core infarctions.

OBJECTIVE

To determine whether patients with large core infarcts undergoing mechanical thrombectomy in which first pass reperfusion is achieved experience improved outcomes compared with those who undergo more than one pass.

METHODS

The ASSIST Registry, a prospective, global, multicenter registry of patients with anterior circulation large vessel occlusion (LVO) undergoing mechanical thrombectomy was used. Adults with internal carotid artery/M1/M2 occlusions and preprocedural Alberta Stroke Program Early CT Score (ASPECTS) <6 were included. The variable of interest was number of thrombectomy passes (dichotomized to 1 or >1) performed for the target occlusion. The primary outcome was 90-day good functional outcome defined as modified Rankin Scale (mRS) score 0-3.

RESULTS

150 patients with a mean age of 66 years were included. Most patients had ASPECTS of 4 (33%) or 5 (59%). 77 patients (51%) underwent one pass. Compared with patients with one pass, those with more than one pass had significantly lower odds of good functional outcome (OR=0.44, 95% CI 0.21 to 0.93; P=0.03). More than one pass was not significantly associated with 90-day mRS score 0-2 (OR=0.46, 95% CI 0.15 to 1.43; P=0.17) or mortality (OR=2.03, 95% CI 0.81 to 5.08; P=0.13). FPE (one pass eTICI≥2c) and modified FPE (one pass extended thrombolysis in cerebral infarction ≥2b50) were not significantly associated with 90-day mRS 0-3, mortality, or symptomatic intracranial hemorrhage.

CONCLUSION

This analysis suggests that use of multiple passes is associated with worse outcomes in patients with large core infarcts.

Endovascular thrombectomy for distal medium vessel occlusions: A literature review

BACKGROUND

There is a lack of substantial evidence supporting the safety and effectiveness of endovascular thrombectomy in treating distal medium vessel occlusions (DMVOs).

OBJECTIVE

To summarize the current evidence regarding endovascular thrombectomy for DMVOs.

METHODS

We conducted a narrative review of key articles related to the diagnosis and management of DMVOs. We manually searched PubMed and Google Scholar from January 2010 to July 2023, and only included articles published in the English language.

RESULTS

While diagnosing and treating DMVOs is tricky due to access limitations and potential limited benefit from mechanical clot removal, recent improvements in catheter and retrieval technology suggest that endovascular thrombectomy might be a potential treatment option. However, more high-quality research is needed to confirm its effectiveness for DMVOs.

CONCLUSION

Experts disagree on how to classify DMVOs and what the best mode of endovascular treatment is.

Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy

BACKGROUND

Acute ischemic stroke (AIS) from primary medium vessel occlusions (MeVO) is a prevalent condition associated with substantial morbidity and mortality. Despite the common use of mechanical thrombectomy (MT) in AIS, predictors of poor outcomes in MeVO remain poorly characterized.

METHODS

In this prospectively collected, retrospectively reviewed, multicenter, multinational study, data from the MAD-MT (Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy) registry were analyzed. The study included 1568 patients from 37 academic centers across North America, Asia, and Europe, treated with MT, with or without intravenous tissue plasminogen activator (IVtPA), between September 2017 and July 2021.

RESULTS

Among the 1568 patients, 347 (22.2%) experienced very poor outcomes (modified Rankin score (mRS), 5-6). Key predictors of poor outcomes were advanced age (odds ratio (OR): 1.03; 95% confidence interval (CI): 1.02 to 1.04; p < 0.001), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (OR: 1.07; 95% CI: 1.05 to 1.10; p < 0.001), pre-operative glucose levels (OR: 1.01; 95% CI: 1.00 to 1.02; p < 0.001), and a baseline mRS of 4 (OR: 2.69; 95% CI: 1.25 to 5.82; p = 0.011). The multivariable model demonstrated good predictive accuracy with an area under the receiver-operating characteristic (ROC) curve of 0.76.

CONCLUSIONS

This study demonstrates that advanced age, higher NIHSS scores, elevated pre-stroke mRS, and pre-operative glucose levels significantly predict very poor outcomes in AIS-MeVO patients who received MT. These findings highlight the importance of a comprehensive risk assessment in primary MeVO patients for personalized treatment strategies. However, they also suggest a need for cautious patient selection for endovascular thrombectomy. Further prospective studies are needed to confirm these findings and explore targeted therapeutic interventions.

Symptomatic intracerebral hemorrhage in proximal and distal medium middle cerebral artery occlusion patients treated with mechanical thrombectomy

BACKGROUND

Acute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in endovascular procedures have led to increased use of mechanical thrombectomy (MT) in DMVO stroke patients. However, symptomatic intracerebral hemorrhage (sICH) remains a critical complication of AIS, particularly after undergoing intervention. This study aims to identify factors associated with sICH in DMVO stroke patients undergoing MT.

METHODS

This retrospective analysis utilized data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. Middle cerebral artery (MCA) DMVO stroke patients were included. The primary outcome measured was sICH, as defined per the Heidelberg Bleeding Classification. Univariable and multivariable logistic regression were used to identify factors independently associated with sICH.

RESULTS

Among 1708 DMVO stroke patients, 148 (8.7%) developed sICH. Factors associated with sICH in DMVO patients treated with MT included older age (adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 1.00 to 1.03, P=0.048), distal occlusion site (M3, M4) compared with medium occlusions (M2) (aOR 1.71, 95% CI 1.07 to 2.74, P=0.026), prior use of antiplatelet drugs (aOR 2.06, 95% CI 1.41 to 2.99, P<0.001), lower Alberta Stroke Program Early CT Scores (ASPECTS) (aOR 0.75, 95% CI 0.66 to 0.84, P<0.001), higher preoperative blood glucose level (aOR 1.00, 95% CI 1.00 to 1.01, P=0.012), number of passes (aOR 1.27, 95% CI 1.15 to 1.39, P<0.001), and successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b-3) (aOR 0.43, 95% CI 0.28 to 0.66, P<0.001).

CONCLUSION

This study provides novel insight into factors associated with sICH in patients undergoing MT for DMVO, emphasizing the importance of age, distal occlusion site, prior use of antiplatelet drugs, lower ASPECTS, higher preoperative blood glucose level, and procedural factors such as the number of passes and successful recanalization. Pending confirmation, consideration of these factors may improve personalized treatment strategies.

Hypoperfusion Intensity Ratio Is Associated with Early Neurologic Deficit Severity and Deterioration after Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke

BACKGROUND AND PURPOSE

The hypoperfusion intensity ratio is a surrogate marker for collateral status and a predictor of infarct growth, malignant cerebral edema, and hemorrhagic transformation. Its utility to predict a poor NIHSS score and early neurologic deterioration after mechanical thrombectomy for large vessel (LVO) versus distal and medium vessel occlusions (DMVO) has not been investigated. The objective of this study was to determine whether the higher hypoperfusion intensity ratio is associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy and early neurologic deterioration in LVO versus DMVO acute ischemic stroke.

MATERIALS AND METHODS

This was a retrospective study of 231 patients with acute ischemic stroke with LVO or DMVO amenable for mechanical thrombectomy and available CTP for hypoperfusion intensity ratio assessment pre-mechanical thrombectomy. Clinical and imaging characteristics were abstracted from the medical records. The primary outcome was the NIHSS score at 24 hours post-mechanical thrombectomy. The secondary outcome was early neurologic deterioration, defined as a >4-point increase in the NIHSS score between the initial assessment and 24 hours post-mechanical thrombectomy. All analyses were first conducted in the entire cohort and then separately for the LVO versus DMVO groups.

RESULTS

The optimal hypoperfusion intensity ratio threshold to detect early neurologic deterioration was 0.54. A hypoperfusion intensity ratio ≥ 0.54 was more frequently present in LVO versus DMVO (n = 37 [77.1%] versus n = 11 [22.9%]; P < .001). On multivariable linear regression, the hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy in the entire cohort (β = 0.163; P = .002) and the LVO group (β = 0.210; P = .005), but not in the DMVO group. The early neurologic deterioration occurred in 26 (11.3%) subjects. On multivariable logistic regression, there was no association of the hypoperfusion intensity ratio ≥ 0.54 with early neurologic deterioration in the entire cohort. However, when analyzed separately, a hypoperfusion intensity ratio ≥ 0.54 significantly increased the odds of early neurologic deterioration in subjects with LVO (OR = 5.263; 95% CI, 1.170-23.674; P = .030) but not in the DMVO group.

CONCLUSIONS

The hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse 24-hour post-mechanical thrombectomy NIHSS score and early neurologic deterioration in LVO, but not in DMVO acute ischemic stroke. Pending confirmation in future, prospective studies assessing the hypoperfusion intensity ratio may help identify patients at risk of secondary decline to improve peri-thrombectomy care and clinical decision-making.

Pretreatment CTP Collateral Parameters Predict Good Outcomes in Successfully Recanalized Middle Cerebral Artery Distal Medium Vessel Occlusions

BACKGROUND/PURPOSE

Distal medium vessel occlusions (DMVOs) account for a large percentage of vessel occlusions resulting in acute ischemic stroke (AIS) with disabling symptoms. We aim to assess whether pretreatment quantitative CTP collateral status (CS) parameters can serve as imaging biomarkers for good clinical outcomes prediction in successfully recanalized middle cerebral artery (MCA) DMVOs.

METHODS

We performed a retrospective analysis of consecutive patients with AIS secondary to primary MCA-DMVOs who were successfully recanalized by mechanical thrombectomy (MT) defined as modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3. We evaluated the association between the CBV index and HIR independently with good clinical outcomes (modified Rankin score 0-2) using Spearman rank correlation, logistic regression, and ROC analyses.

RESULTS

From 22 August 2018 to 18 October 2022 8/22/2018 to 10/18/2022, 60 consecutive patients met our inclusion criteria (mean age 71.2 ± 13.9 years old [mean ± SD], 35 female). The CBV index (r = -0.693, p < 0.001) and HIR (0.687, p < 0.001) strongly correlated with 90-day mRS. A CBV index ≥ 0.7 (odds ratio, OR, 2.27, range 6.94-21.23 [OR] 2.27 [6.94-21.23], p = 0.001)) and lower likelihood of prior stroke (0.13 [0.33-0.86]), p = 0.024)) were independently associated with good outcomes. The ROC analysis demonstrated good performance of the CBV index in predicting good 90-day mRS (AUC 0.73, p = 0.003) with a threshold of 0.7 for optimal sensitivity (71% [52.0-85.8%]) and specificity (76% [54.9-90.6%]). The HIR also demonstrated adequate performance in predicting good 90-day mRS (AUC 0.77, p = 0.001) with a threshold of 0.3 for optimal sensitivity (64.5% [45.4-80.8%]) and specificity (76.0% [54.9-90.6%]).

CONCLUSION

A CBV index ≥ 0.7 may be independently associated with good clinical outcomes in our cohort of AIS caused by MCA-DMVOs that were successfully treated with MT. Furthermore, a HIR < 0.3 is also associated with good clinical outcomes. This is the first study of which we are aware to identify a CBV index threshold for MCA-DMVOs.

Mechanical thrombectomy with Embolus Retriever with Interlinked Cages device for medium vessel occlusions: First pass results and safety profile

BACKGROUND

Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions.

METHODS

A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded.

RESULTS

There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%.

CONCLUSION

In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study

INTRODUCTION

First pass effect (FPE), achievement of complete recanalization (mTICI 2c/3) with a single pass, is a significant predictor of favorable outcomes for endovascular treatment (EVT) in large vessel occlusion stroke (LVO). However, data concerning the impact on functional outcomes and predictors of FPE in medium vessel occlusions (MeVO) are scarce.

PATIENTS AND METHODS

We conducted an international retrospective study on MeVO cases. Multivariable logistic modeling was used to establish independent predictors of FPE. Clinical and safety outcomes were compared between the two study groups (FPE vs non-FPE) using logistic regression models. Good outcome was defined as modified Rankin Scale 0-2 at 3 months.

RESULTS

Eight hundred thirty-six patients with a final mTICI ⩾ 2b were included in this analysis. FPE was observed in 302 patients (36.1%). In multivariable analysis, hypertension (aOR 1.55, 95% CI 1.10-2.20) and lower baseline NIHSS score (aOR 0.95, 95% CI 0.93-0.97) were independently associated with an FPE. Good outcomes were more common in the FPE versus non-FPE group (72.8% vs 52.8%), and FPE was independently associated with favorable outcome (aOR 2.20, 95% CI 1.59-3.05). 90-day mortality and intracranial hemorrhage (ICH) were significantly lower in the FPE group, 0.43 (95% CI, 0.25-0.72) and 0.55 (95% CI, 0.39-0.77), respectively.

CONCLUSION

Over 2/3 of patients with MeVOs and FPE in our cohort had a favorable outcome at 90 days. FPE is independently associated with favorable outcomes, it may reduce the risk of any intracranial hemorrhage, and 3-month mortality.

Predictors of futile recanalization in basilar artery occlusion patients undergoing endovascular treatment: a post hoc analysis of the ATTENTION trial

Background

Few studies have focused on factors associated with futile recanalization in patients with an acute basilar artery occlusion (BAO) that was treated with modern endovascular therapy (EVT). The aim of this study was to explore the factors associated with futile recanalization in patients with an acute BAO presented within 12 h.

Methods

This is a post-hoc analysis of the ATTENTION trial (The Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion, ClinicalTrials.gov, number NCT04751708). Demographics, clinical characteristics, acute stroke workflow interval times, and imaging characteristics were compared between the futile recanalization and favorable recanalization groups. The favorable outcome was defined as a modified Rankin scale (mRS) score of 0-3 at 90 days, successful reperfusion was defined as thrombolysis in cerebral infarction (TICI) 2b and 3 on the final angiogram, and futile recanalization was defined as failure to achieve a favorable outcome despite successful reperfusion. A multivariate analysis was performed to identify the predictors of futile recanalization.

Results

In total, 185 patients were included in the final analysis: 89 (48.1%) patients had futile recanalization and 96 (51.9%) patients had favorable recanalization. In the multivariable logistic regression analysis, older age (OR 1.04, 95% CI 1.01 to 1.08, p = 0.01) and diabetes mellitus (OR 3.35, 95% CI 1.40 to 8.01, p = 0.007) were independent predictors of futile recanalization.

Conclusion

Futile recanalization occurred in nearly half of patients with acute BAO following endovascular treatment. Old age and diabetes mellitus were identified as independent predictors of futile recanalization after endovascular therapy for acute BAO.