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Martins PN, Nogueira RG, Tarek MA, Dolia JN, Sheth SA, Ortega-Gutierrez S, Salazar-Marioni S, Iyyangar A, Galecio-Castillo M, Rodriguez-Calienes A, Pabaney A, Grossberg JA, Haussen DC. Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when? J Neurointerv Surg 2024:jnis-2024-021545. [PMID: 38479798 DOI: 10.1136/jnis-2024-021545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/02/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined. OBJECTIVE To evaluate the association between early changes to the EVT approach and reperfusion. METHODS Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c-3, following the second and third passes. RESULTS Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c-3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c-3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c-3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c-3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar. CONCLUSIONS Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.
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Affiliation(s)
- Pedro N Martins
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
- UPMC, Pittsburgh, Pennsylvania, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jaydevsinh N Dolia
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Sunil A Sheth
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Ananya Iyyangar
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Milagros Galecio-Castillo
- Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Aaron Rodriguez-Calienes
- Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Cientifica del Sur Facultad de Ciencias de la Salud, Lima, Peru
| | - Aqueel Pabaney
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jonathan A Grossberg
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
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Aboul-Nour H, Dolia J, Tarek MA, Grossberg JA, Pabaney A, Damiani M, Al-Bayati AR, Nogueira RG, Haussen DC. Competitive leptomeningeal flow impact on thrombectomy reperfusion grade rating. J Neurointerv Surg 2024:jnis-2023-021268. [PMID: 38302419 DOI: 10.1136/jnis-2023-021268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Competitive leptomeningeal flow (CLF) can be observed immediately after mechanical thrombectomy (MT) reperfusion with retrograde contrast clearing of the distal leptomeningeal branches from non-contrast opacified flow through different vascular territories. We aim to evaluate the frequency of the CLF phenomenon, to determine if it has an association with the degree of leptomeningeal collateral status, and to understand the potentia impact it may have on the final expanded Treatment in Cerebral Ischemia (eTICI) score rating. METHODS Retrospective analysis of a prospective MT database spanning November 2020 to December 2021. Consecutive cases of intracranial internal carotid (i-ICA) or middle cerebral artery (MCA) M1 occlusions were included. CLF was defined by the observation of retrograde clearing of distal MCA branches that were previously opacified by antegrade reperfusion. The clearance of the distal branches is presumed to occur due to CLF via non-contrast opacified posterior cerebral artery or anterior cerebral artery flow. The washout was considered CLF if it cleared abruptly with or without forward reconstitution of antegrade opacification. RESULTS A total of 125 patients met the inclusion criteria. The median age was 64 years (IQR 52.5-75) and 64 (51%) were men. The baseline median National Institutes of Health Stroke Scale score was 17 (IQR 12-22) and the Alberta Stroke Program Early CT Score was 9 (IQR 8-10). Median last known well time to puncture was 7 hours (IQR 4-13.1) and 30.4% received tissue plasminogen activator. Final eTICI 2c-3 was achieved in 80%. CLF was present in 32 (25.6%) patients, who had comparable baseline characteristics to patients without CLF. Twelve (37.5%) patients had regional CLF and 20 (62.5%) had focal CLF. The CLF arm had better leptomeningeal single-phase CTA collaterals than the non-CLF arm (P=0.01). The inter-rater agreement for the eTICI score was moderate when CLF was present and strong in its absence (Krippendorf's alpha=0.65 and 0.81, respectively). There was minimal agreement (Kappa=0.3) for the presence versus absence of CLF between the two operators, possibly related to reader experience. CONCLUSION CLF was observed in 32% of patients, was associated with better collateral flow, and impacted the reported procedural eTICI rating.
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Affiliation(s)
- Hassan Aboul-Nour
- Departments of Neurology and Neurosurgery, University of Kentucky College of Medicine, Lexington, KY, USA
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jaydevsinh Dolia
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mateus Damiani
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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Mohammaden MH, Tarek MA, Aboul Nour H, Haussen DC, Fifi JT, Matsoukas S, Farooqui M, Ortega-Gutierrez S, Zevallos CB, Galecio-Castillo M, Hassan AE, Tekle W, Al-Bayati AR, Salem MM, Burkhardt JK, Pukenas B, Cortez GM, Hanel RA, Aghaebrahim A, Sauvageau E, Hafeez M, Kan P, Tanweer O, Jumaa M, Zaidi SF, Oliver M, Sheth SA, Nahhas M, Salazar-Marioni S, Khaldi A, Li H, Kuybu O, Abdalkader M, Klein P, Peng S, Alaraj A, Nguyen TN, Nogueira RG. Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study. J Neurointerv Surg 2023:jnis-2023-020676. [PMID: 37699704 DOI: 10.1136/jnis-2023-020676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUNDS Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-). METHODS This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively. RESULTS A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results. CONCLUSION In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.
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Affiliation(s)
- Mahmoud H Mohammaden
- Neurology, South Valley University Faculty of Medicine, Qena, Egypt
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Hassan Aboul Nour
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
- Neurology and Neurosurgery, University of Kentucky, Lexington, Kentucky, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros Matsoukas
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | | | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | | | | | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bryan Pukenas
- Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ricardo A Hanel
- Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | | | - Eric Sauvageau
- Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Muhammad Hafeez
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Omar Tanweer
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Mouhammad Jumaa
- Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Syed F Zaidi
- Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Marion Oliver
- Department of Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Sunil A Sheth
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Michael Nahhas
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | - Ahmad Khaldi
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Hanzhou Li
- Department of Neurosciences, WellStar Health System, Marietta, Georgia, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Piers Klein
- Neurology, Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sophia Peng
- Neurosurgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Ali Alaraj
- Neurosurgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Thanh N Nguyen
- Neurology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
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