A review of endovascular treatment for medium vessel occlusion stroke

Ospel, Johanna M.; Goyal, Mayank

doi:10.1136/neurintsurg-2021-017321

Cited by 97 publications

(94 citation statements)

References 57 publications

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“…Goyal et al proposed the anatomical definition of MEVO that M2/3, A2/3 or P2/3, in addition, the functional definition includes NIHSS ≥5 or NIHSS <5 with disabling deficit. [44][45][46] These vessel occlusions are common but can be devastating clinically. Although emerging reports suggest that EVT may be safe and effective for MEVO, at present there is a lack of clear guideline recommendations.…”

Section: Medium Vessel Occlusions (Mevos)mentioning

confidence: 99%

Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions

Guo

Miao²

2021

Stroke Vasc Neurol

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Advances in endovascular treatment of acute ischaemic stroke from intracranial large vessel occlusions have continued in the past decade. Here, we performed a detailed review of all the new trials and studies that had the highest evidence, the guidelines for mechanical thrombectomy, the selection of the particular population outside the guidelines and endovascular therapeutic strategies for acute ischemic stroke from occluded intracranial arteries.

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Section: Medium Vessel Occlusions (Mevos)mentioning

confidence: 99%

Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions

Guo

Miao²

2021

Stroke Vasc Neurol

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“…Lastly, the registry included only patients with residual distal occlusions after MT, but distal occlusions may also be encountered as primary or secondary occlusions after spontaneous or lysis-induced clot migration. [32][33][34][35][36][37] The potential role of IAF in these scenarios cannot be deduced from the presented data, because these thrombi may represent with distinct histopathological and/or mechanical features. 38,39 Limitations This is a retrospective single-arm observational study with its associated limitations.…”

Section: Discussionmentioning

confidence: 88%

Factors associated with early reperfusion improvement after intra-arterial fibrinolytics as rescue for mechanical thrombectomy

Kaesmacher

Peschi

Abdullayev

et al. 2021

Clinical and Translational Neuroscience

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Objective: To identify factors associated with early angiographic reperfusion improvement (EARI) following intra-arterial fibrinolytics (IAF) after failed or incomplete mechanical thrombectomy (MT). Methods: A subset of patients treated with MT and IAF rescue after incomplete reperfusion included in the INFINITY (INtra-arterial FIbriNolytics In ThrombectomY) multicenter observational registry was analyzed. Multivariable logistic regression was used to identify factors associated with EARI. Heterogeneity of the clinical effect of EARI on functional independence (defined as modified Rankin Score ≤2) was tested with interaction terms. Results: A total of 228 patients (median age: 72 years, 44.1% female) received IAF as rescue for failed or incomplete MT and had a post-fibrinolytic angiographic control run available (50.9% EARI). A cardioembolic stroke origin (adjusted odds ratio (aOR) 3.72, 95% confidence interval (CI) 1.39–10.0) and shorter groin puncture to IAF intervals (aOR 0.82, 95% CI 0.71–0.95 per 15-min delay) were associated with EARI, while pre-interventional thrombolysis showed no association (aOR 1.15, 95% CI 0.59–2.26). The clinical benefit of EARI after IAF seemed more pronounced in patients without or only minor early ischemic changes (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥9, aOR 4.00, 95% CI 1.37–11.61) and was absent in patients with moderate to severe ischemic changes (ASPECTS ≤8, aOR 0.94, 95% CI 0.27–3.27, p for interaction: 0.095). Conclusion: Early rescue and a cardioembolic stroke origin were associated with more frequent EARI after IAF. The clinical effect of EARI seemed reduced in patients with already established infarcts. If confirmed, these findings can help to inform patient selection and inclusion criteria for randomized-controlled trials evaluating IAF as rescue after MT.

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“…EVT device choice in MeVO stroke is likely largely determined by the device's safety profile. Because the affected vessels in MeVO strokes are smaller, more distal, and more fragile, the risk of complications such as vasospasm, manipulation-related subarachnoid hemorrhage, and dissection is increased ( 3 ). These risks should be mitigated in order for EVT to result in a net benefit for the patients undergoing recanalization.…”

Section: Discussionmentioning

confidence: 99%

“…Given the high efficacy of endovascular treatment (EVT) for acute ischemic stroke due to large vessel occlusion (LVO) and recently recognized substantial morbidity associated with stroke due to medium vessel occlusions (MeVO; distal M2/3, A2/3, P2/3 vessel segments) ( 1 ), EVT is now increasingly considered as a treatment for MeVO stroke ( 2 ), despite the lack of high-level evidence for MeVO EVT ( 3 , 4 ). The smaller caliber, more distal location, and longer and more tortuous course of the affected vessels of MeVO compared to LVO makes EVT for MeVO stroke more challenging.…”

Section: Introductionmentioning

confidence: 99%

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Endovascular Device Choice and Tools for Recanalization of Medium Vessel Occlusions: Insights From the MeVO FRONTIERS International Survey

et al. 2021

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Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs.Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression.Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07–1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53–3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16–14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01–4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26–8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11–10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38–3.24; and RR 0.49, 95% CI 0.34–0.70, respectively) compared to the United States and Canada.Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.

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A review of endovascular treatment for medium vessel occlusion stroke

Cited by 97 publications

References 57 publications

Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions

Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions

Factors associated with early reperfusion improvement after intra-arterial fibrinolytics as rescue for mechanical thrombectomy

Endovascular Device Choice and Tools for Recanalization of Medium Vessel Occlusions: Insights From the MeVO FRONTIERS International Survey

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