Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

Abstract

BACKGROUND: The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation. METHODS: TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events. RESULTS: A total of 141 patients met the inclusion criteria and were treated endovascularly for primary isolated DMVO in the P2 (84.4%, 119) or P3 segment (15.6%, 22) of the posterior cerebral artery. The median age was 75 (IQR, 62–81), and 45.4% (64) were female. The initial reperfusion strategy was aspiration only in 29% (41) and stent retriever in 71% (100), both achieving similar first-pass effect rates of 53.7% (22) and 44% (44; P =0.297), respectively. There were no significant differences in early neurological improvement (aspiration: 64.7% versus stent retriever: 52.2%; P =0.933) and modified Rankin Scale rates (modified Rankin Scale score 0–1, aspiration: 60.5% versus stent retriever 68.6%; P =0.4). In multivariable logistic regression analysis, the time from groin puncture to recanalization was associated with the first-pass effect (adjusted odds ratio, 0.97 [95% CI, 0.95–0.99]; P <0.001) that in turn was associated with early neurological improvement (aOR, 3.27 [95% CI, 1.16–9.21]; P <0.025). Symptomatic intracranial hemorrhage occurred in 2.8% (4) of all cases. CONCLUSIONS: Both first-pass aspiration and stent retriever thrombectomy for primary isolated posterior circulation DMVO seem to be safe and technically feasible leading to similar favorable rates of angiographic and clinical outcome.

First-line thrombectomy strategy for distal and medium vessel occlusions: a systematic review

“…A PRISMA diagram detailing our search results is shown in figure 1. Six two-armed studies compared the performance of SR and ASP techniques 16–21. Four three-armed studies compared the performance of SR+ASP to ASP and SR 22–25.…”

“…All studies provided data for thrombus location. Data regarding IVT utilization in DMVOs were available in 10 studies 16 17 19 20 22 24–28. Even though Bernsen et al provided overall IVT utilization data, they did not provide separate baseline characteristics for DMVOs 18.…”

“…Even though Bernsen et al provided overall IVT utilization data, they did not provide separate baseline characteristics for DMVOs 18. Functional independence data were available in nine studies,16–19 21 24–26 28 and eight articles presented complete recanalization16 18 20–22 24 26 27 data. Also, nine studies provided sICH data,16–22 27 28 and seven articles presented SAH data 16 19 21 24 26–28.…”

“…Functional independence data were available in nine studies,16–19 21 24–26 28 and eight articles presented complete recanalization16 18 20–22 24 26 27 data. Also, nine studies provided sICH data,16–22 27 28 and seven articles presented SAH data 16 19 21 24 26–28. Alawieh et al provided raw overall functional independence, successful recanalization, and sICH data for their cohort 25.…”

“…In a subgroup analysis of the retrospective TOPMOST study, Meyer et al compared the outcomes of ASP and SR techniques in 141 posterior circulation MeVOs (119 PCA P2 occlusions, 22 PCA P3 occlusions) 20. Of these 141 cases, 41 were treated with ASP thrombectomy and 100 were treated with SR thrombectomy.…”