Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy

Abstract

Purpose Treatment of distal vessel occlusions causing incomplete reperfusion after mechanical thrombectomy (MT) is debated. We hypothesized that pretreatment with intravenous thrombolysis (IVT) may facilitate delayed reperfusion (DR) of residual vessel occlusions causing incomplete reperfusion after MT. Methods Retrospective analysis of patients with incomplete reperfusion after MT, defined as extended thrombolysis in cerebral infarction (eTICI) 2a–2c, and available perfusion follow-up imaging at 24 ± 12 h after MT. DR was defined as absence of any perfusion deficit on time-sensitive perfusion maps, indicating the absence of any residual occlusion. The association of IVT with the occurrence of DR was evaluated using a logistic regression analysis adjusted for confounders. Sensitivity analyses based on IVT timing (time between IVT start and the occurrence incomplete reperfusion following MT) were performed. Results In 368 included patients (median age 73.7 years, 51.1% female), DR occurred in 225 (61.1%). Atrial fibrillation, higher eTICI grade, better collateral status and longer intervention-to-follow-up time were all associated with DR. IVT did not show an association with the occurrence of DR (aOR 0.80, 95% CI 0.44–1.46, even in time-sensitive strata, aOR 2.28 [95% CI 0.65–9.23] and aOR 1.53 [95% CI 0.52–4.73] for IVT to incomplete reperfusion following MT timing <80 and <100 min, respectively). Conclusion A DR occurred in 60% of patients with incomplete MT at ~24 h and did not seem to occur more often in patients receiving pretreatment IVT. Further research on potential associations of IVT and DR after MT is required.

External Validation of a Model for Persistent Perfusion Deficit in Patients With Incomplete Reperfusion After Thrombectomy

“…Multimorbidity, worse baseline profile, or sudden clinical deterioration make it less likely for a patient to undergo perfusion imaging on follow-up. 4 , 21 Therefore, rates of reported PPD should be handled cautiously because they are likely to differ from the absolute PPD rates among patients without follow-up perfusion imaging. Furthermore, reference standard for the management of incomplete reperfusion does not exist; therefore, performance of this model could not be compared with an appropriate reference threshold.…”

“…Based on previous reports, we assumed C-statistic = 0.8 with standard error = 0.025 and PPD prevalence = 40%. 4 , 7 , 21 This led to the recommended sample size of n = 315 (including 126 event cases, i.e., patients with PPD).…”

Prediction of delayed reperfusion in patients with incomplete reperfusion following thrombectomy

“…33,34 However, the impact of intravenous thrombolysis on the occurrence of DR remains unclear. 35 Patients without perfusion follow-up imaging were excluded from the present analysis. This selection bias might overestimate absolute rates of DR, as these might differ in the patients not undergoing perfusion imaging on follow-up.…”

Value of Immediate Flat Panel Perfusion Imaging after Endovascular Therapy (AFTERMATH): A Proof of Concept Study

“…7,8 Besides a general overestimation bias, specific locations may also be more prone to false-positive TICI 3 ratings. 7,8 Periprocedural perfusion imaging might serve as an adjunct for more accurate evaluation of reperfusion success, [9][10][11][12][13] especially in cases of subtle distal occlusions or overlapping capillary phase hypoperfusions, which are hard to detect on DSA runs alone. [10][11][12][13] Pronounced collaterals with competing flow in peripheral vessels, on the other hand, may result in an underestimation of reperfusion outcome.…”