Complete reperfusion is required for maximal benefits of mechanical thrombectomy in stroke patients

Chamorro, Ángel; Blasco, Jordi; López, Antonio; Román, Luís San; Llull, Laura; Renú, Arturo; Rudilosso, Salvatore; Laredo, Carlos; Obach, Vı́ctor; Urra, Xabier; Planas, Anna M.; Leira, Enrique C.; Macho, Juan

doi:10.1038/s41598-017-11946-y

Cited by 49 publications

(40 citation statements)

References 33 publications

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“…Nevertheless, there is a strong correlation between successful reperfusion and patients' outcome, as shown in recent literature [9,10,19,40]. The study cohort is the same size as in other comparable studies.…”

Section: Limitationmentioning

confidence: 83%

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Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

et al. 2020

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Purpose Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke. However, recanalization fails in about 16.5% of interventions. We report our experience with unsuccessful MT and analyze technical reasons plus patient-related parameters for failure. Methods Five hundred ninety-six patients with acute ischemic stroke in the anterior circulation and intention to perform MT with an aspiration catheter and/or stent retriever were analyzed. Failure was defined as 0, 1, or 2a on the mTICI scale. Patients with failing MT were analyzed for interventional progress and compared to patients with successful intervention, whereby parameters included demographics, medical history, stroke presentation, and treatment.Results One hundred of the 596 (16.8%) interventions failed. In 20 cases, thrombus could not be accessed or passed with the device. Peripheral arterial occlusive disease is common in those patients. In 80 patients, true stent retriever failure occurred. In this group, coagulation disorders are associated with poor results, whereas atrial fibrillation is associated with success.The administration of intravenous thrombolysis and intake of nitric oxide donors are associated with recanalization success. Intervention duration was significantly longer in the failing group. Conclusion In 20% of failing MT, thrombus cannot be reached/passed. Direct carotid puncture or surgical arterial access could be considered in these cases.In 80% of failing interventions, thrombus can be passed with the device, but the occluded vessel cannot be recanalized. Rescue techniques can be an option. Development of new devices and techniques is necessary to improve recanalization rates. Assessment of pre-existing illness could sensitize for occurring complications.

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Section: Limitationmentioning

confidence: 83%

“…Elevation of recanalization rates is an important step for improved stroke therapy and better patient outcome [9,10].…”

Section: Introductionmentioning

confidence: 99%

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

et al. 2020

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“…Further evidence supporting this idea comes from Jain et al . [ 69 ], who observe the predicted negative correlation between genome size and flowering time among a diverse panel of maize inbreds (although the relationship is not significant after correcting for kinship). Finally, though additional environmental factors have been hypothesized to elicit adaptive changes in genome size e.g .…”

Section: Discussionmentioning

confidence: 99%

Parallel altitudinal clines reveal trends in adaptive evolution of genome size in Zea mays

et al. 2018

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While the vast majority of genome size variation in plants is due to differences in repetitive sequence, we know little about how selection acts on repeat content in natural populations. Here we investigate parallel changes in intraspecific genome size and repeat content of domesticated maize (Zea mays) landraces and their wild relative teosinte across altitudinal gradients in Mesoamerica and South America. We combine genotyping, low coverage whole-genome sequence data, and flow cytometry to test for evidence of selection on genome size and individual repeat abundance. We find that population structure alone cannot explain the observed variation, implying that clinal patterns of genome size are maintained by natural selection. Our modeling additionally provides evidence of selection on individual heterochromatic knob repeats, likely due to their large individual contribution to genome size. To better understand the phenotypes driving selection on genome size, we conducted a growth chamber experiment using a population of highland teosinte exhibiting extensive variation in genome size. We find weak support for a positive correlation between genome size and cell size, but stronger support for a negative correlation between genome size and the rate of cell production. Reanalyzing published data of cell counts in maize shoot apical meristems, we then identify a negative correlation between cell production rate and flowering time. Together, our data suggest a model in which variation in genome size is driven by natural selection on flowering time across altitudinal clines, connecting intraspecific variation in repetitive sequence to important differences in adaptive phenotypes.

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“…Since 2013, and based on these assumptions, mTICI has been accepted as the stan- dard scale and mTICI 2b and mTICI 3 grades as successful revascularization [1]. However, mTICI 2b grade encompasses a wide range of revascularization states (from just over 50% reperfusion of the vessel territory to complete reperfusion but slow contrast filling), with differences in clinical outcomes between mTICI 2b and mTICI 3 grades recently demonstrated by our group [4] and by other reports [2,3,5]. Thus, it may partially justify the dissociation of approximately 15-30% between angiographic successful revascularization and good outcome rates verified in clinical trials [6,[10][11][12][13][14].…”

Section: Discussionmentioning

confidence: 95%

“…This scale was selected mainly for 2 key reasons: its higher inter-rater agreement and its capacity of clinical outcome prediction [1]. Although mTICI 2b and mTICI 3 grades have been equally accepted as successful revascularization, this cutoff has been questioned since the magnitude of benefit derived from each of these angiographic scores does not seem to be equivalent [2][3][4][5]. We previously showed that patients with mTICI 3 grade had significant better efficacy and safety outcomes than mTICI 2b patients and suggested that the definition of successful revascularization should be redefined [4].…”

Section: Introductionmentioning

confidence: 99%

Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

et al. 2018

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Background: A 2013 consensus statement recommended the use of the modified Treatment In Cerebral Ischemia (mTICI) scale to evaluate angiographic revascularization after endovascular treatment (EVT) of acute ischemic stroke due to its higher inter-rater agreement and capacity of clinical outcome prediction. The current definition of successful revascularization includes the achievement of grades mTICI 2b or 3. However, mTICI 2b grade encompasses a large heterogeneity of revascularization states, and prior studies suggested that the magnitude of benefit derived from mTICI 2b and mTICI 3 does not seem to be equivalent. In a way to restrain the referred heterogeneity, Goyal et al. [J Neurointerv Surg 2014; 6: 83–86] proposed a revised mTICI scale that includes a 2c grade (rTICI). Methods: Retrospective analysis of prospectively collected data from consecutive cases of EVT for anterior circulation large-vessel occlusion, performed between January 2015 and July 2017. Patients with mTICI 2b or 3 grades were reclassified according to the rTICI scale, and the outcomes between the 3 revascularization grades (rTICI 2b, 2c, 3) compared. Results: Our study population of 226 patients (64 rTICI 2b, 30 rTICI 2c, 132 rTICI 3) has a mean age of 71 years, 48.2% males, median baseline NIHSS of 16 (13–19) and ASPECTS of 8 (7–9). The 3 revascularization grades are represented by homogeneous populations. Logistic regression analysis showed statistically significant higher rates of functional independence at 3 months (65.9 vs. 50.0%; adjusted OR 0.39, 95% CI 0.18–0.86), with lower rates of mortality (8.3 vs. 15.6%; adjusted OR 3.54, 95% CI 1.14–10.97) and intracranial hemorrhage (ICH) in rTICI 3 than 2b groups. When comparing rTICI 3 with 2c groups, there were only statistically significant differences in the total ICH rate (8.3 vs. 26.7%; adjusted OR 7.08, 95% CI 1.80–27.82) but not in symptomatic ICH. Conclusions: These results corroborate the scarce prior findings suggesting that patients with rTICI 2c grade should be reported separately, since they have similar outcomes to rTICI 3, and better than rTICI 2b patients. Therefore, we suggest resetting the angiographic revascularization endpoint to perfect revascularization (rTICI 2c or 3 grades), a target that neurointerventionalists should strive to achieve.

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Complete reperfusion is required for maximal benefits of mechanical thrombectomy in stroke patients

Cited by 49 publications

References 33 publications

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

Parallel altitudinal clines reveal trends in adaptive evolution of genome size in Zea mays

Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

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