Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke

Hartog, Sanne J. den; Roozenbeek, Bob; Boodt, Nikki; Bruggeman, Agnetha A E; Es, Adriaan C.G.M. van; Emmer, Bart J.; Majoie, Charles B. L. M.; Wijngaard, Ido R. van den; Doormaal, Pieter Jan van; Zwam, Wim H van; Lingsma, Hester F.; Dippel, Diederik W.J.

doi:10.1136/neurintsurg-2021-017507

Cited by 23 publications

(23 citation statements)

References 32 publications

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“…First-pass mTICI 2b/3 failed to be a predictor of good clinical outcome in multivariate analysis. Similar results were recently confirmed by other authors [28][29][30]. Nonetheless, first-pass complete reperfusion should be the goal of every MT procedure [31], since it is linked to a better clinical outcome, a lower mortality, and fewer procedural adverse events.…”

Section: Discussionsupporting

confidence: 84%

Posterior Circulation Endovascular Thrombectomy for Large Vessels Occlusion in Patients Presenting with NIHSS Score ≤ 10

Alexandre

Valente

Consoli

et al. 2021

Life

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Mechanical thrombectomy (MT) is currently the gold standard treatment for ischemic stroke due to large vessel occlusion (LVO). However, the evidence of clinical usefulness of MT in posterior circulation LVO (pc-LVO) is still doubtful compared to the anterior circulation, especially in patients with mild neurological symptoms. The database of 10 high-volume stroke centers in Europe, including a period of three year and a half, was screened for patients with an acute basilar artery occlusion or a single dominant vertebral artery occlusion (“functional” BAO) presenting with a NIHSS ≤10, and with at least 3 months follow-up. A total of 63 patients were included. Multivariate analysis demonstrated that female gender (adjusted OR 0.04; 95% CI 0–0.84; p = 0.04) and combined technique (adj OR 0.001; 95% CI 0–0.81; p = 0.04) were predictors of worse outcome. Higher pc-ASPECTS (adj OR 4.75; 95% CI 1.33–16.94; p = 0.02) and higher Delta NIHSS (adj OR 2.06; 95% CI 1.16–3.65; p = 0.01) were predictors of better outcome. Delta NIHSS was the main predictor of good outcome at 90 days in patients with posterior circulation LVO presenting with NIHSS score ≤ 10.

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Section: Discussionsupporting

confidence: 84%

Posterior Circulation Endovascular Thrombectomy for Large Vessels Occlusion in Patients Presenting with NIHSS Score ≤ 10

Alexandre

Valente

Consoli

et al. 2021

Life

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“…Excellent and complete reperfusion (eTICI 2C and 3) are associated with better functional outcomes (90-day mRS) than good reperfusion (eTICI 2B) 4 5. In general, increasing the number of passes and increasing the treatment time to achieve successful reperfusion were shown to lead to worse functional outcome 1 6–12. This trend to worse functional outcome was also seen when excellent or complete reperfusion (eTICI 2C/3) was reached 6 13.…”

Section: Discussionmentioning

confidence: 97%

“…However, additional EVT device passes have been associated with worse functional outcomes 1 6–12. As such, too many additional attempts could ultimately outweigh the benefit of an improved reperfusion grade.…”

Section: Introductionmentioning

confidence: 99%

“…The question arises whether during EVT, additional passes to achieve eTICI 2C/3 should be undertaken when eTICI 2B has been achieved after one pass. Although it is known that more attempts lead to worse outcomes,1 6–12 it is unknown whether an optimal or maximum number of attempts can be defined when trying to achieve the highest possible reperfusion grade if sufficient reperfusion has already been achieved during the procedure. This question hinges on when the disadvantages associated with additional passes begin to outweigh the expected benefit of improved tissue reperfusion.…”

Section: Introductionmentioning

confidence: 99%

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Successful reperfusion in relation to the number of passes: comparing outcomes of first pass expanded Treatment In Cerebral Ischemia (eTICI) 2B with multiple-pass eTICI 3

Bruggeman

Kappelhof

Hartog

et al. 2022

J NeuroIntervent Surg

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BackgroundHigher expanded Treatment In Cerebral Ischemia (eTICI) reperfusion scores after endovascular treatment (EVT) are associated with better outcomes. However, the influence of the number of passes on this association is unclear. We aimed to compare outcomes of single-pass good reperfusion (eTICI 2B) with multiple-pass excellent/complete reperfusion (eTICI 2C/3) in daily clinical practice.MethodsWe compared outcomes of patients in the MR CLEAN Registry with good reperfusion (eTICI 2B) in a single pass to those with excellent/complete reperfusion (eTICI 2C/3) in multiple passes. Regression models were used to investigate the association of single-pass eTICI 2B versus multiple-pass eTICI 2C/3 reperfusion with 90-day functional outcome (modified Rankin Scale (mRS)), functional independence (mRS 0–2), per-procedural complications and safety outcomes.ResultsWe included 699 patients: 178 patients with single-pass eTICI 2B, and 242 and 279 patients with eTICI 2C/3 after 2 and ≥3 passes, respectively. Patients with eTICI 2C/3 after 2 or ≥3 passes did not achieve significantly better functional outcomes compared with patients with single-pass eTICI 2B (adjusted common OR (acOR) 1.06, 95% CI 0.75 to 1.50 and acOR 0.88, 95% CI 0.74 to 1.05 for 90-day mRS, and adjusted OR (aOR) 1.24, 95% CI 0.78 to 1.97 and aOR 0.79, 95% CI 0.52 to 1.22 for functional independence).ConclusionsOur results did not show better outcomes for patients who achieved eTICI 2C/3 in multiple, that is, two or more, passes when compared with patients with single-pass eTICI 2B. However, this concerns observational data. Further research is necessary to investigate the per-pass effect in relation to reperfusion and functional outcome.

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“…In a study by den Hartog et al , the authors reported that patients with posterior circulation occlusion who achieve successful recanalization after a single pass have superior functional outcome compared with multiple passes 24. The detrimental effect of repeated clot retrieval attempt on functional outcome is not straightforward and has not yet been fully explained.…”

Section: Discussionmentioning

confidence: 99%

Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion

Havenon

Elhorany

Boulouis

et al. 2022

J NeuroIntervent Surg

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BackgroundThe number of mechanical thrombectomy (MT) passes is strongly associated with angiographic reperfusion as well as clinical outcomes in patients with anterior circulation ischemic stroke. However, these associations have not been analyzed in patients with basilar artery occlusion (BAO). We investigated the influence of the number of MT passes on the degree of reperfusion and clinical outcomes, and compared outcome after ≤3 passes versus >3 passes.MethodsWe used data from the prospective multicentric Endovascular Treatment in Ischemic Stroke (ETIS) Registry at 18 sites in France. Patients with BAO treated with MT were included. The primary outcome was a favorable outcome, defined as a modified Rankin Scale score of 0–3 at 90 days. We fit mixed multiple regression models, with center as a random effect.ResultsWe included 275 patients. Successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3) was achieved in 88.4%, and 41.8% had a favorable outcome. The odds ratio for favorable outcome with each pass above 1 was 0.41 (95% CI 0.23 to 0.73) and for recanalization (mTICI 2b-3) it was 0.70 (95% CI 0.57 to 0.87). In patients with ≤3 passes, the rate of favorable outcome in recanalized versus non-recanalized patients was 50.5% versus 10.0% (p=0.001), while in those with >3 passes it was 16.7% versus 15.2% (p=0.901).ConclusionsWe found that BAO patients had a significant relationship between the number of MT passes and both recanalization and favorable functional outcome. We further found that the benefit of recanalization in BAO patients was significant only when recanalization was achieved within three passes, encouraging at least three passes before stopping the procedure.

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Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke

Cited by 23 publications

References 32 publications

Posterior Circulation Endovascular Thrombectomy for Large Vessels Occlusion in Patients Presenting with NIHSS Score ≤ 10

Posterior Circulation Endovascular Thrombectomy for Large Vessels Occlusion in Patients Presenting with NIHSS Score ≤ 10

Successful reperfusion in relation to the number of passes: comparing outcomes of first pass expanded Treatment In Cerebral Ischemia (eTICI) 2B with multiple-pass eTICI 3

Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion

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