Endovascular Thrombectomy in Patients With Acute Ischemic Stroke With Simultaneous Multivessel Occlusions

Abstract

BACKGROUND Simultaneous multivessel occlusions (MVOs) are a rare condition, which may be encountered during endovascular thrombectomy (EVT) for acute ischemic stroke. This study aimed to investigate the prevalence, associated factors, and outcome of patients with acute ischemic stroke and MVO who underwent EVT. METHODS Consecutive patients with acute ischemic stroke who received EVT between September 2014 and April 2021 were included. Acute MVO was defined as simultaneous occlusions of ≥2 intracranial or extracranial major vessels in either bilateral anterior circulation or anterior plus posterior circulation. Patients’ baseline characteristics and outcome of MVO were analyzed. RESULTS Of 602 patients with acute ischemic stroke (mean age, 71±13 years; male, 53.1%) who received EVT, 11 patients (1.8%) had acute MVO. The involved vessels included bilateral internal carotid arteries in 3, bilateral middle cerebral arteries in 4, vertebral artery and distal middle cerebral artery in 1, and internal carotid artery and distal posterior cerebral artery in 3 patients. Preadmission dependence (modified Rankin scale score >2), higher initial stroke severity, and posterior cerebral artery occlusion were more frequently found in MVO. The cause of MVO included large vessel atherosclerosis in 4, cardioembolic in 4, cancer‐related hypercoagulability in 2, and postpartum in 1 patient. Several patients had received simultaneous multitargeted EVT, but only 4 of them achieved optimal reperfusion in both vessels. Compared with patients without MVO, those with MVO had higher mortality (adjusted odds ratio, 6.75; 95% CI, 1.93–23.6) and poor functional outcome (common odds ratio for 1‐point improvement at modified Rankin scale, 0.14, 95% CI, 0.05–0.45) at 90 days. CONCLUSION Acute simultaneous MVO in patients who underwent EVT is a rare yet devastating condition. Multitarget mechanical thrombectomy to achieve reperfusion is challenging but still possible.

Outcome of patients with multivessel occlusion stroke after endovascular treatment

“…Previous studies also observed worse functional outcome in MVO patients. [1][2][3][4][5] A Swiss multicenter study that reviewed 6081 EVT patients found that of 21 MVO patients, only 20% reached functional independence at 90 days, fairly similar to 13% in our study. 2 A Taiwanese, multicenter study of 602 EVT patients with 11 MVO patients, reported a mortality rate of 54% at 90 days for MVO patients.…”

“…In the current literature, the reported prevalence of MVO among large vessel occlusion stroke patients ranges between 0.35% and 10.7%. [1][2][3][4][5] Importantly, when multiple vascular territories are involved, compensatory collateral circulation may be affected, leading to expedited infarction and worse functional outcome. Also, compared to single-territory infarcts, infarctions in multiple vascular territories are associated with an increased risk of recurrent stroke, and with etiologies such as cardioembolism, malignancy, and possibly coronavirus disease 2019.…”

“…Multitarget EVT has been reported in a small series of MVO patients, however, functional outcome was poor despite successful recanalization of multiple vessels. 3 Administration of intravenous alteplase (IVT) might help dissolve occlusions that cannot be reached with a thrombectomy device.…”

Mechanical thrombectomy for acute multivessel occlusions with duplicated middle cerebral artery: A case report

“…Simultaneous MVOs are rare conditions but devastating diseases, which may be encountered during MT for AIS ( 7 ). The prevalence of MVOs is 0.34–2.0% in patients with AIS who underwent MT ( 2 , 7 ).…”

“…Simultaneous MVOs are rare conditions but devastating diseases, which may be encountered during MT for AIS ( 7 ). The prevalence of MVOs is 0.34–2.0% in patients with AIS who underwent MT ( 2 , 7 ). Most simultaneous MVOs are caused by cardioembolic origin or artery-to-artery embolism ( 2 , 4 ).…”