Importance of Delayed Reperfusions in Patients With Incomplete Thrombectomy

Abstract

Background: There is paucity of data regarding the effects of delayed reperfusion (DR) on clinical outcomes in patients with incomplete reperfusion following mechanical thrombectomy. We hypothesized that DR has a strong association with clinical outcome in patients with incomplete reperfusion after mechanical thrombectomy (expanded Thrombolysis in Cerebral Infarction, 2a–2c). Methods: Single-institution’s stroke registry retrospective analysis of patients admitted from February 2015 to December 2020. DR was defined as the absence of any perfusion delay on ≈24-hour contrast-enhanced follow-up perfusion imaging, whereas persistent perfusion deficit denotes a perfusion delay corresponding to the catheter angiographic deficit directly after the intervention. The association of perfusion outcome (DR versus persistent perfusion deficit) with the occurrence of new infarcts and 90-day functional independence (modified Rankin Scale score 0–2) was evaluated using logistic regression analyses. Comparison of predictive accuracy was evaluated by calculating area under the curve for models with and without perfusion outcome. Results: In 566 patients (mean age 74, 49.6% female), new infarcts in the incomplete reperfusion areas were less common in DR versus persistent perfusion deficit patients (small punctiform: 17.1% versus 25%, large confluent: 7.9% versus 63.2%; P =0.001). After adjustment for confounders, DR was a strong predictor of functional independence (adjusted odds ratio, 2.37 [95% CI 1.34–4.23]). There was a significant improvement in predictive accuracy of functional independence when perfusion outcome was added to expanded Thrombolysis in Cerebral Infarction alone (area under the curve 0.57 versus 0.62, P =0.01). Conclusions: Occurrence of DR is closely associated with tissue outcome and functional independence. DR may be an independent prognostic parameter, suggesting it as a potential outcome surrogate for medical rescue therapies.

Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion

“…At the macrocirculatory level, the treatment benefit of IVT may be explained by delayed reperfusion after MT has been discontinued with failed or only partial recanalization of the large-vessel occlusion. A recent study 32 described the phenomenon of delayed reperfusion in patients with stroke who underwent incomplete mechanical recanalization, largely due to persisting distal occlusions, and its favorable association with both tissue outcome and functional independence. To date, empirical evidence of delayed reperfusion and its clinical benefit in patients with unsuccessful MT is missing.…”

Prediction of delayed reperfusion in patients with incomplete reperfusion following thrombectomy

“…The model's discrimination is reported with C-statistics (Harrell's concordance), which varies from Details on grading and evaluation of perfusion imaging outcome have been described previously. 8 In short, TTP and Tmax perfusion maps were evaluated as they had the highest sensitivity. Final angiography runs are displayed with high contrast to emphasize the capillary phase deficits.…”

“…Details on grading and evaluation of perfusion imaging outcome have been described previously. 8 Only large-vessel occlusion anterior circulation AIS patients who had final eTICI grade 2a-2c and available 24 ± 12-h follow-up perfusion imaging were included in the final cohort (Supplemental Figure I).…”

“…[12][13][14][15][16][17] Taking these risks may be unwarranted in patients who are likely to develop DR, which is associated with lack of infract growth and a comparable outcome to patients with primary eTICI3 reperfusion. 8 Therefore, a better prediction of what patients show a naturally benign disease progression may be of value. While the present model offers fair prediction of perfusion imaging outcomes, it is not clear if there may still be a benefit of immediate complete reperfusion even in patients which show DR.…”

“…6,7 Specifically, more than 50% of patients with incomplete reperfusion show spontaneous delayed reperfusion (DR) at 24 h, which is associated with a favorable clinical course almost identical to TICI3 patients and minimal infarct growth. 8 While even in these patients there may be a benefit of additional reperfusion attempts, the benefit is certainly smaller than in patients with a persistent perfusion deficit (PPD) on follow-up imaging. For the complex decisions regarding proceeding with additional reperfusion attempts or stopping the procedure, it may be helpful to know if the patient is more likely to have a favorable (i.e.…”