Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR Collaboration

Anadani, Mohammad; Alawieh, Ali; Chalhoub, Reda M; Jabbour, Pascal; Starke, Robert M.; Arthur, Adam S; Goyal, Nitin; Wolfe, Stacey Quintero; Fargen, Kyle M; Grossberg, Jonathan A; Howard, Brian M.; Leacy, Reade De; Kellner, Christopher P.; Kan, Peter; Dumont, Travis M.; Rai, Ansaar; Osbun, Joshua W.; Crosa, Roberto; Maier, Ilko; Nascimento, Fábio A.; Park, Min; Levitt, Michael R.; Fragata, Isabel; Matouk, Charles; Crowley, R. Webster; Chowdhry, Shakeel A.; Ogilvy, Christopher S.; Mokin, Maxim; Yoo, Albert J.; Williamson, Richard; Webb, Sharon; Psychogios, Marios; Kasab, Sami Al; Spiotta, Alejandro M

doi:10.1016/j.wneu.2021.04.136

Cited by 26 publications

(15 citation statements)

References 24 publications

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“…7,17,18 In our study, both first-line aspiration and stent retriever thrombectomy led to a similarly high rate of FPE that was associated with faster reperfusion times and early neurological improvement in this international multicenter cohort. Corroborating the post hoc analysis of the ASTER trial, 18 our finding translates the angiographic effectiveness of thrombectomy from proximal to distal occlusions with currently available devices and adds to the growing body of literature suggesting thrombectomy as a reasonable therapy option in selected cases with distal arterial occlusions 19–22 Accordingly, the choice of the first-pass device of our study was in line with the distribution of a recent international multidisciplinary survey observing that the preference of stent retrievers with combined aspiration is slightly favored for endovascular treatment of DMVOs in the posterior circulation. 23 However, the role of additional aspiration in stent retriever thrombectomy for DMVOs will need to be further assessed with the development of new devices dedicated for the distal medium-sized arterial vasculature and the current ongoing debate on combined aspiration versus single approaches for LVO stroke.…”

Section: Discussionsupporting

confidence: 70%

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

Meyer

Stracke

Wallocha

et al. 2022

Stroke

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BACKGROUND: The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation. METHODS: TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events. RESULTS: A total of 141 patients met the inclusion criteria and were treated endovascularly for primary isolated DMVO in the P2 (84.4%, 119) or P3 segment (15.6%, 22) of the posterior cerebral artery. The median age was 75 (IQR, 62–81), and 45.4% (64) were female. The initial reperfusion strategy was aspiration only in 29% (41) and stent retriever in 71% (100), both achieving similar first-pass effect rates of 53.7% (22) and 44% (44; P =0.297), respectively. There were no significant differences in early neurological improvement (aspiration: 64.7% versus stent retriever: 52.2%; P =0.933) and modified Rankin Scale rates (modified Rankin Scale score 0–1, aspiration: 60.5% versus stent retriever 68.6%; P =0.4). In multivariable logistic regression analysis, the time from groin puncture to recanalization was associated with the first-pass effect (adjusted odds ratio, 0.97 [95% CI, 0.95–0.99]; P <0.001) that in turn was associated with early neurological improvement (aOR, 3.27 [95% CI, 1.16–9.21]; P <0.025). Symptomatic intracranial hemorrhage occurred in 2.8% (4) of all cases. CONCLUSIONS: Both first-pass aspiration and stent retriever thrombectomy for primary isolated posterior circulation DMVO seem to be safe and technically feasible leading to similar favorable rates of angiographic and clinical outcome.

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Section: Discussionsupporting

confidence: 70%

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

Meyer

Stracke

Wallocha

et al. 2022

Stroke

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“…There were no significant differences in terms of patient cardiovascular risk factors. Both groups had no significant discrepancy in baseline NIHSS [13 (10-18) for ENI+ vs. 11 (8)(9)(10)(11)(12)(13)(14)(15) for ENI-, p = 0.105]. ENI+ patients showed a significantly smaller ischemic core volume on baseline imaging [0.3 ml (0.3-3.2) vs. 4 ml (0.3-8), p = 0.045] and a higher rate of left-sided occlusions (71 vs. 43%, p = 0.036).…”

Section: Resultsmentioning

confidence: 99%

“…In contrast, strokes due to distal, medium vessel occlusions (DMVO) have been understudied. Yet, recent advancements in retrieval devices and aspiration technology have allowed more and more centers to add thrombectomy to their therapeutic arsenal when treating DMVOs (7)(8)(9)(10)(11). While there are some data on predictors of a good clinical outcome (9,12), the effect of ENI remains unstudied in this population.…”

Section: Introductionmentioning

confidence: 99%

Early Neurological Improvement Predicts Clinical Outcome After Thrombectomy for Distal Medium Vessel Occlusions

et al. 2022

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Background and PurposeGood clinical outcome predictors have been established in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). An early neurological improvement (ENI), defined as a reduction of ≥8 on the National Institutes of Health Stroke Scale (NIHSS), compared with the baseline score or an NIHSS of 0 or 1 at 24 h after MT, is a strong predictor of favorable outcome. We aimed to study the impact of ENI after MT for distal medium vessel occlusions (DMVO).MethodsWe retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center. We compared clinical outcomes between patients with DMVO stratified by ENI. Multivariate analyses were performed to determine the impact of ENI on good 90-day outcome (modified Rankin scale of 0–2) and identify factors contributing to ENI.ResultsBetween January 2018 and January 2021, 61 patients underwent an MT for an AIS with a primary DMVO. An ENI was seen in 24 (39%) patients (ENI+). Outcomes were significantly better in ENI+ patients, with 83% achieving a good outcome at 3 months vs. 43% for patients without ENI (ENI–; p = 0.019). ENI was an independent predictive factor of good clinical outcome even after adjusting for potential confounding factors [odds ratio 12.49 (1.49–105.01), p = 0.020]. The use of intravenous tissue plasminogen activator [IVtPA; Odds-ratio 6.59 (1.82–23.89), p = 0.004] was a positive predictor of ENI.ConclusionENI at day 1 following MT for DMVO stroke is a strong independent predictor of good to excellent 3-month clinical outcome.

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“…This is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR) 2 13. STAR is an ongoing registry that enrolls adult patients with LVO treated with MT.…”

Section: Methodsmentioning

confidence: 99%

Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct

Anadani

Almallouhi

Maier³

et al. 2023

J NeuroIntervent Surg

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BackgroundThe safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.MethodsThis is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.ResultsA total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0–2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.ConclusionPretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

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Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR Collaboration

Cited by 26 publications

References 24 publications

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

Early Neurological Improvement Predicts Clinical Outcome After Thrombectomy for Distal Medium Vessel Occlusions

Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct

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