Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

Salahuddin, Hisham; Espinosa, Aixa; Buehler, Mark; Khuder, Sadik A.; Khan, Abdur Rahman; Tietjen, Gretchen E.; Zaidi, Syed; Jumaa, Mouhammad A.

doi:10.1159/000477589

Cited by 10 publications

(6 citation statements)

References 45 publications

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“…The estimated incidence of M2 occlusions in the population is 7 per 100 000, with M2 segment strokes accounting for approximately 4.2% of all AIS . Multiple studies and registries have attempted to explore outcomes in patients with M2 and M3 occlusions treated with ECR . To date, no randomised control studies have been published for this M2/M3 subgroup, however, as described below, retrospective studies demonstrated efficacy of treatment with good recanalisation rates and good patient outcomes comparable to many studies investigating ECR in more proximal occlusions.…”

Section: Introductionmentioning

confidence: 99%

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Findakly

Maingard

Phan

et al. 2020

Internal Medicine Journal

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Background: Endovascular clot retrieval (ECR) is the standard of care for acute ischaemic stroke due to large vessel occlusion. However, isolated occlusion of the M2 segment of the middle cerebral artery (MCA) was underrepresented in the landmark trials.Aims: Given the potential treatment benefit associated with M2 MCA occlusions, we aimed to evaluate the outcome of patients undergoing ECR for M2 occlusion. Methods:We conducted a systematic review and meta-analysis of the available literature that included patients with M2 MCA occlusions who underwent ECR. Successful reperfusion was defined as a treatment in cerebral ischaemia score of 2b-3. Good outcome was defined as a modified Rankin Scale score ≤ 2. We also analysed complications such as postprocedure symptomatic intracranial haemorrhage and mortality at 3 months.Results: Fifteen studies including 1105 patients with isolated M2 occlusions were analysed. Successful reperfusion occurred in 75.4% (95% confidence interval (CI) 67.7-84.1%) of patients; good outcome was observed in 58.3% (95% CI 51.7-63.8% of patients. The rate of symptomatic intracranial haemorrhage was 5.1% (95% CI 4.2-8.3%), and 3-month mortality rate was 12.2% (95% CI 10.4-16.3%). Conclusion:The outcomes of ECR treatment of M2 occlusions are favourable, with good safety profile. Comparison to medical management from large registries or randomised controlled trials is warranted.

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Section: Introductionmentioning

confidence: 99%

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Findakly

Maingard

Phan

et al. 2020

Internal Medicine Journal

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“…7,9,10,15 A recent subanalysis from the ARISE II trial (Analysis of Revascularization in Ischemic Stroke With EmboTrap) showed no difference in rates of reperfusion (92.1% versus 91.2%, P=1.0), good outcome (70.2% versus 69.7%, P=0.946), and mortality (6.6% versus 10.5%, P=0.37) in M1 versus M2 patients, respectively 7. The MR CLEAN Registry reported data from 244 M2 MT and 759 M1 sICH Although we found no difference in rates of good functional outcomes in M1 and M2 patients, M2 patients in STRATIS had a significantly higher rate of sICH (4% versus 1%, P=0.01).…”

mentioning

confidence: 99%

“…6 Data on M2 occlusions in the United States is limited to small cohorts and several meta-analyses which demonstrated the safety and feasibility of MT. [5][6][7][8][9][10][11] The recent American Heart Association guidelines for early management of acute ischemic stroke acknowledged this paucity of data and recommended treatment in carefully selected patients within the first 6 hours from symptoms onset. 12 Moreover, the time to treatment effect in association with functional outcomes remains unknown in this population.…”

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confidence: 99%

Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry

Jumaa

Castonguay

Salahuddin

et al. 2021

Stroke

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Background and Purpose: The safety and benefit of mechanical thrombectomy in the treatment of acute ischemic stroke patients with M2 segment middle cerebral artery occlusions remain uncertain. Here, we compare clinical and angiographic outcomes in M2 versus M1 occlusions in the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) Registry. Methods: The STRATIS Registry was a prospective, multicenter, nonrandomized, observational study of acute ischemic stroke large vessel occlusion patients treated with the Solitaire stent-retriever as the first-choice therapy within 8 hours from symptoms onset. Primary outcome was defined as functional disability at 3 months measured by dichotomized modified Rankin Scale. Secondary outcomes included reperfusion rates and rates of symptomatic intracranial hemorrhage. Results: A total of 984 patients were included, of which 538 (54.7%) had M1 and 170 (17.3%) had M2 occlusions. Baseline demographics were well balanced within the groups, with the exception of mean baseline National Institutes of Health Stroke Scale score which was significantly higher in the M1 population (17.3±5.5 versus 15.7±5.0, P ≤0.001). No difference was seen in mean puncture to revascularization times between the cohorts (46.0±27.8 versus 45.1±29.5 minutes, P =0.75). Rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2b) were similar between the groups (91% versus 95%, P =0.09). M2 patients had significantly increased rates of symptomatic ICH at 24 hours (4% versus 1%, P =0.01). Rates of good functional outcome (modified Rankin Scale score of 0–2; 58% versus 59%, P =0.83) and mortality (15% versus 14%, P =0.75) were similar between the 2 groups. There was no difference in the association of outcome and onset to groin puncture or onset to successful reperfusion in M1 and M2 occlusions. Conclusions: In the STRATIS Registry, M2 occlusions achieved similar rates of successful reperfusion, good functional outcome, and mortality, although increased rates of symptomatic ICH were demonstrated when compared with M1 occlusions. The time dependence of benefit was also similar between the 2 groups. Further studies are needed to understand the benefit of mechanical thrombectomy for M2 occlusions. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239640.

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“…20 MT was suggested to provide similar safe access with high recanalization rates and functional independence between MeVO, which is mainly M2 occlusion, and LVO of M1. [4][5][6]21 Conversely, the tendency for an increased risk of symptomatic hemorrhage had been controversial. 22,23 Based on these circumstances, we focused on MeVO with thrombus migration after MT and reported the outcomes of intraarterial UK.…”

Section: Discussionmentioning

confidence: 99%

“…MT for acute ischemic stroke with medium vessel occlusion (MeVO) was reported to be angiographically effective and safe. [4][5][6] The patient status and vessel condition in MeVO with thrombus migration are different from those in direct MeVO. Moreover, the role of MT for MeVO after LVO remains unclear.…”

Section: Introductionmentioning

confidence: 99%

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke

et al. 2021

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Background Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. Methods We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0–2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. Results The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group ( p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group ( p < 0.05). Conclusion The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

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Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

Cited by 10 publications

References 45 publications

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke

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