Predicting Death After Thrombectomy in the Treatment of Acute Stroke

Abstract

Introduction: Treatments for acute stroke have significantly improved in the past decade, with emergent thrombectomy emerging as the standard of care. Despite these advancements, death after successful thrombectomy continues to pose a significant problem. Identifying patients least likely to benefit from thrombectomy would improve use of a limited resource and management of patient expectations. Method: We retrospectively reviewed the medical records of patients who underwent emergent thrombectomy of either anterior or posterior circulation strokes between January 2012 and January 2017. Relevant patient clinical data was collected and analyzed in a multivariable regression with a primary outcome of death at 90 days. Results: A total of 134 patients underwent emergent endovascular thrombectomy during the study period; sufficient clinical data was available in 111 of the them. Of these, 42 patients died during the 90 day post-procedural period and 69 patients survived this period. The mean NIHSS score at presentation was 14.9 in surviving patients and 19.6 in non-surviving patients (p < 0.002). Surviving patients were less likely to have a history of cancer (4.4% vs. 26.2%, p < 0.002), achieved higher rates of revascularization (78.3% vs. 50.0%, p < 0.003), had a lower rate of hemorrhagic conversion (21.7% vs. 47.6%, p < 0.004), and experienced fewer technical complications during their treatment (7.4% vs. 26.2%, p < 0.01). Overall, there were 16 intraprocedural complications and no procedural deaths. Conclusion: As emergent thrombectomy for the treatment of acute stroke becomes more prevalent, appropriate patient selection will be crucial in the utilization of a limited and costly intervention. Death within 90 days after thrombectomy appears to be more prevalent among patients with higher NIHSS at presentation, those with postprocedural hemorrhage or intraprocedural complications, and those with a history of cancer.

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

“…28 It should be noted that the majority of deaths in our study occurred in patients who were at least 80 years old and mostly with pre-existing conditions. Since it is known that octogenarians are at greater risk of mortality, 29 the safety profile of the Tigertriever 13 device may be higher in younger patients.…”

A Glutamate N-Methyl-d-Aspartate (NMDA) Receptor Subunit 2B–Selective Inhibitor of NMDA Receptor Function with Enhanced Potency at Acidic pH and Oral Bioavailability for Clinical Use

“…Cerebral ischemia, stroke, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI) all produce substantial neuronal death that, if not fatal, can create lasting disabilities with significant societal impact. Few therapeutic options are currently available for stroke apart from dissolution of the vessel clot in a subset of patients (Turner et al, 2020), or clot retrieval when blockages occur in large arteries (Awad et al, 2020). SAH can be treated with Ca 2+ channel blockers (Carlson et al, 2020), however there remains considerable opportunity for improved therapies as a significant fraction of patients progress to subsequent ischemic episodes and death (Longstreth et al, 1993).…”

Mortality after large artery occlusion acute ischemic stroke

“…Moreover, while good revascularization may improve survival in the thrombectomy population 24 – 26 , our study demonstrated that TICI 2b-3 revascularization, compared to no EVT, produced a survival benefit. This may seem intuitive, as patients receiving no EVT may be categorized into the “no revascularization” or “poor revascularization” group of a thrombectomy-only study.…”

“…Good reperfusion, defined as achieving TICI 2b-3, has been associated with improved functional outcome after LAO stroke 29 , 30 and may improve survival in the subset of LAO patients that are treated with EVT 24 – 26 . Our study demonstrated that compared to no EVT, good revascularization improved odds of survival.…”