Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment

Abstract

Background and Purpose-Preinterventional reperfusion before endovascular treatment (ET) is a benefit of bridging with intravenous tPA (tissue-type plasminogen activator). However, detailed data on reperfusion quality and rates of obviating ET in a cohort of patients with immediate access to ET is lacking. Purpose of this analysis was to evaluate prevalence and quality of preinterventional reperfusion in mothership patients. Methods-All mothership patients (n=627) from a prospective registry subjected to angiography with an intention to perform ET were reviewed. Preinterventional change of occlusion site (COS) was categorized into COS with Thrombolysis in Cerebral Infarction (TICI) 0/1, COS with TICI ≥2a, COS with TICI ≥2b, and COS with perfusion worsening. Predictors and clinical relevance were evaluated using multivariable logistic regression and results are displayed as adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI). Results-Prevalence of COS in all patients was 10.7% (95% CI, 8.3%-13.1%), subdividing into 2.7% COS with TICI 0/1, 6.2% COS with ≥TICI 2a (including 2.9% with TICI ≥2b), and 1.8% COS with perfusion worsening. Factors related to COS with ≥TICI 2a were intravenous tPA (aOR, 11.98; 95% CI, 4.5-31.6), cardiogenic thrombus origin (aOR, 2.3; 95% CI, 1.1-4.6), and thrombus length (aOR per 1 mm increase 0.926; 95% CI, 0.87-0.99). Additional ET was performed despite COS with ≥TICI 2a in 51.3%. COS with ≥TICI 2a showed a tendency for favorable outcomes (modified Rankin Scale, ≤2; aOR, 2.65; 95% CI, 0.98-7.17). Rates of COS with ≥TICI 2a were particularly low in internal carotid artery and proximal M1 occlusions (2.2%; 95% CI, 0.9%-5%), where intravenous tPA was associated with perfusion worsening (aOR, 4.33; 95% CI, 1.12-16.80). Conclusions-Prevalence of preinterventional reperfusion is non-negligible in patients with direct access to ET and is clearly favored by intravenous tPA treatment. However, it is often incomplete and often requires additional ET. Preinterventional reperfusion of internal carotid artery and proximal M1 occlusions is rare and usually of low quality, where intravenous tPA may also promote perfusion worsening.

Thrombus Migration Paradox in Patients With Acute Ischemic Stroke

“…13,16,19,20 However, this study showed a lower incidence of thrombus resolution, which may be the result of a difference in definition; we defined thrombus resolution as complete recanalization before the intervention. 16,25 While the association of IVT and changes in thrombus location has been demonstrated, 20 especially in patients with preinterventional reperfusion, 25,26 the association was not present in other thrombus migration studies. 13,16 Our study found that in patients treated with IVT, both thrombus migration and resolution were more frequent.…”

“…Kaesmacher et al 13 included patients with both direct (angiographic) and indirect evidence of thrombus migration by evaluating perfusion deficits within the lenticulostriate artery territory. 26 In our study, only direct evidence was used. The association between thrombus migration and a lower chance of successful reperfusion was also previously reported.…”

“…The association between thrombus migration and a lower chance of successful reperfusion was also previously reported. 13,26…”

Functional Outcome Prediction in Ischemic Stroke: A Comparison of Machine Learning Algorithms and Regression Models

“…Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV tPA Using Serial CT Angiography (INTERRSeCT) (13) INTERRSeCT is a prospective multi-center hospital-based cohort of patients treated with intravenous alteplase comparing the rates of early recanalization in 684 patients. Patient eligibility included the following: presentation to the emergency department with symptoms consistent with ischemic stroke 12 h from last known well, age at least 40 years, and a baseline CTA (before alteplase bolus, if given) with evidence of a symptomatic intracranial thrombus.…”

“…The primary radiological outcome was recanalization, while the primary clinical outcome was functional independence, as measured by the mRS (range, 0 [no symptoms] to 6 [death]) at 90 days. Details about this study have been published elsewhere (13). A subset of 507 patients were included in this study, and the rest of the patients were excluded for being a participant in the PROVE-IT study.…”