ADAPT technique in ischemic stroke treatment of M2 middle cerebral artery occlusions in comparison to M1 occlusions: Post hoc analysis of the PROMISE study

Navía, Pedro; Schramm, Peter; Fiehler, Jens

doi:10.1177/1591019919894800

Cited by 15 publications

(13 citation statements)

References 40 publications

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“…Trials and large studies enrolled few M2 occlusions, despite the fact that they comprise approximately 40% of patients with ischemic stroke and a visible Ischemic stroke occlusion on computed tomography angiography (CTA) and can lead to permanent disabilities. [11][12][13] This was understandable given the goal of trials at the time, but as stent-retrievers are now produced in smaller sizes and some aspiration catheters have been deployed for distal occlusions, the optimal technical approach for patients with M2 occlusion remains unclear and of increasing interest.…”

Section: Introductionmentioning

confidence: 99%

Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

Renieri

Valente

Dmytriw

et al. 2021

J NeuroIntervent Surg

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BackgroundM2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking.MethodsA retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques.ResultsThere were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1–6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9–44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1–24.3)) and combined technique (OR 4.6 (1.1–20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome.ConclusionStent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.

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Section: Introductionmentioning

confidence: 99%

Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

Renieri

Valente

Dmytriw

et al. 2021

J NeuroIntervent Surg

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“…6 Navia et al found that good postprocedure reperfusion (an mTICI score of 2b/3) (93% vs. 92%, p ¼ 1.00), functional independence (57% vs. 70%, p ¼ 0.18), symptomatic intracranial hemorrhage (1.6% vs. 2.7%, p ¼ 0.55), device-or procedure-related serious adverse events at 30 days (4.0% vs. 8.1%, p ¼ 0.39), and mortality at 90 days (6.6% vs. 2.7%, p ¼ 0.69) were comparable between patients with M1 and M2 occlusions. 12 In the present study, we did not compare results of endovascular treatments for M1 and M2 occlusions.…”

Section: Discussionmentioning

confidence: 82%

Aspiration thrombectomy as the first-line treatment of M2 occlusions

et al. 2020

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Purpose The aim of the present study was (i) to evaluate the safety and efficacy of aspiration thrombectomy in patients with M2 occlusions and (ii) to compare outcome of treatment of occlusion of different M2 segments. Materials and methods Between March 2016 and June 2019, 82 patients with acute ischemic stroke and isolated M2 occlusions were treated in cerebrovascular stroke center with aspiration thrombectomy as the first-line treatment. Functional outcomes of patients with different types of M2 occlusions were statistically compared. Multivariable logistic regression analysis was performed to determine the factors associated with good clinical outcome. Results The mean age was 71.9 ± 13.4 years, 47.6% were men. Aspiration thrombectomy alone was utilized in 72.5% of patients, with 27.5% of patients being treated with a combination of aspiration thrombectomy and stent retriever. At the three-month follow-up, there was no statistically significant difference in functional outcome between different types of M2 occlusions (p = 0.662), however in the underpowered analysis because of the small sample size of patients, with good clinical outcome mRS 0–2 in 50% of all treated patients. Symptomatic intracranial hemorrhage was found in 6.1% of patients. Lower age (OR 0.932, 95% CI 0.878–0.988) and lower NIHSS score upon admission (OR 0.893, 95% CI 0.805–0.991) were independent predictors of good clinical outcome. Conclusion Aspiration thrombectomy appeared to be a safe and effective first-line treatment option for patients with M2 occlusion, being the first-line option for almost three-quarters of patients.

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“…Our results are also in this range (83%), comparable to those of a recent meta-analysis (81%) [ 23 ], and higher than in the Hermes registry (71%) [ 6 ]. As far as the available literature shows, the chance for successful recanalization is equal or even higher for M2 than for M1 occlusions [ 9 , 14 , 24 , 25 ]. Compared to the STRATIS-Registry, the overall results for good clinical outcome and mortality within the GSR are less favorable, especially when considering M1 occlusions [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…However, vascular injury may be more common in smaller diameter vessels with conventional stent retrievers, and as a result, the rate of hemorrhagic complications may be higher in M2 rather than in M1 occlusions [ 9 , 11 , 12 , 13 ]. Furthermore, not all M2 occlusions are accessible using distal aspiration catheters, potentially making direct contact aspiration or a combined technique such as SAVE (stent retriever assisted vacuum-locked extraction) impossible [ 14 , 15 ].…”

Section: Introductionmentioning

confidence: 99%

Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR)

Herzberg

Dorn

Trumm

et al. 2022

JCM

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There is ongoing debate concerning the safety and efficacy of various mechanical thrombectomy (MT) approaches for M2 occlusions. We compared these for MT in M2 versus M1 occlusions. Subgroup analyses of different technical approaches within the M2 MT cohort were also performed. Patients were included from the German Stroke Registry (GSR), a multicenter registry of consecutive MT patients. Primary outcomes were reperfusion success events. Secondary outcomes were early clinical improvement (improvement in NIHSS score > 4) and independent survival at 90 days (mRS 0–2). Out of 3804 patients, 2689 presented with M1 (71%) and 1115 with isolated M2 occlusions (29%). The mean age was 76 (CI 65–82) and 77 (CI 66–83) years, respectively. Except for baseline NIHSS (15 (CI 10–18) vs. 11 (CI 6–16), p < 0.001) and ASPECTS (9 (CI 7–10) vs. 9 (CI 8–10, p < 0.001), baseline demographics were balanced. Apart from a more frequent use of dedicated small vessel stent retrievers (svSR) in M2 (17.4% vs. 3.0; p < 0.001), intraprocedural aspects were balanced. There was no difference in ICH at 24 h (11%; p = 1.0), adverse events (14.4% vs. 18.1%; p = 0.63), clinical improvement (62.5% vs. 61.4 %; p = 0.57), mortality (26.9% vs. 22.9%; p = 0.23). In M2 MT, conventional stent retriever (cSR) achieved higher rates of mTICI3 (54.0% vs. 37.7–42.0%; p < 0.001), requiring more MT-maneuvers (7, CI 2–8) vs. 2 (CI 2–7)/(CI 2–2); p < 0.001) and without impact on efficacy and outcome. Real-life MT in M2 can be performed with equal safety and efficacy as in M1 occlusions. Different recanalization techniques including the use of svSR did not result in significant differences regarding safety, efficacy and outcome.

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ADAPT technique in ischemic stroke treatment of M2 middle cerebral artery occlusions in comparison to M1 occlusions: Post hoc analysis of the PROMISE study

Cited by 15 publications

References 40 publications

Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

Aspiration thrombectomy as the first-line treatment of M2 occlusions

Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR)

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