Anterior cerebral artery embolism during thrombectomy increases disability and mortality

Chalumeau, Vanessa; Blanc, Raphaël; Redjem, Hocine; Cicciò, Gabriele; Smajda, Stanislas; Desilles, Jean‐Philippe; Botta, D.; Escalard, Simon; Boisseau, William; Maïer, Benjamin; Labreuche, Julien; Obadia, Mickaël Alexandre; Piotin, Michel; Mazighi, Mikaël

doi:10.1136/neurintsurg-2018-013793

Cited by 42 publications

(33 citation statements)

References 29 publications

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“…[41] Clot debris may migrate downstream with antegrade blood flow and can cause distal embolization in previously affected or unaffected vascular territories, potentially blocking collateral flow to salvageable tissue. [42,43] If thrombus fragments occlude large arterial branches, then remedial strategies such as further thrombectomy attempts or intra-arterial thrombolysis can be employed. However, in vitro studies show that the majority of clot fragments generated during thrombectomy are very small (<10 μm), occluding microvessels.…”

Section: Distal Embolizationmentioning

confidence: 99%

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Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes

Zhao

Dornbos

et al. 2020

Brain Circ

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While several large pivotal clinical trials recently revealed a substantial benefit of endovascular thrombectomy for acute ischemic stroke (AIS) caused by large-vessel occlusion, many patients still experience mediocre prognosis. Enlargement of the ischemic core, failed revascularization, incomplete reperfusion, distal embolization, and secondary reperfusion injury substantially impact the salvaging of brain tissue and the functional outcomes of AIS. Here, we propose novel concept of "Multiphase Adjuvant Neuroprotection" as a new paradigm that may help guide our search for adjunctive treatments to be used together with thrombectomy. The premise of multiphase adjuvant neuroprotection is based on the diverse and potentially nonoverlapping pathophysiologic mechanisms that are triggered before, during, and after thrombectomy therapies. Before thrombectomy, strategies should focus on preventing the growth of the ischemic core; during thrombectomy, improving recanalization while reducing distal embolization and maximizing reperfusion are of significant importance; after reperfusion, strategies should focus on seeking targets to reduce secondary reperfusion injury. The concept of multiphase adjuvant neuroprotection, wherein different strategies are employed throughout the various phases of clinical care, might provide a paradigm to minimize the final infarct size and improve functional outcome in AIS patients treated with thrombectomy. With the success of thrombectomy in selected AIS patients, there is now an opportunity to revisit stroke neuroprotection. Notably, if the underlying mechanisms of these neuroprotective strategies are identified, their role in the distinct phases will provide further avenues to improve patient outcomes of AIS.

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Section: Distal Embolizationmentioning

confidence: 99%

“…[44,45] Although not detectable on angiogram, these distal microemboli translate to enlargement of ischemic core and poor functional outcomes. [42,43,46]…”

Section: Distal Embolizationmentioning

confidence: 99%

Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes

Zhao

Dornbos

et al. 2020

Brain Circ

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“…Given rapid expansion of EVT for AIS and increasing interest in revascularizing patients with large baseline ischemic core, periprocedural management of these physiologic factors may be of particular importance for optimal clinical outcome. 11–13…”

Section: Introductionmentioning

confidence: 99%

Physiologic predictors of collateral circulation and infarct growth during anesthesia – Detailed analyses of the GOLIATH trial

Raychev

Liebeskind

Yoo³

et al. 2019

J Cereb Blood Flow Metab

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Collateral circulation plays a pivotal role in acute ischemic stroke due to large vessel occlusion (LVO) and may be affected by multiple variables during sedation for endovascular therapy (EVT). We conducted detailed analyses of the GOLIATH trial to identify predictors of collateral circulation grade and infarct growth. We also modified the ASITN collateral grading scale and sought to determine its impact on clinical outcome and infarct growth. Multivariable analysis was used to identify predictors of collaterals and infarct growth. Ordinal analysis demonstrated nominal, but non-significant association between modified ASITN scale and infarct growth. Among all analyzed baseline clinical and procedural variables, the most significant predictors of infarct growth at 24 h were phenylephrine dose (estimate 6.78; p = 0.014) and baseline infarct volume (estimate 0.93; p = 0.03). The most significant predictors of worse collateral grade were mean arterial pressure (MAP) <70 mmHg (OR 0.35; p = 0.048) and baseline infarct volume (OR 0.96; p = 0.003). Hypotension during sedation for EVT for LVO negatively impacts collateral circulation, while higher pressor dose is a strong predictor of infarct growth. Avoidance of anesthesia-induced hypotension and consequent need for pressor therapy may prevent collateral failure and minimize infarct growth.

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“…Another notable difference is that the BGC is used in the ARTS and PROTECTPLUS techniques, whereas the large guiding sheath is recommended for the CAPTIVE, CASPER and SAVE techniques. It should be addressed that limited use of BGC may be due to the size incompatibility between BGCs and the principal chosen technique 5) . Despite these variations, all techniques achieved successful recanalization (modified TICI ≥2b) in nearly 100% of the cases, according to the prior retrospective studies.…”

Section: Balloon Guide Catheter In Stent Re-triever Thrombectomymentioning

confidence: 99%

Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy

Chueh

Kang

Kim

et al. 2020

J Korean Neurosurg Soc

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Proximal flow control achieved with a balloon guide catheter (BGC) during endovascular treatment of acute ischemic stroke is reviewed in this article. In clinical practice, BGCs offer a multi-faceted approach for clot retrieval by creating proximal flow arrest, reducing embolic burden, and shortening procedure time. Evaluation of frontline thrombectomy procedures with BGCs revealed advantages of combined use over the conventional guide catheter (CGC), notably in the significant reduction of distal emboli to both the affected and previously unaffected territories. Recently, new measures of early and complete reperfusion at first thrombectomy pass have been identified as independent predictors of improved outcomes, which were consistently demonstrated with use of BGC as a safe and effective option to minimize number of passes during intervention. Prior randomized controlled trials reported the positive correlation between BGC-treated patients and a lower risk of mortality as well as shortened procedure time. While BGC use is more common in stent retriever-mediated mechanical thrombectomy, preliminary data has shown the potential benefit of device application during contact aspiration thrombectomy to achieve successful recanalization. However, the question of which major endovascular strategy reigns superior as a frontline remains to be answered. Along with clinical case assessments, BGC performance during in-vitro simulation was analyzed to further understand mechanisms for optimization of thrombectomy technique.

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Anterior cerebral artery embolism during thrombectomy increases disability and mortality

Abstract: Procedural ACAE was not an uncommon condition, and was associated with increased mortality and disability rates, regardless of the success of reperfusion.

Cited by 42 publications

References 29 publications

Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes

Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes

Physiologic predictors of collateral circulation and infarct growth during anesthesia – Detailed analyses of the GOLIATH trial

Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy

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