Effect of First‐Pass Reperfusion on Outcome After Endovascular Treatment for Ischemic Stroke

Abstract

Background First‐pass reperfusion (FPR) is associated with favorable outcome after endovascular treatment. It is unknown whether this effect is independent of patient characteristics and whether FPR has better outcomes compared with excellent reperfusion (Expanded Thrombolysis in Cerebral Infarction [eTICI] 2C‐3) after multiple‐passes reperfusion. We aimed to evaluate the association between FPR and outcome with adjustment for patient, imaging, and treatment characteristics to single out the contribution of FPR. Methods and Results FPR was defined as eTICI 2C‐3 after 1 pass. Multivariable regression models were used to investigate characteristics associated with FPR and to investigate the effect of FPR on outcomes. We included 2686 patients of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Factors associated with FPR were as follows: history of hyperlipidemia (adjusted odds ratio [OR], 1.05; 95% CI, 1.01–1.10), middle cerebral artery versus intracranial carotid artery occlusion (adjusted OR, 1.11; 95% CI, 1.06–1.16), and aspiration versus stent thrombectomy (adjusted OR, 1.07; 95% CI, 1.03–1.11). Interventionist experience increased the likelihood of FPR (adjusted OR, 1.03 per 50 patients previously treated; 95% CI, 1.01–1.06). Adjusted for patient, imaging, and treatment characteristics, FPR remained associated with a better 24‐hour National Institutes of Health Stroke Scale (NIHSS) score (−37%; 95% CI, −43% to −31%) and a better modified Rankin Scale (mRS) score at 3 months (adjusted common OR, 2.16; 95% CI, 1.83–2.54) compared with no FPR (multiple‐passes reperfusion+no excellent reperfusion), and compared with multiple‐passes reperfusion alone (24‐hour NIHSS score, (−23%; 95% CI, −31% to −14%), and mRS score (adjusted common OR, 1.45; 95% CI, 1.19–1.78)). Conclusions FPR compared with multiple‐passes reperfusion is associated with favorable outcome, independently of patient, imaging, and treatment characteristics. Factors associated with FPR were the experience of the interventionist, history of hyperlipidemia, location of occluded artery, and use of an aspiration device compared with stent thrombectomy.

Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke

“…The association between FPR and 24-hour NIHSS is comparable to our results in patients with anterior circulation ischemic stroke (compared with no FPR; −45% vs −37% compared with MPR −14% vs −23%). 12 In contrast to patients with anterior circulation ischemic stroke, in patients with PCS there is no significant benefit of FPR over MPR in our results. In a previous study with a pooled analysis of patients with either anterior or posterior circulation stroke, no differences in outcome (dichotomized mRS) between the FPR and MPR group were noted.…”

Influence of the interventionist’s experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry

“…In the MR CLEAN Registry, an association was found between a higher EXPno and increased probability for first pass reperfusion. Additionally, first pass reperfusion itself was associated with an increased probability of good clinical outcome 5…”

Successful reperfusion in relation to the number of passes: comparing outcomes of first pass expanded Treatment In Cerebral Ischemia (eTICI) 2B with multiple-pass eTICI 3

“…While a previously performed MR CLEAN Registry sub-study focused on the effect of the number of passes on functional outcome and found that first-pass reperfusion was associated with favorable functional outcome,25 we went one step further and compared single pass good reperfusion with multiple pass excellent/complete reperfusion. In line with a previous descriptive analysis,6 we found that if three or more passes were necessary to achieve excellent/complete reperfusion, functional outcome was not better compared with good reperfusion in a single pass.…”