Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes

Tomsick, Thomas A.; Carrozzella, Janice; Foster, Lydia D; Hill, Michael D.; Kummer, Rüdiger von; Goyal, Mayank; Demchuk, Andrew M.; Khatri, Pooja; Palesch, Yuko Y.; Broderick, Joseph P.; Yeatts, Sharon D.; Liebeskind, David S

doi:10.3174/ajnr.a4979

Cited by 31 publications

(32 citation statements)

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“…With distal M2 branches tortuosity leads to a theoretical increased risk of vessel perforation and dissection . Five studies commented on findings of vessel perforation and/or dissection in their results of complications, with five patients experiencing a vessel perforation and a further two experiencing a vessel dissection. The remaining studies failed to comment specifically on the aetiology of post procedural haemorrhage.…”

Section: Discussionmentioning

confidence: 99%

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Findakly

Maingard

Phan

et al. 2020

Internal Medicine Journal

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Background: Endovascular clot retrieval (ECR) is the standard of care for acute ischaemic stroke due to large vessel occlusion. However, isolated occlusion of the M2 segment of the middle cerebral artery (MCA) was underrepresented in the landmark trials.Aims: Given the potential treatment benefit associated with M2 MCA occlusions, we aimed to evaluate the outcome of patients undergoing ECR for M2 occlusion. Methods:We conducted a systematic review and meta-analysis of the available literature that included patients with M2 MCA occlusions who underwent ECR. Successful reperfusion was defined as a treatment in cerebral ischaemia score of 2b-3. Good outcome was defined as a modified Rankin Scale score ≤ 2. We also analysed complications such as postprocedure symptomatic intracranial haemorrhage and mortality at 3 months.Results: Fifteen studies including 1105 patients with isolated M2 occlusions were analysed. Successful reperfusion occurred in 75.4% (95% confidence interval (CI) 67.7-84.1%) of patients; good outcome was observed in 58.3% (95% CI 51.7-63.8% of patients. The rate of symptomatic intracranial haemorrhage was 5.1% (95% CI 4.2-8.3%), and 3-month mortality rate was 12.2% (95% CI 10.4-16.3%). Conclusion:The outcomes of ECR treatment of M2 occlusions are favourable, with good safety profile. Comparison to medical management from large registries or randomised controlled trials is warranted.

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Section: Discussionmentioning

confidence: 99%

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Findakly

Maingard

Phan

et al. 2020

Internal Medicine Journal

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“…The core lab defined M2 as the continuation of the distal M1 trunk beyond a holotemporal or posterior temporal branch. 22 The target vessel was defined by the most proximal face of the clot. Patients with tandem occlusions were excluded.…”

Section: Introductionmentioning

confidence: 99%

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

2019

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Background/purpose The benefit of endovascular thrombectomy in acute ischemic stroke (AIS) therapy of proximal large vessel occlusions (LVO) is established. However, there are few prospective studies evaluating the use of a direct aspiration first pass technique in distal vessel occlusions. This post hoc analysis of the PROMISE study examines the safety and effectiveness of the Penumbra System with the ACE68 and ACE64 Reperfusion Catheters for aspiration thrombectomy in the M1 and M2 segments of the middle cerebral artery. Methods PROMISE is a prospective, multicenter study that enrolled 204 patients with anterior circulation LVO AIS-treated frontline with ACE68/ACE64 catheters. We compared clinical and angiographic outcomes, complications, and mortality in patients with M1 and M2 occlusions. The association of M1 and M2 location and functional independence or mTICI 2b-3 reperfusion was described in univariable and multivariable analyses. Results One hundred sixty-one patients (124 M1 and 37 M2 locations) met the study criteria. Post procedure mTICI 2b-3 reperfusion (93% vs. 92%, p = 1.00), functional independence (57% vs. 70%, p = 0.18), symptomatic intracranial hemorrhage (1.6% vs. 2.7%, p = 0.55), device- or procedure-related serious adverse events at 30 days (4.0% vs. 8.1%, p = 0.39), and mortality at 90 days (6.6% vs. 2.7%, p = 0.69) were comparable between M1 and M2 occlusions. In multivariable analysis, lower age, lower baseline NIHSS, and shorter time from onset to admission were independent predictors of functional independence. Conclusions For frontline aspiration thrombectomy of stroke, use of large-bore ACE68/ACE64 catheters for treatment of M2 occlusions appeared as safe and effective as for M1 occlusions.

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“…After detailed evaluation, 12 studies [ 8 , 9 , 20 - 30 ] were included for assessment ( Supplementary Table 1 ), including 835 cases of distal occlusions of the MCA (predominantly M2 occlusions). Results for contact aspiration were reported in 6 studies [ 9 , 20 , 21 , 24 , 25 , 30 ] whilst stent-retrieval outcomes were reported in 10 studies [ 8 , 9 , 21 - 24 , 26 - 29 ]. Out of the 835 included cases, there were 223 patients in the contact aspiration group and 612 patients in the stent-retrieval group.…”

Section: Resultsmentioning

confidence: 99%

“…Varying anatomical complexity, such as branching and tortuosity, could not be accounted for in this meta-analysis and has the potential to contribute to the reduced effectiveness of mechanical thrombectomy. There was also a lack of homogeneity in terms of definition of M2 used in the included studies (Supplementary Table 2 ), and there is prior evidence that M2 segment definition and occlusion location can lead to differences in reported revascularization rates and good outcomes [ 29 ]. The use of general anesthesia versus conscious sedation has also been shown to have a significant influence on clinical outcome in large vessel occlusions; however, we were unable to test this in our meta-analysis.…”

Section: Discussionmentioning

confidence: 99%

Contact Aspiration versus Stent-Retriever Thrombectomy for Distal Middle Cerebral Artery Occlusions in Acute Ischemic Stroke: Meta-Analysis

et al. 2018

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PurposeThe evidence for endovascular therapy and choice of technique in distal middle cerebral artery (MCA) M2 segment occlusions in acute ischemic stroke remains controversial. We aimed to conduct a systematic review and meta-analysis primarily comparing reperfusion rates of stent-retrieval versus contact aspiration for M2 occlusions.Materials and MethodsStudy selection included cohorts of patients with distal MCA occlusions in acute ischemic strokes treated with an endovascular approach including stent-retrieval or contact aspiration. Twelve studies were selected for meta-analysis for a total of 835 cases. Meta-analysis by proportions was conducted on parameters including baseline and procedural characteristics, thrombolysis in cerebral infarction (TICI) 2b–3 outcomes, and 90-day modified Rankin scale (mRS) outcomes.ResultsHypertension and hyperlipidemia were more prevalent in stent-retriever patients. Pooled baseline National Institute of Health Stroke Scale scores and Alberta Stroke Program Early Computed Tomography Score imaging scores were similar. Pooled time onset of symptoms to door arrival was higher for the stent-retrieval group (154 vs. 97.4 minutes, P=0.01), as was time to groin puncture (259.9 vs. 156.2 minutes, P=0.02), but there was no difference in procedure time. The TICI 2b–3 recanalization rate was similar (80.5% vs. 86.8%, P=0.168). The frequency of mRS 0–2 at 90-day was also similar (74.5% vs. 59.9%, P=0.120), and an excellent mRS 0–1 was lower for stent-retrievers (39.9% vs. 65.6%, P=0.003). A significant negative correlation was found between onset to groin puncture time and the proportion of patients with a good mRS (r=-0.71, P=0.048).ConclusionBoth endovascular techniques achieved recanalization rates greater than 80% and 90-day outcomes of minimal disability with similar complication rates. The literature is skewed by aspiration cases being performed sooner after onset of stroke compared to stent-retriever cases.

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Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes

Cited by 31 publications

References 28 publications

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis

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

Contact Aspiration versus Stent-Retriever Thrombectomy for Distal Middle Cerebral Artery Occlusions in Acute Ischemic Stroke: Meta-Analysis

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