Impact of thrombus surface on first pass reperfusion in contact aspiration and stent retriever thrombectomy

Abstract

BackgroundTo assess whether thrombus surface morphology has an impact on first pass reperfusion in contact aspiration (CA) and stent retriever (SR) thrombectomy.MethodsFrom January 2016 to December 2018, consecutive stroke patients with an occlusion of the middle cerebral artery and thrombectomy (CA or SR) were examined in this retrospective study. We assessed patients’ characteristics, procedural data and clinical outcome. Thrombus surface on pretreatment digital subtraction angiography (DSA) was categorized into regular versus irregular phenotype by blinded three-reader-consensus. Primary outcome was successful reperfusion (modified treatment in cerebral ischemia (mTICI) 2b-3) after first pass. Data analysis was stratified according to thrombectomy technique and thrombus phenotype.ResultsAmong 203 patients (76 years (IQR 65.5–81.9), 47.3% male, National Institutes of Health Stroke Scale Score 16 (IQR 12–20)), 155 patients were treated primarily with CA and 48 with SR. 40% (n=62/155) CA and 41.7% (n=20/48) SR-treated patients had a regular thrombus phenotype. In the CA group, successful reperfusion after first pass was more frequently obtained in patients with regular compared with irregular phenotype (69.4% (n=43/62) vs 34.4% (n=32/93); P<0.0001). In contrast, in the SR group, reperfusion after first pass was achieved in 35% (n=7/20; P=0.01) of patients with regular phenotypes. In the CA group, median number of passes (1 (1–2) vs 2 (1–4); P<0.00001) and time from reaching the thrombus to reperfusion (19±27 vs 38±36 min; P=0.0001) were lower among patients with a regular phenotype.ConclusionDirect CA is associated with higher rates of successful first pass reperfusion in patients with a regular thrombus phenotype in pretreatment DSA.

Stent-Based Retrieval Techniques in Acute Ischemic Stroke Patients with and Without Susceptibility Vessel Sign

“…Efforts to increase MT suc-K Fig. 4 First-pass expanded treatment in cerebral infarction (eTICI) distribution according to first-line SR-based retrieval technique for patients with acute anterior circulation stroke without susceptibility vessel sign cess by identifying imaging parameters that would allow prospective selection of the most effective retrieval technique for a specific clot are ongoing [2][3][4]. Bourcier et al [4] published the first study comparing MT techniques in AIS patients with SVS and concluded that first-line SRonly thrombectomy is superior to contact aspiration among those patients [4].…”

“…Nevertheless, efforts to increase the chances of reperfusion after MT continue. Recent studies have focused on the identification of critical clot characteristics visible on imaging that might guide the choice of the best retrieval technique [2][3][4]. Due to the paramagnetic property of deoxygenated hemoglobin in trapped blood cells, susceptibility-weighted sequences can be used to locate thrombus material in occluded vessels after AIS, which may be seen as a distinct loss of signal within the affected vessel.…”

Association of Regular Thrombus Surface Phenotype With Complete Recanalization in First-Line Contact Aspiration Thrombectomy for Basilar Artery Occlusion

“…We found that a regular thrombus phenotype, cardioembolic stroke etiology, and occlusion in the middle segment of the BA might be predictors of complete recanalization if CA is chosen as the first-line thrombectomy method in BAO patients. However, phenotyping of the thrombus surface in BAO was technically less feasible compared to anterior circulation large vessel occlusions (acLVO) (9,18).…”

“…Anatomical variants of the V4-segment of vertebral arteries (VA) were scored as described before (15). The readers independently categorized the proximal surface of the thrombus on the pretreatment DSA as "regular" if the profile was smoothly straight, convex, or concave (i.e., meniscoid-like) in the full vessel diameter, and "irregular" if these criteria were not met (Figure 1) (9). If readers were unable to determine the phenotype, we categorized the thrombus surface as not assessable and stated a reason.…”

“…First-line contact aspiration (CA) thrombectomy may be associated with higher rates of complete recanalization and a shorter procedure time in BAO compared to stent retriever (SR) (7,8). In patients with an acLVO, the presence of a regular thrombus surface on pre-treatment digital subtraction angiography (DSA) seems to be associated with higher recanalization rates if treated by first-line CA (9,10). This association has not been shown for BAO.…”