Instant Reocclusion following Mechanical Thrombectomy of in situ Thromboocclusion and the Role of Low-Dose Intra-Arterial Tirofiban

Abstract

Background: An in situ thromboocclusion (IST) is defined as an infarct extensively involving all or most of a stenosed arterial territory, which is one major stroke mechanism related to intracranial atherosclerosis (ICAS). We focused on ISTs occurring in major cerebral arteries and analyzed their rate of instant reocclusion during mechanical thrombectomy (MT) compared with non-ISTs. Also, we introduced a treatment strategy of low-dose intra-arterial tirofiban administration to prevent such reocclusion following repeat recanalization, and evaluated its safety and efficacy. Methods: We analyzed 168 consecutive patients treated with MT over a 2-year period from May 2011 to April 2013. During MT, if angiography following a successful recanalization showed stenosis at the occlusion site, we performed additional angiographic runs every 10 min for 30 min after the recanalization. Then, if angiography revealed reocclusion, we performed a repeat recanalization, using the same MT technique but additionally followed by low-dose intra-arterial tirofiban infusion. Time-of-flight MR angiography or CT angiography was performed to confirm any underlying ICAS at the occlusion site 5-7 days after the procedure. The patients who had confirmed underlying ICAS were included in the IST cohort. Results: Of 168 enrolled patients, we excluded 36 who could not be checked for underlying ICAS at the occlusion site for one of the following reasons: recanalization failure (n = 11), rescue stenting after tirofiban failure (n = 5) and lack of follow-up vascular imaging (n = 20). The incidence of IST was 30.3% (40/132). All IST patients were confirmed to have underlying ICAS by follow-up vascular imaging. Instant reocclusion after successful recanalization was significantly more frequent in the IST cohort [26/40 (65%) vs. 3/92 (3.3%); p < 0.001]. Regarding the efficacy of low-dose intra-arterial tirofiban infusion, 85.7% of the reocclusion patients finally achieved a thrombolysis in cerebral infarction score 2/3 recanalization, but in the remaining 14.3% of the cases, the condition was refractory to the procedure and required rescue stenting. There were no cases of symptomatic intracranial hemorrhage following the procedure. Conclusions: In situ thromboocclusion was characterized by a significantly higher chance of instant reocclusion during MT. In such cases, low-dose intra-arterial tirofiban administration may be effective and safe. However, future confirmation by prospective multicenter trials seems necessary.

Negative Susceptibility Vessel Sign and Underlying Intracranial Atherosclerotic Stenosis in Acute Middle Cerebral Artery Occlusion

“…Although the optimal treatment for underlying ICAS in patients presenting with hyperacute stroke remains unknown, 21 the identification of underlying ICAS before endovascular therapy could help interventionists make appropriate therapeutic decisions. 5,18,22 Recently, Kang et al 22 reported that patients with underlying ICAS who presented with acute stroke had an increased tendency for instant reocclusion of the treated arteries after the initial mechanical thrombectomy. They suggested that the infusion of intra-arterial antiplatelet agents in combination with a thrombolytic agent might reduce the rate of reocclusion in pa- tients with acute stroke with underlying ICAS.…”

Effect of Intracranial Atherosclerotic Disease on Endovascular Treatment for Patients with Acute Vertebrobasilar Occlusion

“…Significant stenosis was defined according to the following criteria: 1) degree of fixed stenosis of Ͼ70%, 19 or 2) moderate stenosis with either flow and perfusion impairment on angiography or an evident tendency toward reocclusion, 13 even after sufficient primary endovascular treatment was performed. Underlying IAD can be observed from partial recanalization spontaneously or after intravenous thrombolytic treatment, but these cases were excluded in this study because primary thrombectomy devices for intracranial occlusions were allowed.…”

“…If reperfusion was not achieved or the occlusion was sustained, we applied rescue treatments, including the switching strategy, 22 angioplasty, 23 stent placement, 24 and intra-arterial tirofiban infusion, 13 with consensus from the neurointerventionalist and neurologist. Follow-up angiography was performed 10 -20 minutes after recanalization.…”

“…Regarding the pathomechanism of stroke, in situ thrombotic occlusions may occur in addition to hemodynamic compromise due to stenosis. [11][12][13] This IAD-related occlusion causes acute ischemic stroke and was reported to be more frequent in the posterior circulation than in the anterior circulation. 14 According to previous literature, the prognosis of acute vertebrobasilar occlusions has been associated with various factors, including the initial severity of neurologic deficits, time to treatment, location of the occlusion, degree of collaterals, treatment modalities, and timely reperfusion.…”

Prediction of the Multisegment Clot Sign on Dynamic CT Angiography of Cardioembolic Stroke

“…17,18 The etiology of acute LAO seems related to stent retriever refractoriness and some other complications, such as inadvertent detachment, stent retrievers getting stuck, and frequent reocclusions. [19][20][21][22] The presence of truncal-site occlusion reflecting intracranial atherosclerosis was associated with a lower chance of stent retriever success, and these patients more frequently required adjunctive therapies, such as stent placement or use of glycoprotein IIb/IIIa inhibitors. 4 Failure of stroke intervention was associated with longer procedural times and delayed recanalization, resulting in larger infarct volumes and worse neurologic outcomes.…”