Posterior Circulation Occlusions May Be Associated with Distal Emboli During Thrombectomy

Yeo, Leonard L.L.; Holmberg, Åke; Mpotsaris, Anastasios; Söderman, Michael; Holmin, Staffan; Söderqvist, Åsa Kuntze; Ohlsson, Marcus; Bhogal, Pervinder; Gontu, Vamsi; Andersson, Tommy; Brouwer, Patrick A.

doi:10.1007/s00062-018-0679-z

Cited by 31 publications

(28 citation statements)

References 42 publications

(51 reference statements)

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“…Distal embolization has been reported to be due to clot fragments during thrombectomy procedures and is predictive of worse clinical outcomes (25). We found similar overall rate (4.8%) of distal embolization as previous studies reported (14, 26). But 7.1% of patients in heparinization group developed distal embolization compared with that in the non-heparinization group, which we postulated that the softening effects on the thrombus derived from the antithrombotic effects of heparin may potentially generate clot fragment and cause distal embolization.…”

Section: Discussionsupporting

confidence: 91%

“…The secondary safety outcome was any ICH on follow-up CT or T2 * MR images and distal embolization during MT. Distal embolization are procedure-related complications that filling defects distal to the occlusion presented on DSA after the retrieval or aspiration, but absent on preceding CTA/MRA or the initial DSA were considered as distal embolization as previous reported (14). The long-term functional outcome was assessed with mRS (range 0~6) at 3-month follow-up by trained research coordinators who were blinded to subjects' baseline characters.…”

Section: Methodsmentioning

confidence: 99%

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Safety and Efficacy of Heparinization During Mechanical Thrombectomy in Acute Ischemic Stroke

et al. 2019

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Background: The benefits of heparization during mechanical thrombectomy (MT) with newer generation thrombectomy devices, and if it is counterbalanced by the increased risk of intracranial hemorrhage (ICH) remain unknown. Methods: We included eligible patients who underwent MT from the ANGEL registry study (2015-2017) in China. Subjects in the current analysis were dichotomized into two groups according to whether adequate heparinization during MT was performed. In the heparinization group, unfractionated heparin was infused at 50–100 IU/Kg at first and additional 1,000 IU at intervals of an hour during the operation. Safety outcomes (symptomatic intracerebral hemorrhage [sICH], ICH and distal embolization) and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups. Results: We included 619 patients from the entire cohort of 917 patients. The average age of them was 63.9 ± 13.7 years, 269 (43.5%) were treated with heparinization during MT. Heparinization during MT didn't significantly influence recanalization rates, total ICH and long-term mortality (adjusted p > 0.05 for all). But sICH and distal embolization occurred more frequently (9.3 vs. 5.1%, adjusted p = 0.02; 7.1 vs. 3.1%, adjusted p = 0.04, respectively), while functional independence appeared less likely (39.8 vs. 47.4%, adjusted p = 0.01) in heparinization group than that in non-heparinization group. Multivariable logistic regression analyses showed that heparinization during MT was an independent predictor for sICH (Odds ratio 2.36 [1.19–4.67], p = 0.01) in addition to cardio-embolism stroke and posterior circulation stroke (PCS), and an independent predictor for poor outcome (Odds ratio 1.79 [1.23–2.59], p < 0.01) besides age, bridging intravenous thrombolysis, admission NIHSS, drinking and PCS. Conclusion: Heparinization during MT may be associated with increased risk of safety outcomes over sICH and distal embolization, as well as efficacy outcomes over long-term poor outcome. Further randomized controlled trials are needed.

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Section: Discussionsupporting

confidence: 91%

Section: Methodsmentioning

confidence: 99%

Safety and Efficacy of Heparinization During Mechanical Thrombectomy in Acute Ischemic Stroke

et al. 2019

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“…In contrast, more classical reperfusion of more than 50% of the involved territory (mTICI2b) failed to predict END. Compared to the anterior circulation, EVT for posterior circulation is prone to Willisian collateral failure by distal embolization (21). Thus, aiming for a higher reperfusion grade may be able to prevent END on VBO, and future advances in EVT may also need to focus on higher reperfusion grades, such as distal vessel thrombectomy (22).…”

Section: Discussionmentioning

confidence: 99%

Predictors of Early Neurological Deterioration in Stroke Due to Vertebrobasilar Occlusion

et al. 2021

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Background and Aims: This study explores the predictors of early neurological deterioration (END) in patients with vertebrobasilar occlusion (VBO) in both primary endovascular therapy (EVT) and medical management (MM) groups.Methods: Patients diagnosed with VBO from 2010 to 2018 were included. Comparative and multivariate analyses were used to identify predictors of all-cause END in the EVT group, and END due to ischemia progression (END-IP) in the MM group.Results: In 174 patients with VBO, 43 had END. In the primary EVT group (N = 66), 17 all-cause END occurred. Distal basilar occlusion (odds ratio (OR), 14.5 [95% confidence interval (CI), 1.4–154.4]) and reperfusion failure (eTICI < 2b67 (OR, 5.0 [95% CI, 1.3–19.9]) were predictive of END in multivariable analysis. In the MM group (N=108), 17 END-IP occurred. Higher systolic blood pressure (SBP) at presentation (per 10 mmHg increase, OR, 1.5 [95% CI, 1.1–2.0]), stroke onset-to-door time <24 h (OR, 5.3 [95% CI, 1.1–2.0]), near-total occlusions (OR, 4.9 [95% CI, 1.2–19.6]), lower posterior circulation-Alberta Stroke Program Early CT scores (OR, 1.6 [95% CI, 1.0–2.5]), and lower BATMAN collateral scores (OR, 1.6 [95% CI, 1.1–2.2]) were predictive of END-IP.Conclusions: In patients with stroke due to VBO, potential predictors of END can be identified. In the primary EVT group, failure to achieve reperfusion and distal basilar occlusion were associated with all-cause END. In the MM group, higher SBP at presentation, onset-to-door time less than 24 h, incomplete occlusions, larger infarct cores, and poorer collaterals were associated with END-IP.

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“…However, this has not been studied extensively. A study of Yeo et al [25] found that IV-tPA was associated with the occurrence of distal emboli on univariable analysis, but this did not reach statistical significance in multivariable analysis in their study.…”

Section: Discussionmentioning

confidence: 67%

Risk Factors for Distal Clot Migration during Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusion

et al. 2020

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Introduction: Distal clot migration (DCM) is a known complication of mechanical thrombectomy (MT), but neither risk factors for DCM nor ways of how it might affect clinical outcomes have been extensively studied to date. Methods: To identify risk factors for and outcomes in the setting of DCM, the records of all patients with acute ischemic stroke due to anterior circulation large vessel occlusion (LVO) treated with MT at a single center between May 2016 and June 2018 were retrospectively reviewed. Uni-and multivariable analyses were performed to evaluate predictors of DCM and good functional outcome (90-day modified Rankin Scale; mRS 0-2). Results: A total of 65 patients were included, DCM was identified in 22 patients (33.8%). Patients with DCM had significantly higher pre-procedural intravenous tissue plasminogen activator (IV-tPA) administration (81.8 vs. 53.5%, p = 0.03), stentrievers thrombectomy (95.5 vs. 62.8%, p = 0.006), and longer median puncture to recanalization time (44 [34-97] vs. 30 [20-56] min, p = 0.028) as compared to group with non-DCM. Also, they had lower rates of Thrombolysis in Ce-rebral Infarction (TICI) 2b/3 recanalization (p = 0.002), higher median National Institutes of Health Stroke Scale (NIHSS) scores at discharge (p = 0.01), and lower rates of 90-day mRS (0-2; 18.2 vs. 48.8%; p = 0.016). On subgroup analysis, patients with middle cerebral artery occlusions who underwent MT with stentrievers < 40 mm in length had a higher risk of DCM (p = 0.026). On multivariable analysis, IV-tPA administration (OR; 5.019, 95% CI [1. .102], p = 0.018) and stentrievers thrombectomy (OR; 10.031, 95% CI [1. 090-92.344]; p = 0.04) remained significant predictors of DCM. Baseline NIHSS score (OR; 0.872, 95% CI [0.788-0.965], p = 0.008) and DCM (OR; 0.250, 95% CI [0.075-0.866], p = 0.03) were independent predictors of 90-day mRS 0-2. Conclusion: In patients undergoing MT for anterior circulation LVO, DCM is associated with lower rates of TICI 2b/3 recanalization and worse functional outcomes at 90 days. IV-tPA administration and MT with short stentrievers are independent predictors of DCM development.

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Posterior Circulation Occlusions May Be Associated with Distal Emboli During Thrombectomy

Cited by 31 publications

References 42 publications

Safety and Efficacy of Heparinization During Mechanical Thrombectomy in Acute Ischemic Stroke

Safety and Efficacy of Heparinization During Mechanical Thrombectomy in Acute Ischemic Stroke

Predictors of Early Neurological Deterioration in Stroke Due to Vertebrobasilar Occlusion

Risk Factors for Distal Clot Migration during Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusion

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