Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients

Abstract

Background and Purpose-Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods-A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results-Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI: 1.1-3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI: 1.01-1.02), prestroke functional dependence (aOR, 7.12; 95% CI: 1.49-34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI: 1.10-47.05 and aOR, 36.50; 95% CI: 4.47-298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI: 0.03-0.57). Conclusions-Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the past angiographic run. (Stroke. 2018;49:00-00.

Prognosis and risk factors for reocclusion after mechanical thrombectomy

“…Although reocclusion is infrequent after MT, once occlusion recurs, it will gravely affect the patient's functional prognosis. 12,13,[17][18][19][20] Due to the low incidence of reocclusion, there are relatively few current related studies. Qureshi et al evaluated 56 endovascular treatment patients in 2008; early reocclusion was only found in five cases (9%).…”

“…Males accounted for 72.7% of the participants in the reocclusion group and 75.8% of the participants in the non-reocclusion group (P = 0.649). The median NIHSS scores of the two groups were 15 (12)(13)(14)(15)(16)(17)(18)(19)(20) in the reocclusion group and 16 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23) in the non-reocclusion group (P> 0.05); the median ASPECT score of both groups was 9 (8-10). There were no significant differences in the onset-to-recanalization time (median: 499 vs. 440 min, P = 0.471); puncture-to-recanalization time (median: 65 vs. 68 min, P = 0.463); general anesthesia rate (45.5% vs. 51.4%, P = 0.447); or postoperative tirofiban utilization rate (56.8% vs. 62.8%, P = 0.429) ( Table 1).…”

“…The 24-h NIHSS score was 15 , the 7-day NIHSS score was 9 [3][4][5][6][7][8][9][10][11][12][13][14][15], the 90-day mRS score was 3 [2][3][4][5], and the good prognosis rate at 90 days was 37.5% (230/ 614). The 24-h NIHSS score was significantly higher in the reocclusion group than that in the non-occlusion group (15 [12-30] vs. 13 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], P = 0.015). The 7-day NIHSS scores in the reocclusion group (15 [9][10][11][12][13][14][15][16][17][18][19][20][21][22]…”

“…The 24-h NIHSS score was significantly higher in the reocclusion group than that in the non-occlusion group (15 [12-30] vs. 13 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], P = 0.015). The 7-day NIHSS scores in the reocclusion group (15 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]) were significantly higher than those in the non-occlusion group (9 [13-15], P = 0.001) ( Table 2, Fig. 2).…”

“…9,10 Studies have reported that MT has resulted in recanalization rates over 80%, but the rate of reocclusion within 24 h after MT is approximately 3-9%. 11,12 Reocclusion after MT can lead to disease deterioration and increased mortality and disability.…”