Repeated mechanical thrombectomy in short-term large vessel occlusion recurrence: multicenter study and systematic review of the literature

Styczen, Hanna; Maegerlein, Christian; Yeo, Leonard L.L.; Clajus, Christin; Kastrup, Andreas; Abdullayev, Nuran; Behme, Daniel; Maurer, Christoph J.; Meyer, Lukas; Goertz, Lukas; Ikenberg, Benno; Tan, Benjamin Yong-Qiang; Lobsien, Donald; Papanagiotou, Panagiotis; Kabbasch, Christoph; Hesse, Amélie Carolina; Berlis, Ansgar; Fiehler, Jens; Fischer, Sebastian; Forsting, Michael; Maus, Volker

doi:10.1136/neurintsurg-2020-015938

Cited by 12 publications

(14 citation statements)

References 20 publications

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“…Besides, COVID-19 patients with stroke tend to have an elevated incidence of potentially fatal thrombotic complications that could have contributed to the increased risk of death 12. Indeed, we found a noticeably higher rate of re-occlusion within 30 days compared with a previous analysis of non-infected patients (4.5% vs 0.4%) 24. Re-occlusions might be promoted by a prothrombotic state, antiphospholipid syndrome, cytokine storm or other coagulopathies—factors that have already been described with COVID-19 and related stroke pathogenesis 25 26…”

Section: Discussionsupporting

confidence: 50%

“…12 Indeed, we found a noticeably higher rate of re-occlusion within 30 days compared with a previous analysis of non-infected patients (4.5% vs 0.4%). 24 Re-occlusions might be promoted by a prothrombotic state, antiphospholipid syndrome, cytokine storm or other coagulopathies-factors that have already been described with COVID-19 and related stroke pathogenesis. 25 26 Notably, patients with subsided COVID-19 infection tend to have a better clinical outcome than patients with acute COVID-19 infection.…”

Section: Discussionmentioning

confidence: 99%

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Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases

Styczen

Maus²,

Goertz

et al. 2022

J NeuroIntervent Surg

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BackgroundData on the frequency and outcome of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in patients with COVID-19 is limited. Addressing this subject, we report our multicenter experience.MethodsA retrospective cohort study was performed of consecutive acute stroke patients with COVID-19 infection treated with MT at 26 tertiary care centers between January 2020 and November 2021. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge and 90 days were noted.ResultsWe identified 111 out of 11 365 (1%) patients with acute or subsided COVID-19 infection who underwent MT due to LVO. Cardioembolic events were the most common etiology for LVO (38.7%). Median baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score were 16 (IQR 11.5–20) and 9 (IQR 7–10), respectively. Successful reperfusion (mTICI ≥2b) was achieved in 97/111 (87.4%) patients and 46/111 (41.4%) patients were reperfused completely. The procedure-related complication rate was 12.6% (14/111). Functional independence was achieved in 20/108 (18.5%) patients at discharge and 14/66 (21.2%) at 90 days follow-up. The in-hospital mortality rate was 30.6% (33/108). In the subgroup analysis, patients with severe acute COVID-19 infection requiring intubation had a mortality rate twice as high as patients with mild or moderate acute COVID-19 infection. Acute respiratory failure requiring ventilation and time interval from symptom onset to groin puncture were independent predictors for an unfavorable outcome in a logistic regression analysis.ConclusionOur study showed a poor clinical outcome and high mortality, especially in patients with severe acute COVID-19 infection undergoing MT due to LVO.

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Section: Discussionsupporting

confidence: 50%

Section: Discussionmentioning

confidence: 99%

Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases

Styczen

Maus²,

Goertz

et al. 2022

J NeuroIntervent Surg

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“…are procedure-related complications like dissection and stent thrombosis. 22 These complications were infrequent in our cohort. The primary cause for rLVO in our cohort was cardioembolic source, about 56% of the 54 patients, with majority due to atrial fibrillation (77%).…”

Section: Clinical and Population Sciencesmentioning

confidence: 63%

“…Similar and slightly lower rates (0.4%-1.5%) have been previously reported in smaller series. 9,[19][20][21][22] These infrequent treatment rates likely represent an underestimate of the actual number of rLVO due to: exclusion of patients with rLVO with severe disability, patients presenting with rLVO to different hospitals, and missed rLVO during hospitalization in patients with a subtle worsening of the original NIHSS.…”

Section: Discussionmentioning

confidence: 99%

Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion: A Multicenter Experience

Mohamed

Nour

Nogueira

et al. 2021

Stroke

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Background and Purpose: Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO. Methods: This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale. Results: Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3–5), and 10 (20%) died. Conclusions: Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients.

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“…There are emerging prospective data to suggest that in the cryptogenic stroke population, LVO is independently associated with covert paroxysmal AF [16]. There is also a higher incidence of cardioembolic aetiology in LVO re currence [17]. Although risk factors for ischaemic stroke are well known, the cause remains undefined in 25-39% of patients who experience an acute event, even with full diagnostic evaluation [18].…”

Section: Discussionmentioning

confidence: 99%

Left Atrial Enlargement on Non-Gated CT Is Associated with Large Vessel Occlusion in Acute Ischaemic Stroke

Butt

Dhillon

Lenthall

et al. 2021

Cerebrovasc Dis Extra

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Background: Recent reports have suggested that atrial fibrillation (AF) is more prevalent in the large vessel occlusion (LVO) subgroup of acute ischaemic stroke patients. Given the association between left atrial enlargement (LAE) and AF, we sought to evaluate the feasibility of assessing LAE on non-gated CT and its association with LVO in the hyperacute stroke setting. Methods: We analysed our prospectively collected database that included all stroke patients referred for consideration of endovascular treatment between April 14, 2020, and May 21, 2020. During this period, a CT chest was included in our regional stroke protocol to aid triage of patients suspected for COVID-19 from which cardiac measurements were obtained. Patients were dichotomized into LVO and no-LVO groups, and LA measurements were trichotomized into normal, borderline, and enlarged. Univariate analyses were performed between groups. Results: Of the included 38 patients, 21 were categorized as LVO and 17 as no LVO. There was a statistically significant association between LAE and LVO (p = 0.028). No significant difference was demonstrated between groups for the baseline AF and other clinical characteristics, except for baseline NIHSS (p = 0.0005). There was excellent inter- and intra-rater reliability (ICC = 0.969) for LA measurements. Conclusion: Our study provides preliminary data to suggest LAE is more prevalent in the LVO stroke subgroup at presentation and can be reliably assessed on non-gated CT in the hyperacute setting. These findings have potential implications for stratifying secondary management and may prompt a more rigorous pursuit of occult AF or other cardiac causes of stroke.

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Repeated mechanical thrombectomy in short-term large vessel occlusion recurrence: multicenter study and systematic review of the literature

Cited by 12 publications

References 20 publications

Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases

Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases

Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion: A Multicenter Experience

Left Atrial Enlargement on Non-Gated CT Is Associated with Large Vessel Occlusion in Acute Ischaemic Stroke

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