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

Abstract

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.

Stent-retriever alone vs. aspiration and stent-retriever combination in large vessel occlusion stroke: A matched analysis

“…Among 678 MT within the study period, a total of 420 patients were eligible for the analysis (Figure I, online data supplement). Mean � SD age was 64.4 � 14.6 years, 208 (49.5%) were females, and median (IQR) baseline NIHSS score was 16 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21). For the overall cohort, the SR alone group had higher rates of current smokers (27.1% vs. 18.2%, p ¼ 0.036), differences in stroke etiology (p ¼ 0.004) with more large vessel disease (14.9% vs. 5.5%) and less cardioembolic strokes (40.8% vs. 50.9%), and shorter median time from last known normal to puncture (391 vs. 497 min, p ¼ 0.03) as compared to the group with the first-line combined technique.…”

“…In this context, it is important to highlight some technical aspects of the procedures in the current report. The similarly high rates of first-pass reperfusion with SR alone thrombectomy may have derived from the utilization of the active deployment SR technique (resulting in greater clot integration and retention) 13 as well as the frequent use of long SR (92.6% in the whole cohort) which have been associated with higher rates of FPE and mFPE than short SR. 14–16 The efficacy of BGC has been previously highlighted by several studies reporting higher rates of first-pass reperfusion and good functional outcomes with the use of BGC. 17–19 Our results reinforce that, at least with the currently available technology, proximal flow arrest and reversal achieved by balloon inflation and aspiration through BGC rather than intracranial CA seems to be key initial step in SR-based anterior circulation thrombectomy.…”

Stenting for subclavian steal phenomenon to restore cerebral perfusion due to acute carotid occlusion following carotid endarterectomy: a case report

“…Endovascular treatment in 107 symptomatic extracranial ICA occlusive patients reported good outcomes in only 65%; moreover, distal emboli occurred in 22% [ 13 , 14 ]. Although recent advancements in endovascular treatment show promise in improved outcomes for intracranial thrombectomies, distal embolization is still reported to be a poor prognostic factor [ 15 ]. Thus, preventing distal embolization was essential for achieving favorable recovery.…”

Biomarkers of Technical Success After Embolectomy for Acute Stroke

“…In 2 studies, it was seen in about 10% and 34% of cases. 37,38 Quantifying distal embolization is challenging owing to the uncertainty of whether a distal occlusion visualized after a thrombectomy pass was present at baseline. MRI data suggest that this phenomenon is rare.…”