Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke—Insights from the STAR Collaboration

Abstract

BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P < .001), higher national institute of health stroke scale (NIHSS) (17.1 vs 15.7, P < .01) and lower rates of good outcomes (31% vs 43%, P < .01). In posterior MT, diabetes (OR = 0.28, 95%CI: 0.12-0.65), admission NIHSS (OR = 0.9, 95%CI: 0.86-0.94), and use of stent retriever (OR = 0.26, 95%CI: 0.11-0.62) or combined approach (OR = 0.35, 95%CI: 0.12-1.01) vs ADAPT were associated with lower odds of good outcome. Stent retriever use was associated with lower odds of good outcomes compared to ADAPT even when including patients with only basilar occlusion or with successful recanalization only. CONCLUSION Despite similar safety profiles, use of ADAPT is associated with higher rates of functional independence after posterior circulation thrombectomy compared to stent retriever or combined approach in large “real-world” retrospective study.

Thrombectomy for acute large vessel occlusion in posterior and anterior circulation: a single institutional retrospective observational study

“…The first-pass devices included the stent retriever in 101 (28.6%) patients, aspiration catheter in 123 (34.8%) patients, combined approach in 103 (29.2%) patients, and other devices in 26 ( 7 ). Between the patients with anterior and posterior circulation occlusions, the door-to-picture time (17 [12][13][14][15][16][17][18][19][20][21][22][23][24] vs. 24 [30.8%] patients, respectively, p = 0.709) were not significantly different between the patients. The details of mRS at discharge in all patients and in those with anterior and posterior circulation occlusions are summarized in Fig.…”

“…Higher NIHSS; more intracranial stenotic lesions; longer door-to-picture time, door-to-needle time, door-to-puncture time, and door-to-reperfusion time; fewer passes; and higher mortality were significantly different, while successful reperfusion and favorable outcome demonstrated no significant differences between the groups. Previous reports have demonstrated that male preponderance [ 24 ], younger age [ 24 , 37 ], higher NIHSS score [ 21 , 22 , 24 ], longer onset-to-puncture time [ 21 , 37 ], longer onset-to-reperfusion time [ 37 ], higher rate of futile reperfusion [ 25 ], lower tendency of favorable outcome [ 21 – 23 , 25 ], and higher mortality [ 22 , 23 , 25 ] were observed in patients with posterior circulation occlusion. In contrast, there have also been some studies that reported similar or lower NIHSS scores [ 37 , 38 ], lower rates of symptomatic hemorrhage [ 25 , 37 ], similar rates of favorable outcome [ 37 , 38 ], and similar mortality [ 24 , 37 , 38 ] between patients with anterior and those with posterior circulation occlusions.…”

“…The locations of the lesions included the ICA (n = 120); M1 (n = 185); M2 (n = 43); BA (n = 37); VA (n = 6); tandem lesions (n = 37); and bilateral lesions (n = 1). Between the patients with anterior and posterior circulation occlusions, the NIHSS score (16 [12][13][14][15][16][17][18][19][20][21] vs. 29 [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34], respectively, p < 0.001) and intracranial stenotic occlusions (26 [8.3%] vs. 9 [23.1%] patients, respectively, p = 0.008) were significantly different; however, other characteristics (age, sex, comorbidities, history of smoking, inter-hospital transfer, drip-and-ship, in-hospital onset, left-sided lesion, preprocedural MRI evaluation, location of lesion, DWI-ASPECTS, pc-ASPECTS based on DWI, disease subtype, tandem lesion, and extracranial stenotic occlusion) demonstrated no significant differences.…”

“…Posterior circulation occlusion, especially basilar artery (BA) occlusion, constitutes approximately 5% of large vessel occlusions [19,20]. It is reported to result in a higher National Institutes of Health Stroke Scale (NIHSS) score, higher mortality, and lower rate of favorable outcomes in comparison with anterior circulation occlusion [21][22][23][24][25]. Despite the relatively high successful reperfusion rate, worse outcomes have been reported in prospective registry studies [26,27].…”

How to Improve the Management of Acute Ischemic Stroke by Modern Technologies, Artificial Intelligence, and New Treatment Methods

“…Direct Aspiration First-Pass Technique (ADAPT) is associated with higher rates of functional independence after posterior circulation thrombectomy, compared to stent retriever or combined approach in large "real-world" retrospective study [122]. Metaanalysis suggested that for patients with acute basilar artery occlusion, first-line ADAPT might achieve higher and faster recanalization, comparable neurological improvement, and safety, compared with first-line stent retrievers [123].…”