Thrombus migration in ischemic stroke due to large vessel occlusion: a question of time

Riegler, Christoph; Siebert, Eberhard; Kleine, Justus F.; Nolte, Christian H.

doi:10.1136/jnis-2022-019365

Cited by 4 publications

(8 citation statements)

References 21 publications

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“…Median age in the study population was 77 years (IQR 65-83) and 5365 patients (52.8%) were women. Median National Institutes of Health Stroke Scale score was 14 (9)(10)(11)(12)(13)(14)(15)(16)(17)(18). The prevalences of occlusion of the carotid T, the proximal or distal M1 segment, and the M2 segment of the middle cerebral artery were 18.9%, 38.2%, 25.5%, and 27.3%, respectively.…”

Section: Resultsmentioning

confidence: 99%

“…The idea to omit IVT was fueled by observations that proximal occlusions with long thrombi have a lower likelihood to recanalize with IVT alone, 5,6 higher rates of symptomatic intracranial hemorrhages in patients treated with IVT, 7 and the potential risks of thrombus migration and distal embolization, increasing EVT complexity. [8][9][10] Moreover, an early meta-analysis suggested that EVT alone may be non-inferior to EVT plus IVT. 11 This conclusion, however, was not based on stringent non-inferiority margins and only included data from the first three RCTs.…”

Section: Introductionmentioning

confidence: 99%

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Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry

Schlemm,

Siebert,

Kleine

et al. 2023

European Stroke Journal

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Introduction: In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. Methods: Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. Results: 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%–3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%–1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%–2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. Conclusion: We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry

Schlemm,

Siebert,

Kleine

et al. 2023

European Stroke Journal

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“…Some of these studies reported improved outcomes in patients with pre-EVT arterial recanalization, 11,15 while others reported no differences. 10,12 In this study, we aimed to determine the incidence of recanalization during interhospital transfer for EVT, the clinical and imaging predictors of recanalization, and the relationship between recanalization and immediate posttransfer and 3-month clinical outcomes.…”

mentioning

confidence: 99%

“…Some of these studies reported improved outcomes in patients with pre-EVT arterial recanalization, 11,15 while others reported no differences. 10,12…”

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confidence: 99%

Arterial Recanalization During Interhospital Transfer for Thrombectomy

Seners,

Wouters,

Ter Schiphorst

et al. 2024

Stroke

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BACKGROUND: Patients with acute ischemic stroke harboring a large vessel occlusion admitted to nonendovascular-capable centers often require interhospital transfer for thrombectomy. We evaluated the incidence and predictors of arterial recanalization during transfer, as well as the relationship between interhospital recanalization and clinical outcomes. METHODS: We analyzed data from 2 cohorts of patients with an anterior circulation large vessel occlusion transferred for consideration of thrombectomy to a comprehensive center, with arterial imaging at the referring hospital and on comprehensive stroke center arrival. Interhospital recanalization was determined by comparison of the baseline and posttransfer arterial imaging and was defined as revised arterial occlusive lesion (rAOL) score 2b to 3. Pretransfer variables independently associated with interhospital recanalization were studied using multivariable logistic regression analysis. RESULTS: Of the 520 included patients (Montpellier, France, n=237; Stanford, United States, n=283), 111 (21%) experienced interhospital recanalization (partial [rAOL=2b] in 77% and complete [rAOL=3] in 23%). Pretransfer variables independently associated with recanalization were intravenous thrombolysis (adjusted odds ratio, 6.8 [95% CI, 4.0–11.6]), more distal occlusions (intracranial carotid occlusion as reference: adjusted odds ratio, 2.0 [95% CI, 0.9–4.5] for proximal first segment of the middle cerebral artery, 5.1 [95% CI, 2.3–11.5] for distal first segment of the middle cerebral artery, and 5.0 [95% CI, 2.1–11.8] for second segment of the middle cerebral artery), and smaller clot burden (clot burden score 0–4 as reference: adjusted odds ratio, 3.4 [95% CI, 1.5–7.6] for 5–7 and 5.6 [95% CI, 2.4–12.7] for 8–9). Recanalization on arrival at the comprehensive center was associated with less interhospital infarct growth (rAOL, 0–2a: 11.6 mL; rAOL, 2b: 2.2 mL; rAOL, 3: 0.6 mL; P trend <0.001) and greater interhospital National Institutes of Health Stroke Scale score improvement (0 versus −5 versus −6; P trend <0.001). Interhospital recanalization was associated with reduced 3-month disability (adjusted common odds ratio, 2.51 [95% CI, 1.68–3.77]) with greater benefit from complete than partial recanalization. CONCLUSIONS: Recanalization is frequently observed during interhospital transfer for thrombectomy and is strongly associated with favorable outcomes, even when partial. Broadening thrombolysis indications in primary centers, and developing therapies that increase recanalization during transfer, will likely improve clinical outcomes.

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“…For instance, catheter aspiration is less effective for massive emboli occupying long distances, and stent retrieval may cause distal migration of the emboli when crossing the lesion, which deteriorates cerebral perfusion by blocking residual collateral flow. 4 , 5 …”

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confidence: 99%

Retrograde thrombectomy of acute common carotid artery occlusion with mobile thrombus: illustrative cases

Okune,

Fukuda,

Matsuoka

et al. 2024

Journal of Neurosurgery: Case Lessons

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BACKGROUND Acute embolic occlusion of the common carotid artery (CCA) alone is rare. However, once it occurs, recanalization is challenging due to the large volume of the clot, larger diameter of the CCA, and risk of procedure-related distal embolism into the intracranial arteries. OBSERVATIONS The authors report two cases of acute embolic occlusion of CCA alone, caused by a cardiac embolus trapped at the proximal end of a preexisting atherosclerotic plaque at the cervical carotid bifurcation. In both cases, the CCA was successfully recanalized using retrograde thrombectomy in a hybrid operating room. In case 1, a 78-year-old male with acute right CCA occlusion underwent retrograde thrombectomy, where the cervical carotid bifurcation was exposed and incised, and the entire embolus was retrieved with forceps. Despite successful revascularization, massive bleeding from the CCA just after the retrieval remained a concern. In case 2, a 79-year-old female with acute right CCA occlusion underwent retrograde thrombectomy in the same manner. Because manual retrieval failed, a Fogarty balloon catheter inserted from the arteriotomy successfully retrieved the entire thrombus with minimal blood loss. LESSONS Retrograde thrombectomy through the arteriotomy of the cervical carotid bifurcation safely and effectively recanalizes acute embolic occlusion of the CCA alone.

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Thrombus migration in ischemic stroke due to large vessel occlusion: a question of time

Cited by 4 publications

References 21 publications

Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry

Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry

Arterial Recanalization During Interhospital Transfer for Thrombectomy

Retrograde thrombectomy of acute common carotid artery occlusion with mobile thrombus: illustrative cases

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