No-Reflow phenomenon in the perspective of endovascular neurosurgery

Abstract

Concept of No-Reflow (NR) phenomenon is largely studied in cardiological intervention characterised by the failure of myocardial reperfusion despite the absence of mechanical obstruction of large and medium sized vessels. NR negatively affects outcome of procedure, so there is great importance of prediction and management. The objective was to introduce concept of NR in neuro-intervention and have an idea of incidence and independent predictors of NR in patients with post intervention no-reflow in large and medium sized brain arteries.This was a single-centre prospective case– control study between march 2017-march 2021 in the department of Neurosurgery, Dr. R.M.L.I.M.S., Lucknow, India. Cases were subjects who suffered NR, and the control comparators were those who did not. Clinical outcomes were documented. Salient variables relating to the patients and their presentation, history and angiographical findings were documented.Of 153 consecutive patients, 11(7.2%) suffered from NR, with all cases occurring post intervention in the form of coiling with or without stent/balloon support or flow diverter placement with or without coiling. Patients with NR had increased risk of in-hospital death and disability (1 patient/9.1% death, 8 patients/72.72% with one or multiple neurological dysfunction with varying severity) in comparison to patients without NR (4 patients/2.8% deaths and 12 patients/8.5% disabilities, out of 142 patients). From baseline variables available prior to neuro-endovascular surgery, the independent predictors of NR were increased complexity of pathology, admission systolic hypertension, weight of more than 75 kg and history of hypertension, history of DM, history of ischaemic vascular disease/dissection/aneurysm in the brain or elsewhere, history of systemic arteritis, history of autoimmune disease and atherosclerosis, history of smoking, female gender, elderly. Patients with NR have a higher rate of morbidity and mortality following ischaemia and embolism. Predictors of NR include lesion complexity, systolic hypertension and high body weight, female gender, elderly, dyslipidaemia and preexisting arterial disease. Further validation of this risk model is required with lager number of patients and multicenter studies.