Abstract
BackgroundComplete reperfusion (mTICI 3) in anterior circulation ischemic stroke patients after a single mechanical thrombectomy (MT) pass has been identified as a predictor of favorable outcome (modified Rankin Score 0–2) and defined as true first-pass effect recently. This effect has not yet been demonstrated in posterior circulation ischemic stroke. We hypothesized a true first-pass effect for the subgroup of acute basilar artery occlusions (BAO). MethodsConsecutive patients with acute thromboembolic occlusions in the posterior circulation, treated between 2010 and 2017, were screened and all BAO patients with complete angiographic reperfusion and known symptom onset included for unmatched and matched analysis after adjustment for multiple confounding factors (demographics, time intervals, stroke severity, posterior circulation Alberta Stroke Program early computed tomography Score and comorbidity. The primary objective was outcome at 90 days between matched cohorts of single pass vs. multi pass complete reperfusion patients. Results90 MTs in BAO were analyzed, yielding 56 patients with known symptom onset, in whom we achieved complete reperfusion (mTICI 3), depending on whether complete reperfusion was achieved after a single pass (n = 28) or multiple passes (n = 28). Multivariable analysis of 56 non-matched patients revealed a significant association between first-pass complete reperfusion and favorable outcome (p < 0.01). In matched cohorts (n = 7 vs. n = 7), favorable outcome was only seen if complete reperfusion was achieved after a single pass (86% vs. 0%). ConclusionSingle pass complete reperfusion in acute basilar artery occlusion is an independent predictor of favorable outcome. Achieving complete reperfusion after multiple passes might impair favorable patient recovery.
Highlights
Complete reperfusion in anterior circulation ischemic stroke patients after a single mechanical thrombectomy (MT) pass has been identified as a predictor of favorable outcome and defined as true first-pass effect recently
Such a true first-pass effect has not been demonstrated yet in basilar artery occlusions (BAO). We addressed this issue by conducting a study in which we compared the clinical outcome of patients in whom we achieved complete reperfusion after a single pass with a matched cohort of patients, in whom we achieved complete reperfusion after ≥ 2 passes
Between 2010 and 2017 a total number of 548 patients underwent MT for the treatment of Acute ischemic stroke (AIS) at our center. 122/548 patients (22%) suffered from an large vessel occlusions (LVO) of the posterior circulation, whereof 90 depicted a BAO (74% of posterior circulation LVOs and 16% of all LVOs). modified Thrombolysis in Cerebral Ischemia (mTICI) 3 reperfusion results were achieved in 56/90 patients (62%)
Summary
Complete reperfusion (mTICI 3) in anterior circulation ischemic stroke patients after a single mechanical thrombectomy (MT) pass has been identified as a predictor of favorable outcome (modified Rankin Score 0-2) and defined as true first-pass effect recently. The question whether stroke patients would benefit if thrombectomy resulted in complete reperfusion, defined as modified Thrombolysis in Cerebral Ischemia (mTICI) grade 3 [17] after one (single) instead of multiple passes remained open until recently, when Nikoubashman et al reported on a so-called “true first-pass effect” [18]: Complete reperfusion with the first stent-retriever-based thrombectomy pass resulted significantly more often in favorable outcome at 90 days compared to complete reperfusion after multiple thrombectomy passes in otherwise matched cohorts This implies that phenomena like microembolizations into the distal vascular territories of the treated proximal vessel, which have been observed in-vitro [19] might be linked to the number of thrombus retrieval attempts in-vivo, impacting functional outcome independent of the elapsed time since symptom onset and the status of collateral flow. We addressed this issue by conducting a study in which we compared the clinical outcome of patients in whom we achieved complete reperfusion (mTICI 3) after a single pass with a matched cohort of patients, in whom we achieved complete reperfusion after ≥ 2 passes
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