Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

Eyad Almallouhi¹, Sara Zandpazandi², Mohammad Anadani², Conor Cunningham², Mohammad-Mahdi Sowlat², Hidetoshi Matsukawa², Atakan Orscelik³, Sameh Samir Elawady², Ilko Maier⁴, Sami Al Kasab^{2

5}, Pascal Jabbour⁶, Joon-Tae Kim⁷, Stacey Q Wolfe⁸, Ansaar Rai⁹, Robert M Starke^{10

11}, Marios-Nikos Psychogios¹², Edgar A Samaniego¹³, Adam S Arthur^{14

15}, Shinichi Yoshimura¹⁶, Hugo Cuellar¹⁷, Jonathan A Grossberg¹⁸, Ali Alawieh¹⁹, Daniele G Romano²⁰, Omar Tanweer²¹, Justin Mascitelli²², Isabel Fragata²³, Adam J Polifka²⁴, Joshua W Osbun²⁵, Roberto Javier Crosa²⁶, Charles Matouk²⁷, Min S Park²⁸, Michael R Levitt²⁹, Waleed Brinjikji³⁰, Mark Moss³¹, Travis M Dumont³², Richard Williamson³³, Pedro Navia³⁴, Peter Kan³⁵, Reade De Leacy³⁶, Shakeel A Chowdhry³⁷, Mohamad Ezzeldin^{38

39}, Alejandro M Spiotta⁴⁰

Affiliations

¹ Neuro Interventional Surgery, Sarasota Memorial Hospital, Sarasota, FL, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA.
⁴ Neurology, University Medicine Goettingen, Goettingen, Germany.
⁵ Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
⁶ Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁷ Chonnam National University Hospital, Gwangju, Korea (the Republic of).
⁸ Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
⁹ Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA.
¹⁰ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹¹ University of Miami School of Medicine, Miami, Florida, USA.
¹² Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹³ Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹⁴ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹⁵ Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹⁶ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
¹⁷ Neurosurgery, LSUHSC, Shreveport, Louisiana, USA.
¹⁸ Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁹ Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
²⁰ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
²¹ NYU Langone Health, New York, New York, USA.
²² Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²³ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²⁴ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²⁵ Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁶ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Uruguay.
²⁷ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁸ University of Virginia, Charlottesville, Virginia, USA.
²⁹ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
³⁰ Mayo Clinic Minnesota, Rochester, Minnesota, USA.
³¹ Washington Regional Medical Center, Fayetteville, Arkansas, USA.
³² Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA.
³³ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
³⁴ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁵ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
³⁶ Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
³⁷ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
³⁸ Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, University of Houston, Houston, Texas, USA.
³⁹ Neuroendovascular surgery, HCA Houston, Houston, Texas, USA.
⁴⁰ Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA spiotta@musc.edu.

PMID: 38041671
DOI: 10.1136/jnis-2023-021046

Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

Eyad Almallouhi et al. J Neurointerv Surg. 2024.

. 2024 Nov 22;16(12):1268-1274.

doi: 10.1136/jnis-2023-021046.

Authors

Affiliations

¹ Neuro Interventional Surgery, Sarasota Memorial Hospital, Sarasota, FL, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA.
⁴ Neurology, University Medicine Goettingen, Goettingen, Germany.
⁵ Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
⁶ Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁷ Chonnam National University Hospital, Gwangju, Korea (the Republic of).
⁸ Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
⁹ Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA.
¹⁰ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹¹ University of Miami School of Medicine, Miami, Florida, USA.
¹² Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹³ Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹⁴ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹⁵ Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹⁶ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
¹⁷ Neurosurgery, LSUHSC, Shreveport, Louisiana, USA.
¹⁸ Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁹ Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
²⁰ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
²¹ NYU Langone Health, New York, New York, USA.
²² Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²³ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²⁴ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²⁵ Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁶ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Uruguay.
²⁷ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁸ University of Virginia, Charlottesville, Virginia, USA.
²⁹ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
³⁰ Mayo Clinic Minnesota, Rochester, Minnesota, USA.
³¹ Washington Regional Medical Center, Fayetteville, Arkansas, USA.
³² Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA.
³³ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
³⁴ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁵ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
³⁶ Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
³⁷ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
³⁸ Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, University of Houston, Houston, Texas, USA.
³⁹ Neuroendovascular surgery, HCA Houston, Houston, Texas, USA.
⁴⁰ Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA spiotta@musc.edu.

PMID: 38041671
DOI: 10.1136/jnis-2023-021046

Abstract

Background: Recent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of MT in LVO patients presenting with extremely large infarction core Alberta Stroke Program Early CT Score (ASPECTS 0-2).

Methods: Data from the Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We identified thrombectomy patients presenting with an occlusion in the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery and extremely large infarction core (ASPECTS 0-2). A favorable outcome was defined by achieving a modified Rankin scale of 0-3 at 90 days post-MT. Successful recanalization was defined by achieving a modified Thrombolysis In Cerebral Ischemia (mTICI) score ≥2B.

Results: We identified 58 patients who presented with ASPECTS 0-2 and underwent MT. Median age was 74.0 (66.3-80.0) years, 30 (51.7%) were females, and 16 (27.6%) patients received intravenous tissue plasminogen activator. There was no difference regarding the location of the occlusion (p=0.57). Aspiration thrombectomy was performed in 34 (64.2%) patients and stent retriever was used in 8 (15.1%) patients. In patients presenting with ASPECTS 0-2 the mortality rate was 41.4%, 31% had mRS 0-3 at day 90, 66.67% ≥70 years of age had mRS of 5-6 at day 90. On multivariable analysis, age, National Institutes of Health Stroke Scale on admission, and successful recanalization (mTICI ≥2B) were independently associated with favorable outcomes.

Conclusions: This multicentered, retrospective cohort study suggests that MT may be beneficial in a select group of patients with ASPECTS 0-2.

Keywords: Intervention; Intracranial Thrombosis; Stenosis; Stroke; Thrombectomy.

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Conflict of interest statement

Competing interests: HM received a lecture fee from Daiichi-Sankyo and Stryker and consulting services fee from B. Braun. SY received a lecture fee from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. Funding The STAR registry currently receives funding from Penumbra, Stryker and Medtronic. Dr IM: speakers honoraria from Pfizer and Bristol-Myers Squibb. Dr SAK: grant from Stryker for RESCUE-ICAS registry. Dr PJ: None. Dr J-TK: None. SQW: None. AR: None. Dr RMS: RMS research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. Dr M-NP: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted grants for the DISTAL trial from Stryker Neurovascular Inc, Phenox GmbH, Penumbra Inc and Rapid Medical Inc, Sponsor-PI SPINNERS trial (funded by a Siemens Healthineers AG Grant), research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials. Speaker fees: Stryker Neurovascular Inc, Medtronic Inc, Penumbra Inc, Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. Dr AS: None. Dr ES consults for Medtronic, microvention, Rapid Medical. Dr ASA: Consultant for Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Perfuze, Scientia, Siemens, Stryker. Research support from Balt, Medtronic, Microvention, Penumbra and Siemens. Shareholder Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros, Perfuze, Revbio, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI. Dr SY: lecture fee from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. Dr HC: Consultant for Medtronic, Penumbra and Microvention. Dr JAG: Grant support: Georgia Research Alliance, Emory Medical Care Foundation, Neurosurgery Catalyst, Consultant: Cognition, Imperative Care. Dr AA: None. Dr DGR: Consultant for Penumbra, Balt, Microvention, Phenox. Dr OT: Consulting Agreements: Viz.AI, Inc, Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention Inc, Medtronic Inc. Educational/Research Grants: Q’apel Inc, Steinberg Foundation. Dr JM: None. Dr IF: None. Dr AP: None. Dr JO: None. Dr RC: None. Dr CM: Consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical. Speaker for Penumbra and Silk Road Medical. Contact PI for NIH Grant R21NS128641. Dr MSP: Consultant for Medtronic. Dr MRL: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers and Metis Innovative; equity interest in Proprio, Cerebrotech, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery. Dr WB: None. Dr MM: None. Dr TD: None. Dr RW: Consultant for Medtronic, Stryker, and Synaptive Medical. Dr PN: Consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt. Dr PK: Grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens. Consultant for Imperative Care and Stryker Neurovascular. Stock ownership in Vena Medical. Dr RDL: PI for Imperative Trial; Research grants from Siemens Healthineers and Kaneka medical. Consultant for Cerenovus, Stryker Neurovascular and Scientia Vascular. Minor equity interest Vastrax, Borvo medical, Synchron, Endostream, Von Vascular. Dr SAC: Consultant and proctor for Medtronic and Microvention. Dr ME: None. Dr AMS: Research support from Penumbra, Stryker, Medtronic, RapidAI, Avail. Consultant for Penumbra, Stryker, Terumo, and RapidAI. Equity Avail. EA, SZ, MA, CC, MMS, SSE have no conflict of interest, received no funding, grant, or financial support from any organizations. This manuscript is presented as an e-poster at SNIS 2023. This research work has not received any funding from any company or organization.

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Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

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Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

Authors

Affiliations

Abstract

Conflict of interest statement

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