Multicenter Study

. 2024 Jun;9(2):328-337.

doi: 10.1177/23969873231219412. Epub 2024 Feb 26.

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study

Adam A Dmytriw^{1

2}, Basel Musmar³, Hamza Salim⁴, Sherief Ghozy⁵, James E Siegler⁶, Hassan Kobeissi⁵, Hamza Shaikh⁶, Jane Khalife⁶, Mohamad Abdalkader⁷, Piers Klein⁷, Thanh N Nguyen⁷, Jeremy J Heit⁸, Robert W Regenhardt¹, Nicole M Cancelliere², Joshua D Bernstock⁹, Kareem El Naamani¹⁰, Abdelaziz Amllay¹⁰, Lukas Meyer¹¹, Anne Dusart¹², Flavio Bellante¹², Géraud Forestier¹³, Aymeric Rouchaud¹³, Suzana Saleme¹³, Charbel Mounayer¹³, Jens Fiehler¹¹, Anna Luisa Kühn¹⁴, Ajit S Puri¹⁴, Christian Dyzmann¹⁵, Peter T Kan¹⁶, Marco Colasurdo^{16

17}, Gaultier Marnat¹⁸, Jérôme Berge¹⁸, Xavier Barreau¹⁸, Igor Sibon¹⁹, Simona Nedelcu²⁰, Nils Henninger^{20

21

22}, Thomas R Marotta², Christopher J Stapleton¹, James D Rabinov¹, Takahiro Ota²³, Shogo Dofuku²³, Leonard Ll Yeo²⁴, Benjamin Yq Tan^{24

25}, Anil Gopinathan^{24

25}, Juan Carlos Martinez-Gutierrez²⁶, Sergio Salazar-Marioni²⁶, Sunil Sheth²⁷, Leonardo Renieri²⁷, Carolina Capirossi²⁷, Ashkan Mowla²⁸, Lina Chervak²⁹, Achala Vagal²⁹, Nimer Adeeb³, Hugo H Cuellar-Saenz³, Stavropoula I Tjoumakaris¹⁰, Pascal Jabbour¹⁰, Priyank Khandelwal³⁰, Arundhati Biswas³¹, Frédéric Clarençon^{32

33}, Mahmoud Elhorany^{32

33

34}, Kevin Premat^{32

33}, Iacopo Valente³⁵, Alessandro Pedicelli³⁵, João Pedro Filipe³⁶, Ricardo Varela³⁶, Miguel Quintero-Consuegra³⁷, Nestor R Gonzalez³⁷, Markus A Möhlenbruch³⁸, Jessica Jesser³⁸, Vincent Costalat³⁹, Adrien Ter Schiphorst⁴⁰, Vivek Yedavalli⁴¹, Pablo Harker⁴², Yasmin Aziz⁴², Benjamin Gory^{43

41}, Christian Paul Stracke⁴⁴, Constantin Hecker⁴⁵, Ramanathan Kadirvel⁵, Monika Killer-Oberpfalzer⁴⁵, Christoph J Griessenauer⁴⁵, Ajith J Thomas⁶, Cheng-Yang Hsieh⁴⁶, David S Liebeskind⁴⁷, Răzvan Alexandru Radu³⁹, Andrea M Alexandre³⁵, Illario Tancredi⁴⁸, Tobias D Faizy¹¹, Robert Fahed⁴⁹, Charlotte Weyland³⁸, Boris Lubicz⁵⁰, Aman B Patel¹, Vitor Mendes Pereira², Adrien Guenego⁵⁰; MAD-MT Consortium

Affiliations

¹ Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
² Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, University of Toronto, ON, Canada.
³ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA.
⁴ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
⁵ Department of Neurological Surgery and Radiology, Mayo Clinic, Rochester, MN, USA.
⁶ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
⁷ Departments of Radiology and Neurology, Boston Medical Center, Boston, MA, USA.
⁸ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
⁹ Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA.
¹⁰ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
¹¹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
¹³ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁴ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁵ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
¹⁶ Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA.
¹⁷ Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
¹⁸ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
¹⁹ Neurology Department, Bordeaux University Hospital, Bordeaux, France.
²⁰ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
²¹ Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA.
²² Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
²³ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan.
²⁴ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
²⁵ Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.
²⁶ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²⁷ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁸ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
²⁹ Department of Neurology and Radiology, University of Cincinnati, Cincinnati, OH, USA.
³⁰ Department of Endovascular Neurosurgery and Neuroradiology, Rutgers New Jersey Medical School, Newark, NJ, USA.
³¹ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³² Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³³ GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³⁴ Neurology Department, Faculty of Medicine, Tanta University, Tanta, Egypt.
³⁵ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Florence, Italy.
³⁶ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁷ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁸ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁹ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
⁴⁰ Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
⁴¹ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
⁴² Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
⁴³ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
⁴⁴ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁵ Department of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴⁶ Neurology Department, Sin-Lau Hospital, Tainan, Taiwan.
⁴⁷ UCLA Stroke Center and Department of Neurology Department, University of California, Los Angeles, Los Angeles, CA USA.
⁴⁸ Department of Radiology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁹ Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada.
⁵⁰ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 38409796
PMCID: PMC11318435
DOI: 10.1177/23969873231219412

Multicenter Study

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study

Adam A Dmytriw et al. Eur Stroke J. 2024 Jun.

. 2024 Jun;9(2):328-337.

doi: 10.1177/23969873231219412. Epub 2024 Feb 26.

Authors

Affiliations

¹ Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
² Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, University of Toronto, ON, Canada.
³ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA.
⁴ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
⁵ Department of Neurological Surgery and Radiology, Mayo Clinic, Rochester, MN, USA.
⁶ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
⁷ Departments of Radiology and Neurology, Boston Medical Center, Boston, MA, USA.
⁸ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
⁹ Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA.
¹⁰ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
¹¹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
¹³ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁴ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁵ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
¹⁶ Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA.
¹⁷ Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
¹⁸ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
¹⁹ Neurology Department, Bordeaux University Hospital, Bordeaux, France.
²⁰ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
²¹ Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA.
²² Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
²³ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan.
²⁴ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
²⁵ Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.
²⁶ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²⁷ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁸ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
²⁹ Department of Neurology and Radiology, University of Cincinnati, Cincinnati, OH, USA.
³⁰ Department of Endovascular Neurosurgery and Neuroradiology, Rutgers New Jersey Medical School, Newark, NJ, USA.
³¹ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³² Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³³ GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³⁴ Neurology Department, Faculty of Medicine, Tanta University, Tanta, Egypt.
³⁵ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Florence, Italy.
³⁶ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁷ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁸ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁹ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
⁴⁰ Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
⁴¹ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
⁴² Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
⁴³ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
⁴⁴ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁵ Department of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴⁶ Neurology Department, Sin-Lau Hospital, Tainan, Taiwan.
⁴⁷ UCLA Stroke Center and Department of Neurology Department, University of California, Los Angeles, Los Angeles, CA USA.
⁴⁸ Department of Radiology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁹ Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada.
⁵⁰ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 38409796
PMCID: PMC11318435
DOI: 10.1177/23969873231219412

Abstract

Background: Mechanical thrombectomy (MT) has revolutionized the treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO), but its efficacy and safety in medium vessel occlusion (MeVO) remain less explored. This multicenter, retrospective study aims to investigate the incidence and clinical outcomes of vessel perforations (confirmed by extravasation during an angiographic series) during MT for AIS caused by MeVO.

Methods: Data were collected from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. A total of 1373 AIS patients with MeVO underwent MT. Baseline characteristics, procedural details, and clinical outcomes were analyzed.

Results: The incidence of vessel perforation was 4.8% (66/1373). Notably, our analysis indicates variations in perforation rates across different arterial segments: 8.9% in M3 segments, 4.3% in M2 segments, and 8.3% in A2 segments (p = 0.612). Patients with perforation had significantly worse outcomes, with lower rates of favorable angiographic outcomes (TICI 2c-3: 23% vs 58.9%, p < 0.001; TICI 2b-3: 56.5% vs 88.3%, p < 0.001). Functional outcomes were also worse in the perforation group (mRS 0-1 at 3 months: 22.7% vs 36.6%, p = 0.031; mRS 0-2 at 3 months: 28.8% vs 53.9%, p < 0.001). Mortality was higher in the perforation group (30.3% vs 16.8%, p = 0.008).

Conclusion: This study reveals that while the occurrence of vessel perforation in MT for AIS due to MeVO is relatively rare, it is associated with poor functional outcomes and higher mortality. The findings highlight the need for increased caution and specialized training in performing MT for MeVO. Further prospective research is required for risk mitigation strategies.

Keywords: AIS; MT; MeVo; Stroke; mechanical thrombectomy; perforation.

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Conflict of interest statement

Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Prof. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading), and Artedrone (Board); all not directly related to the present work. Dr. Henninger received support from NINDS NS131756, during the conduct of the study. Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr. Nguyen reports advisory board with Idorsia. Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro, and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson, and Phenox (paid lectures), all not directly related to the present work. Pr Sibon reports conflict of interest with Medtronic, Sanofi, Bayer, Boehringer-Ingelheim, Novartis, Novo-Nordisk, BMS-Pfizer (board and paid lectures), all not directly related to the present work. Dr. Yedavalli is a consultant for RAPID (Ischemaview, Menlo Park, CA). Dr. Vagal is a consultant for Viz AI. She is also PI of Imaging core lab for ENDOLOW study funded by Cerenovus (monies go to the institution). Dr. Gopinathan reports conflicts of interest with Microvention, Stryker Neurovascular, Medtronic, BD, Penumbra (paid lectures, workshops, and proctoring), all not directly related to the present work. Dr. Bernstock has an equity position in Treovir Inc., an oHSV clinical stage company and UpFront Diagnostics. JDB is also on the Centile Bioscience and NeuroX1 boards of scientific advisors.

Figures

**Figure 1.**
Sankey diagram depicts the transition of mRS scores before stroke versus 90 days after, grouped by perforation status. Colored streams represent the flow of patients from initial mRS scores (0–4) to 90-day outcomes (0–6).

**Figure 2.**
Bar charts display the percentage distribution of 90-day modified Rankin Scale (mRS) scores for stroke patients.

See this image and copyright information in PMC

References

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Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study

Affiliations

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical