Multicenter Study

. 2025 Mar;10(1):63-73.

doi: 10.1177/23969873241272542. Epub 2024 Aug 22.

Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis

Victor Schulze-Zachau¹, Nikki Rommers², Nikolaos Ntoulias¹, Alex Brehm¹, Nadja Krug¹, Ioannis Tsogkas¹, Matthias Mutke¹, Thilo Rusche¹, Amedeo Cervo³, Claudia Rollo³, Markus Möhlenbruch⁴, Jessica Jesser⁴, Kornelia Kreiser⁵, Katharina Althaus⁶, Manuel Requena⁷, Marc Rodrigo-Gisbert⁸, Tomas Dobrocky⁹, Bettina L Serrallach⁹, Christian H Nolte^{10

11}, Christoph Riegler^{10

11}, Jawed Nawabi^{12

13}, Errikos Maslias¹⁴, Patrik Michel¹⁴, Guillaume Saliou¹⁵, Nathan Manning^{16

17}, Alexander McQuinn^{16

17}, Alon Taylor¹⁷, Christoph J Maurer¹⁸, Ansgar Berlis¹⁸, Daniel Po Kaiser¹⁹, Ani Cuberi²⁰, Manuel Moreu²¹, Alfonso López-Frías²¹, Carlos Pérez-García²¹, Riitta Rautio²², Ylikotila Pauli²², Nicola Limbucci²³, Leonardo Renieri²³, Isabel Fragata^{24

25}, Tania Rodriguez-Ares²⁵, Jan S Kirschke²⁶, Julian Schwarting²⁶, Sami Al Kasab²⁷, Alejandro M Spiotta²⁷, Ahmad Abu Qdais²⁸, Adam A Dmytriw^{29

30}, Robert W Regenhardt²⁹, Aman B Patel²⁹, Vitor Mendes Pereira³⁰, Nicole M Cancelliere³⁰, Carsten Schmeel³¹, Franziska Dorn³¹, Malte Sauer³¹, Grzegorz M Karwacki³², Jane Khalife³³, Ajith J Thomas³⁴, Hamza A Shaikh³⁵, Christian Commodaro³⁶, Marco Pileggi³⁶, Roland Schwab³⁷, Flavio Bellante³⁸, Anne Dusart³⁸, Jeremy Hofmeister³⁹, Paolo Machi³⁹, Edgar A Samaniego^{40

41

42}, Diego J Ojeda⁴², Robert M Starke⁴³, Ahmed Abdelsalam⁴³, Frans van den Bergh⁴⁴, Sylvie De Raedt⁴⁵, Maxim Bester⁴⁶, Fabian Flottmann⁴⁶, Daniel Weiss⁴⁷, Marius Kaschner⁴⁷, Peter T Kan⁴⁸, Gautam Edhayan⁴⁸, Michael R Levitt⁴⁹, Spencer L Raub⁴⁹, Mira Katan^{2

50}, Urs Fischer^{2

50}, Marios-Nikos Psychogios^{1

2}

Affiliations

¹ Department of Diagnostic & Interventional Neuroradiology, Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland.
² Clinical Research Department, University Basel, Basel, Switzerland.
³ Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milano, Italy.
⁴ Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, Heidelberg University Hospital, Heidelberg, Germany.
⁵ Radiology and Neuroradiology Clinic, University and Rehabilitation Clinic Ulm, Ulm, Germany.
⁶ Neurology Clinic, University Hospital Ulm, Ulm, Germany.
⁷ Interventional Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
⁸ Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
⁹ Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
¹⁰ Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.
¹¹ Center for Stroke Research Berlin (CSBand Berlin Institute of Healths (BIH), Charité Universitätsmedizin Berlin, Berlin, Germany.
¹² Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany.
¹³ Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, Berlin, Germany.
¹⁴ Stroke Center, Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland.
¹⁵ Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland.
¹⁶ Department of Interventional Radiology, Liverpool Hospital, Sydney, Australia.
¹⁷ Neurointervention and Neurovascular Clinic, Prince of Wales Hospital, Sydney, Australia.
¹⁸ Department of Diagnostic and Interventional Neuroradiology, Augsburg University Hospital, Germany.
¹⁹ Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany.
²⁰ Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany.
²¹ Neurointerventional Unit, Radiology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain.
²² Department of Interventional Radiology, Turku University Hospital, Finland.
²³ Department of Neurovascular Intervention, Ospedale Careggi di Firenze, Florence, Italy.
²⁴ NOVA Medical School, Lisbon, Portugal.
²⁵ Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.
²⁶ Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany.
²⁷ Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
²⁸ Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
²⁹ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
³⁰ Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada.
³¹ Clinic for Neuroradiology, University Hospital Bonn, Bonn, Germany.
³² Department of Radiology and Nuclear Medicine, Luzerner Kantonsspital, Luzern, Switzerland.
³³ Department of Neurology, Cooper Neurological Institute, Camden, NJ, USA.
³⁴ Department of Neurosurgery, Cooper Neurological Institute, Camden, NJ, USA.
³⁵ Department of Neurointerventional Surgery, Cooper Neurological Institute, Camden, NJ, USA.
³⁶ Department of Diagnostic and Interventional Neuroradiology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.
³⁷ University Clinic for Neuroradiology, Medical Faculty, Otto-Von-Guericke-University, Magdeburg, Germany.
³⁸ Service de Neurologie, CHU de Charleroi, Charleroi, Belgium.
³⁹ Service of Diagnostic and Interventional Neuroradiology, Geneva University Hospital, Geneva, Switzerland.
⁴⁰ Department of Neurology, University of Iowa, College of Medicine, Iowa City, IA, USA.
⁴¹ Department of Neurosurgery, University of Iowa, College of Medicine, Iowa City, IA, USA.
⁴² University of Iowa, College of Medicine, Iowa City, IA, USA.
⁴³ Miami Miller School of Medicine, Jackson Memorial Hospital, University of Miami Hospital, Miami, USA.
⁴⁴ Department of Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
⁴⁵ Department of Neurology, Universitair Ziekenhuis Brussel, Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
⁴⁶ Department of Neuroradiology, University Hospital Eppendorf, Hamburg, Germany.
⁴⁷ Department of Diagnostic and Interventional Radiology, University Düsseldorf, Düsseldorf, Germany.
⁴⁸ Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA.
⁴⁹ Department of Neurosurgery, University of Washington, Seattle, Washington, USA.
⁵⁰ Neurology Clinic, University Hospital Basel, Basel, Switzerland.

PMID: 39171391
PMCID: PMC11569593
DOI: 10.1177/23969873241272542

Multicenter Study

Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis

Victor Schulze-Zachau et al. Eur Stroke J. 2025 Mar.

. 2025 Mar;10(1):63-73.

doi: 10.1177/23969873241272542. Epub 2024 Aug 22.

Authors

Affiliations

¹ Department of Diagnostic & Interventional Neuroradiology, Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland.
² Clinical Research Department, University Basel, Basel, Switzerland.
³ Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milano, Italy.
⁴ Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, Heidelberg University Hospital, Heidelberg, Germany.
⁵ Radiology and Neuroradiology Clinic, University and Rehabilitation Clinic Ulm, Ulm, Germany.
⁶ Neurology Clinic, University Hospital Ulm, Ulm, Germany.
⁷ Interventional Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
⁸ Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
⁹ Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
¹⁰ Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.
¹¹ Center for Stroke Research Berlin (CSBand Berlin Institute of Healths (BIH), Charité Universitätsmedizin Berlin, Berlin, Germany.
¹² Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany.
¹³ Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, Berlin, Germany.
¹⁴ Stroke Center, Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland.
¹⁵ Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland.
¹⁶ Department of Interventional Radiology, Liverpool Hospital, Sydney, Australia.
¹⁷ Neurointervention and Neurovascular Clinic, Prince of Wales Hospital, Sydney, Australia.
¹⁸ Department of Diagnostic and Interventional Neuroradiology, Augsburg University Hospital, Germany.
¹⁹ Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany.
²⁰ Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany.
²¹ Neurointerventional Unit, Radiology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain.
²² Department of Interventional Radiology, Turku University Hospital, Finland.
²³ Department of Neurovascular Intervention, Ospedale Careggi di Firenze, Florence, Italy.
²⁴ NOVA Medical School, Lisbon, Portugal.
²⁵ Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.
²⁶ Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany.
²⁷ Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
²⁸ Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
²⁹ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
³⁰ Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada.
³¹ Clinic for Neuroradiology, University Hospital Bonn, Bonn, Germany.
³² Department of Radiology and Nuclear Medicine, Luzerner Kantonsspital, Luzern, Switzerland.
³³ Department of Neurology, Cooper Neurological Institute, Camden, NJ, USA.
³⁴ Department of Neurosurgery, Cooper Neurological Institute, Camden, NJ, USA.
³⁵ Department of Neurointerventional Surgery, Cooper Neurological Institute, Camden, NJ, USA.
³⁶ Department of Diagnostic and Interventional Neuroradiology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.
³⁷ University Clinic for Neuroradiology, Medical Faculty, Otto-Von-Guericke-University, Magdeburg, Germany.
³⁸ Service de Neurologie, CHU de Charleroi, Charleroi, Belgium.
³⁹ Service of Diagnostic and Interventional Neuroradiology, Geneva University Hospital, Geneva, Switzerland.
⁴⁰ Department of Neurology, University of Iowa, College of Medicine, Iowa City, IA, USA.
⁴¹ Department of Neurosurgery, University of Iowa, College of Medicine, Iowa City, IA, USA.
⁴² University of Iowa, College of Medicine, Iowa City, IA, USA.
⁴³ Miami Miller School of Medicine, Jackson Memorial Hospital, University of Miami Hospital, Miami, USA.
⁴⁴ Department of Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
⁴⁵ Department of Neurology, Universitair Ziekenhuis Brussel, Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
⁴⁶ Department of Neuroradiology, University Hospital Eppendorf, Hamburg, Germany.
⁴⁷ Department of Diagnostic and Interventional Radiology, University Düsseldorf, Düsseldorf, Germany.
⁴⁸ Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA.
⁴⁹ Department of Neurosurgery, University of Washington, Seattle, Washington, USA.
⁵⁰ Neurology Clinic, University Hospital Basel, Basel, Switzerland.

PMID: 39171391
PMCID: PMC11569593
DOI: 10.1177/23969873241272542

Abstract

Introduction: Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.

Patients and methods: In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.

Results: 459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0-2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, p = 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, p = 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, p = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p < 0.001).

Discussion and conclusion: Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.

Keywords: Stroke; complication; intracranial hemorrhage; intraoperative; thrombectomy; thrombolysis.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: V. S.-Z. discloses speaker fees from Medtronic Inc. (money paid to institution). M.R.L. discloses unrestricted educational grants from Medtronic and Stryker; consulting for Medtronic, Stereotaxis, Metis Innovative and Aeaean Advisers; equity interest in Proprio, Fluid Biomed, Stroke Diagnostics, Hyperion Surgical, Apertur; editorial board of Journal of NeuroInterventional Surgery; data safety monitoring board of Arsenal Medical. M.-N.P. discloses unrestricted grants from Swiss National Science Foundation (SNF), Bangerter-Rhyner Stiftung, Stryker Neurovascular Inc., Phenox GmbH, Medtronic Inc., Rapid Medical Inc., and Penumbra Inc for the DISTAL trial, grant for SPINNERS trial from Siemens Healthineers AG (money paid to institution) and the following speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Rapid Medical Inc. and Siemens Healthineers AG (money paid to institution).

Figures

**Figure 1.**
Box plots of bleeding duration for patients under thrombolysis versus patients without thrombolysis. Left: Box plots for minimum bleeding duration. Right: Box plots for maximum bleeding duration.

**Figure 2.**
Modified Rankin Scale (mRS) at 90 days of: (1) all patients with vessel perforation during thrombectomy (upper graph), (2) patients with large vessel perforation (LV perforation, middle graph), and (3) patients with medium/distal vessel perforation (MDV perforation, lower graph). Four patients suffering from perforation of small vessels are included in the upper graph, too.

**Figure 3.**
Kaplan-Meier curves of patients with medium/distal vessel (MDV) perforation (dark blue) and patients with large vessel (LV) perforation (light blue-gray).

**Figure 4.**
Kaplan-Meier curves of patients with different bleeding durations. Left: Kaplan-Meier curves for patients with minimum bleeding duration of 0–5 min (black), 6–20 min (blue) and >20 min (light blue-gray). Right: Kaplan-Meier curves for patients with maximum bleeding duration of 0–15 min (black), 15–30 min (blue) and >30 min (light blue-gray).

See this image and copyright information in PMC

References

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Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis

Affiliations

Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous