Concurrent Anterior Cerebral Artery and Middle Cerebral Artery Occlusions Predict Poor Neurological Outcome Despite Successful Thrombectomy in Anterior Circulation Stroke

Alice Hsu¹, Bachar El Baba¹, Sheila Eshraghi¹, Francesca Giraudo¹, Sepehr Saberian¹, Reda Chalhoub², Ali Alawieh¹, Zvipo Chisango¹, Brian M Howard¹, Alejandro M Spiotta², Mohammad-Mahdi Sowlat², Frank Tong¹, Feras Akbik¹, Aqueel Pabaney¹, Pascal Jabbour³, Stavropoula I Tjoumakaris³, Ilko L Maier⁴, Stacey Q Wolfe⁵, Ansaar Rai⁶, Robert M Starke⁷, Benjamin Gory⁸, Marios-Nikos Psychogios⁹, Amir Shaban¹⁰, Nitin Goyal^{11

12}, Joon-Tae Kim¹³, Shinichi Yoshimura¹⁴, Peter Kan¹⁵, Reade De Leacy¹⁶, Isabel Fragata¹⁷, Adam Polifka¹⁸, Joshua W Osbun¹⁹, Richard Williamson²⁰, Roberto Javier Crosa²¹, Michael R Levitt²², Mark Moss²³, Min S Park²⁴, Walter Casagrande²⁵, Charles Matouk²⁶, Shakeel A Chowdhry²⁷, C Michael Cawley¹, Jonathan A Grossberg¹; , On behalf of the STAR Collaborators

Affiliations

¹ Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁴ Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
⁵ Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA.
⁶ Department of Radiology, West Virginia University, Morgantown, West Virginia, USA.
⁷ Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida, USA.
⁸ Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, France.
⁹ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹⁰ Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA.
¹¹ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹² Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹³ Neurology, Chonnam National University, Gwangju, Jeollanam-do, Korea (the Republic of).
¹⁴ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
¹⁵ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
¹⁶ Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁷ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
¹⁸ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
¹⁹ Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁰ Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
²¹ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Uruguay.
²² Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²³ Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA.
²⁴ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
²⁵ Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina.
²⁶ Department of Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁷ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.

PMID: 40742212
DOI: 10.1227/neu.0000000000003669

Concurrent Anterior Cerebral Artery and Middle Cerebral Artery Occlusions Predict Poor Neurological Outcome Despite Successful Thrombectomy in Anterior Circulation Stroke

Alice Hsu et al. Neurosurgery. 2025.

. 2025 Jul 31.

doi: 10.1227/neu.0000000000003669. Online ahead of print.

Authors

Affiliations

¹ Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁴ Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
⁵ Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA.
⁶ Department of Radiology, West Virginia University, Morgantown, West Virginia, USA.
⁷ Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida, USA.
⁸ Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, France.
⁹ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹⁰ Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA.
¹¹ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹² Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹³ Neurology, Chonnam National University, Gwangju, Jeollanam-do, Korea (the Republic of).
¹⁴ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
¹⁵ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
¹⁶ Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁷ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
¹⁸ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
¹⁹ Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁰ Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
²¹ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Uruguay.
²² Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²³ Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA.
²⁴ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
²⁵ Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina.
²⁶ Department of Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁷ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.

PMID: 40742212
DOI: 10.1227/neu.0000000000003669

Abstract

Background and objectives: Despite successful endovascular thrombectomy for acute ischemic stroke, a significant proportion of patients demonstrate fast and early progression of infarct core and fail to achieve functional independence at 90 days. The aim of this study was to evaluate the impact of thrombus location and the potential impact of collaterals on concurrent middle cerebral artery (MCA) and anterior cerebral artery (ACA) occlusion.

Methods: Data were included from a multicenter registry for patients undergoing endovascular thrombectomy for anterior circulation stroke from 32 international centers between 2015 and 2021. Patients were included based on thrombus location and categorized into intracranial internal carotid artery (ICA), ICA + MCA, ICA + ACA, or MCA + ACA cohorts. The primary outcome was 90-day functional independence, defined as a modified Rankin Score (mRS) of 0-2. Secondary outcomes included successful recanalization, procedure time, and rates of postprocedural hemorrhage.

Results: In total, 2067 patients were included in the study with 83 patients (4%) having concurrent MCA + ACA occlusions. There were no differences in age, comorbidities, or intravenous thrombolysis use between the ICA and MCA + ACA groups. On univariate analysis, the MCA + ACA group had a significantly lower proportion of patients achieving mRS 0-2 at 90 days (12% vs 33%, P < .05) compared with the ICA groups. There were no differences in secondary technical outcomes between the 2 groups (P > .05); however, mortality was higher in the MCA + ACA group (22 vs 13%) (P < .05). On multivariate regression, MCA + ACA location was an independent predictor of lower odds of mRS 0-2 compared with the ICA group overall (adjusted odds ratio = 0.52, P = .048) and in patients with successful recanalization (adjusted odds ratio = 0.45, P = .035).

Conclusion: Despite similar vascular territories, concurrent occlusion of the MCA and ACA segments results in worse clinical outcomes compared with intracranial ICA occlusion.

Keywords: Dual occlusion; End artery; Endovascular thrombectomy; Stroke.

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References

1. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018.
1. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-1030.
1. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295.
1. Weyland CS, Mokli Y, Vey JA, et al. Predictors for failure of early neurological improvement after successful thrombectomy in the anterior circulation. Stroke. 2021;52(4):1291-1298.
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Concurrent Anterior Cerebral Artery and Middle Cerebral Artery Occlusions Predict Poor Neurological Outcome Despite Successful Thrombectomy in Anterior Circulation Stroke

Affiliations

Concurrent Anterior Cerebral Artery and Middle Cerebral Artery Occlusions Predict Poor Neurological Outcome Despite Successful Thrombectomy in Anterior Circulation Stroke

Authors

Affiliations

Abstract

References

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