Effect of endovascular reperfusion in relation to site of arterial occlusion

Objective: To assess whether the association between reperfusion and improved clinical outcomes after stroke differs depending on the site of the arterial occlusive lesion (AOL). Methods: We pooled data from Solitaire With the Intention for Thrombectomy (SWIFT), Solitaire FR Thrombectomy for Acute Revascularisation (STAR), Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2), and Interventional Management of Stroke Trial (IMS III) to compare the strength of the associations between reperfusion and clinical outcomes in patients with internal carotid artery (ICA), proximal middle cerebral artery (MCA) (M1), and distal MCA (M2/3/4) occlusions. Results: Among 710 included patients, the site of the AOL was the ICA in 161, the proximal MCA in 389, and the distal MCA in 160 patients (M2 = 131, M3 = 23, and M4 = 6). Reperfusion was associated with an increase in the rate of good functional outcome (modified Rankin Scale [mRS] score 0–2) in patients with ICA (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.7–7.2) and proximal MCA occlusions (OR 6.2, 95% CI 3.8–10.2), but not in patients with distal MCA occlusions (OR 1.4, 95% CI 0.8–2.6). Among patients with M2 occlusions, a subset of the distal MCA cohort, reperfusion was associated with excellent functional outcome (mRS 0–1; OR 2.2, 95% CI 1.0–4.7). Conclusions: The association between endovascular reperfusion and better clinical outcomes is more profound in patients with ICA and proximal MCA occlusions compared to patients with distal MCA occlusions. Because there are limited data from randomized controlled trials on the effect of endovascular therapy in patients with distal MCA occlusions, these results underscore the need for inclusion of this subgroup in future endovascular therapy trials.

[1]  G. Duckwiler,et al.  M2 occlusions as targets for endovascular therapy: comprehensive analysis of diffusion/perfusion MRI, angiography, and clinical outcomes , 2014, Journal of NeuroInterventional Surgery.

[2]  J. Martí-Fàbregas,et al.  Endovascular treatment for M2 occlusions in the era of stentrievers: a descriptive multicenter experience , 2014, Journal of NeuroInterventional Surgery.

[3]  R. Bammer,et al.  Patients with Single Distal MCA Perfusion Lesions Have a High Rate of Good Outcome with or without Reperfusion , 2014, International journal of stroke : official journal of the International Stroke Society.

[4]  A. Demchuk,et al.  Alberta Stroke Program Early Computed Tomography Score to Select Patients for Endovascular Treatment: Interventional Management of Stroke (IMS)-III Trial , 2014, Stroke.

[5]  Gerhard Schroth,et al.  Prospective, Multicenter, Single-Arm Study of Mechanical Thrombectomy Using Solitaire Flow Restoration in Acute Ischemic Stroke , 2013, Stroke.

[6]  R. Bammer,et al.  Comparison of the response to endovascular reperfusion in relation to site of arterial occlusion , 2013, Neurology.

[7]  Michael D Hill,et al.  Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. , 2013, The New England journal of medicine.

[8]  A. Ringer,et al.  Is Intra-Arterial Thrombolysis Beneficial for M2 Occlusions? Subgroup Analysis of the PROACT-II Trial , 2013, Stroke.

[9]  Elad I Levy,et al.  Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial , 2012, The Lancet.

[10]  Gregory W Albers,et al.  Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial , 2012, The Lancet.

[11]  Manabu Inoue,et al.  MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study , 2012, The Lancet Neurology.

[12]  Gerhard Schroth,et al.  Endovascular Therapy of 623 Patients With Anterior Circulation Stroke , 2012, Stroke.

[13]  J. Serfaty,et al.  Outcomes of Mechanical Endovascular Therapy for Acute Ischemic Stroke: A Clinical Registry Study and Systematic Review , 2011, Stroke.

[14]  Wade S. Smith,et al.  Predictors of Good Clinical Outcomes, Mortality, and Successful Revascularization in Patients With Acute Ischemic Stroke Undergoing Thrombectomy: Pooled Analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI Trials , 2009, Stroke.

[15]  Penumbra Pivotal Stroke Trial Investigators The Penumbra Pivotal Stroke Trial: Safety and Effectiveness of a New Generation of Mechanical Devices for Clot Removal in Intracranial Large Vessel Occlusive Disease , 2009, Stroke.

[16]  J. Broderick,et al.  Revascularization Results in the Interventional Management of Stroke II Trial , 2008, American Journal of Neuroradiology.

[17]  Jeffrey L Saver,et al.  The Impact of Recanalization on Ischemic Stroke Outcome: A Meta-Analysis , 2007, Stroke.

[18]  Werner Hacke,et al.  Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study , 2007, The Lancet.

[19]  H. Lutsep,et al.  Safety and Efficacy of Mechanical Embolectomy in Acute Ischemic Stroke: Results of the MERCI Trial , 2005, Stroke.

[20]  W. Hacke,et al.  Does arterial recanalization improve outcome in carotid territory stroke? , 1995, Stroke.

[21]  W. Jones Alberta , 1978 .