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Ischemic stroke
Original research
Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core
  1. Eyad Almallouhi1,
  2. Sara Zandpazandi2,
  3. Mohammad Anadani2,
  4. Conor Cunningham2,
  5. Mohammad-Mahdi Sowlat2,
  6. Hidetoshi Matsukawa2,
  7. Atakan Orscelik3,
  8. Sameh Samir Elawady2,
  9. Ilko Maier4,
  10. Sami Al Kasab2,5,
  11. Pascal Jabbour6,
  12. Joon-tae Kim7,
  13. Stacey Q Wolfe8,
  14. Ansaar Rai9,
  15. Robert M Starke10,11,
  16. Marios-Nikos Psychogios12,
  17. Edgar A Samaniego13,
  18. Adam S Arthur14,15,
  19. Shinichi Yoshimura16,
  20. Hugo Cuellar17,
  21. Jonathan A Grossberg18,
  22. Ali Alawieh19,
  23. Daniele G Romano20,
  24. Omar Tanweer21,
  25. Justin Mascitelli22,
  26. Isabel Fragata23,
  27. Adam J Polifka24,
  28. Joshua W Osbun25,
  29. Roberto Javier Crosa26,
  30. Charles Matouk27,
  31. Min S Park28,
  32. Michael R Levitt29,
  33. Waleed Brinjikji30,
  34. Mark Moss31,
  35. Travis M Dumont32,
  36. Richard Williamson33,
  37. Pedro Navia34,
  38. Peter Kan35,
  39. Reade De Leacy36,
  40. Shakeel A Chowdhry37,
  41. Mohamad Ezzeldin38,39,
  42. Alejandro M Spiotta2
  1. 1 Neuro Interventional Surgery, Sarasota Memorial Hospital, Sarasota, FL, USA
  2. 2 Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3 Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
  4. 4 Neurology, University Medicine Goettingen, Goettingen, Germany
  5. 5 Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  6. 6 Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  7. 7 Chonnam National University Hospital, Gwangju, Korea (the Republic of)
  8. 8 Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  9. 9 Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
  10. 10 Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  11. 11 University of Miami School of Medicine, Miami, Florida, USA
  12. 12 Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  13. 13 Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  14. 14 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  15. 15 Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  16. 16 Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
  17. 17 Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
  18. 18 Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  19. 19 Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
  20. 20 Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', Salerno, Italy
  21. 21 NYU Langone Health, New York, New York, USA
  22. 22 Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  23. 23 Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  24. 24 Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  25. 25 Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  26. 26 Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Uruguay
  27. 27 Neurosurgery, Yale University, New Haven, Connecticut, USA
  28. 28 University of Virginia, Charlottesville, Virginia, USA
  29. 29 Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  30. 30 Mayo Clinic Minnesota, Rochester, Minnesota, USA
  31. 31 Washington Regional Medical Center, Fayetteville, Arkansas, USA
  32. 32 Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  33. 33 Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
  34. 34 Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
  35. 35 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  36. 36 Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  37. 37 Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
  38. 38 Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, University of Houston, Houston, Texas, USA
  39. 39 Neuroendovascular surgery, HCA Houston, Houston, Texas, USA
  1. Correspondence to Dr Alejandro M Spiotta; spiotta{at}musc.edu

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.

  • Thrombectomy
  • Intervention
  • Intracranial Thrombosis
  • Stenosis
  • Stroke

Data availability statement

Data are available from the corresponding author upon reasonable request. Anonymized data not published within this article will be made available by request from any qualified investigator. Investigators interested in working with the data should contact the corresponding author.

https://doi.org/10.1136/jnis-2023-021046

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    Data availability statement

    Data are available from the corresponding author upon reasonable request. Anonymized data not published within this article will be made available by request from any qualified investigator. Investigators interested in working with the data should contact the corresponding author.

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    Footnotes

    • X @mahdisowlat, @PascalJabbourMD, @Starke_neurosurgery, @AdamArthurMD, @JAGrossbergMD, @rocrossa, @DrMichaelLevitt, @pnavia, @PeterKa80460001, @rdeleacymd

    • Correction notice This article has been corrected since publication. The authors reported that an error was made while transferring the 90-day mRS outcomes to Table 3 and, as a result, the reported 90-day mortality rate and mRS 0-3 were not accurate. The stated mortality rate in the manuscript was 4.5% and 27.9% for mRS 0-3 which has been corrected to 41.4% and 31% for mRS 0-3. In the abstract, the reported characteristics (age, sex, IV tPA rate, and thrombectomy technique) were for the overall population (ASPECTS 0-2 and ASPECTS 3-5). This has been amended to reflect characteristics of the main group in the study (ASPECTS 0-2). Finally, Figure 2 has been updated for clarity to remove the number "0" from the number of patients with mRS 1, which previously suggested the number "10" due to its placement next to the adjacent "1". The above mentioned errors do not impact the conclusions of the manuscript which relate to the possibility of favourable outcomes in patients with ASPECTS 0-2.

    • Contributors EA, the lead author, wrote the first draft. SZ performed the statistical analysis, and critically reviewed the final draft. MA helped with the conception and study design. CC contributed to the discussion section, revised the language MMS, data entry, and contributed to the introduction. HM helped with the study design. AO, data entry. SSE, data entry. AMS, overall content guarantor, corresponding author, supervised the study and critically reviewed the final draft. All the STAR collaborators: IM, SAK, PJ, JTK, SQW, AR, RMS, M-NP, EAS, ASA, SY, HC, JAG, AA, DGR, OT, JM, IF, AJP, JWO, RJC, CM, MSP, MRL, WB, MM, TMD, RW Jr, PN, PK, RDL, SAC, ME, revised the manuscript for important intellectual content and approved the final version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • 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.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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