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Ischemic stroke
Original research
Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions
  1. Leonardo Renieri1,
  2. Iacopo Valente2,
  3. Adam A Dmytriw3,
  4. Ajit S Puri4,
  5. Jasmeet Singh4,
  6. Sergio Nappini5,
  7. Patrizia Nencini6,
  8. Artem Kaliaev7,
  9. Mohamad Abdalkader7,
  10. Andrea Alexandre2,
  11. Giuseppe Garignano2,
  12. Sheela Vivekanandan8,
  13. Reginald P Fong8,
  14. Carmen Parra-Fariñas9,
  15. Julian Spears10,
  16. Santiago Gomez-Paz11,
  17. Christopher Ogilvy11,
  18. Robert W Regenhardt12,
  19. Naif Alotaibi13,
  20. André Beer-Furlan14,
  21. Krishna C Joshi14,
  22. Melanie Walker15,
  23. Juan Vicenty-Padilla16,
  24. Jean Darcourt17,
  25. Paul Foreman18,
  26. Anna L Kuhn4,
  27. Thanh N Nguyen19,
  28. Christoph J Griessenauer8,
  29. Thomas R Marotta9,
  30. Ajith Thomas11,
  31. Aman B Patel13,
  32. Thabele M Leslie-Mazwi13,
  33. Michael Chen14,
  34. Michael R Levitt15,
  35. Karen Chen16,20,
  36. Christophe Cognard17,
  37. Alessandro Pedicelli2,
  38. Nicola Limbucci1
  1. 1 Interventional Neuroravascular Unit, University Hospital Careggi, Firenze, Italy
  2. 2 UOC Radiologia e Neuroradiologia, Policlinico Universitario Agostino Gemelli, Roma, Italy
  3. 3 Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
  4. 4 Division of Neuroradiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  5. 5 Neurovascular Interventional Unit, University Hospital Careggi, Firenze, Italy
  6. 6 Stroke Unit, University Hospital Careggi, Firenze, Italy
  7. 7 Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
  8. 8 Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
  9. 9 Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, Toronto, Ontario, Canada
  10. 10 Division of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
  11. 11 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  12. 12 Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
  13. 13 Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
  14. 14 Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
  15. 15 Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  16. 16 Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
  17. 17 Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
  18. 18 Department of Neurosurgery, Orlando Health Corp, Orlando, Florida, USA
  19. 19 Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
  20. 20 Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Iacopo Valente, UOC Radiologia e Neuroradiologia, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy; iacopovalentemd{at}gmail.com

Abstract

Background M2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking.

Methods A retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques.

Results There were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1–6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9–44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1–24.3)) and combined technique (OR 4.6 (1.1–20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome.

Conclusion Stent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.

  • catheter
  • device
  • intervention
  • stroke
  • thrombectomy

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/neurintsurg-2021-017425

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • Twitter @artemka__crh, @SantiagoGP92, @rwregen, @cgriessenauer, @dr_mchen, @DrMichaelLevitt

    • LR and IV contributed equally as first authors.

    • Collaborators Catholic University Radiology Residency Program; Pietro Trombatore, Luca Milonia.

    • Contributors All authors have read and approved the submitted manuscript. They all contributed to data collection, interpretation and analysis. All the authors contributed to writing the draft or reviewing it. All the authors agree 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 MC is a member of the JNIS editorial board.

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