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  • Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study

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Ischemic stroke
Original research
Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study
  1. Mahmoud H Mohammaden1,2,3,
  2. Mohamed A Tarek2,3,
  3. Hassan Aboul Nour2,3,4,
  4. Diogo C Haussen2,3,
  5. Johanna T Fifi5,
  6. Stavros Matsoukas5,
  7. Mudassir Farooqui6,
  8. Santiago Ortega-Gutierrez7,
  9. Cynthia B Zevallos8,
  10. Milagros Galecio-Castillo9,
  11. Ameer E Hassan10,
  12. Wondwossen Tekle11,
  13. Alhamza R Al-Bayati12,
  14. Mohamed M Salem13,
  15. Jan Karl Burkhardt13,
  16. Bryan Pukenas14,
  17. Gustavo M Cortez15,
  18. Ricardo A Hanel15,
  19. Amin Aghaebrahim15,
  20. Eric Sauvageau15,
  21. Muhammad Hafeez16,
  22. Peter Kan17,
  23. Omar Tanweer18,
  24. Mouhammad Jumaa19,
  25. Syed F Zaidi19,
  26. Marion Oliver20,
  27. Sunil A Sheth21,
  28. Michael Nahhas22,
  29. Sergio Salazar-Marioni21,
  30. Ahmad Khaldi23,
  31. Hanzhou Li24,
  32. Okkes Kuybu25,
  33. Mohamad Abdalkader26,
  34. Piers Klein27,
  35. Sophia Peng28,
  36. Ali Alaraj28,
  37. Thanh N Nguyen29,
  38. Raul G Nogueira2,30
  1. 1 Neurology, South Valley University Faculty of Medicine, Qena, Egypt
  2. 2 Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
  3. 3 Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
  4. 4 Neurology and Neurosurgery, University of Kentucky, Lexington, Kentucky, USA
  5. 5 Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  6. 6 Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  7. 7 Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  8. 8 Neurology, University of Iowa, Iowa City, Iowa, USA
  9. 9 Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  10. 10 Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
  11. 11 Neurology, UTRGV School of Medicine, Harlingen, Texas, USA
  12. 12 Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
  13. 13 Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  14. 14 Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  15. 15 Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
  16. 16 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  17. 17 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  18. 18 Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  19. 19 Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
  20. 20 Department of Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
  21. 21 Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
  22. 22 Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
  23. 23 Neurosurgery, WellStar Health System, Marietta, Georgia, USA
  24. 24 Department of Neurosciences, WellStar Health System, Marietta, Georgia, USA
  25. 25 Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  26. 26 Radiology, Boston University Medical Center, Boston, Massachusetts, USA
  27. 27 Neurology, Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
  28. 28 Neurosurgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
  29. 29 Neurology, Boston University Medical Center, Boston, Massachusetts, USA
  30. 30 Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Raul G Nogueira; raul.g.nogueira{at}icloud.com

Abstract

Backgrounds Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS−).

Methods This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS− (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0–2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0–2 and mRS 0–3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively.

Results A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0–2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0–3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS− (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results.

Conclusion In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.

  • Stroke
  • Thrombectomy
  • Stent

Data availability statement

Data are available upon reasonable request. Only de-identified data were used.

https://doi.org/10.1136/jnis-2023-020676

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    Data availability statement

    Data are available upon reasonable request. Only de-identified data were used.

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    Footnotes

    • X @Mahmoudneuro, @aboulnourh, @diogohaussen, @StavrosMatsouk, @CerebrovascLab, @wondeasa, @AlAlBayati1, @drnimajax, @PeterKa80460001, @MichaelNahhas, @hanssenli, @PiersKlein

    • Contributors MHM: study conception, design of the work, statistical analysis, interpretation of data, drafting of the manuscript, responsible for the overall content as the guarantor. HAN: interpretation of data, drafting of the manuscript. RGN: interpretation of data, critical revision of manuscript. Other co-authors: critical revision of manuscript. All authors gave final approval of the version to be published and 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 RGN reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Imperative Care and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte and Cerebrotech. DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI. ARA is a consultant for Stryker Neurovascular. AEH - 1. Consultant/speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NovaSignal and Vesalio. 2. Principal investigator: COMPLETE study Penumbra, LVO SYNCHRONISE-Viz.ai. 3. Steering committee/publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR. 4. Proctor: Pipeline, FRED, Wingspan, and Onyx. 5. Supported by grants from: GE Healthcare. TNN: advisory board for Idorsia, Brainomix. SOG reports consulting fees for advisory roles with Stryker Neurovascular, Medtronic and microvention. Research support from Medtronic, Stryker, Microvention, VizAI. AA is consultant for Cerenovus. JB is an Advisory Board Member and consultant for Longeviti Neuro Solutions, and Consultant for Q’Apel Medical. BG is a consultant for Medtronic and Microvention. RAH is a consultant for Medtronic, Stryker, Cerenovus, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel, advisory board for MiVI, eLum, Three Rivers, Shape Medical and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. ES reports a speakers’ agreement with Stryker. AA is on the advisory board for iSchema View. JES reports consulting fees from Ceribell, speakers’ bureau for AstraZeneca (both unrelated to the present work).

    • Provenance and peer review Not commissioned; externally 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.