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Original research
Association of reperfusion success and emboli in new territories with long term mortality after mechanical thrombectomy
  1. Morin Beyeler1,
  2. Loris Weber1,
  3. Christoph C Kurmann2,
  4. Eike Immo I Piechowiak2,
  5. Pascal J Mosimann2,3,
  6. Felix Zibold2,
  7. Thomas Raphael Meinel1,
  8. Mattia Branca4,
  9. Martina Goeldlin1,
  10. Sara M Pilgram-Pastor2,
  11. Lorenz Grunder5,
  12. Marcel Arnold1,
  13. David Seiffge1,
  14. Raphael Meier2,6,
  15. Mirjam R Heldner1,
  16. Tomas Dobrocky2,
  17. Pasquale Mordasini2,
  18. Jan Gralla2,
  19. Urs Fischer1,
  20. Johannes Kaesmacher2,5
  1. 1 Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
  2. 2 Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
  3. 3 Department of Diagnostic and Interventional Neuroradiology, Alfried-Krupp Krankenhaus, Essen, Nordrhein-Westfalen, Germany
  4. 4 Institute of Social and Preventive Medicine, CTU Bern, University of Bern, Switzerland, Bern, Switzerland
  5. 5 Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
  6. 6 Support Center for Advanced Neuroimaging, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
  1. Correspondence to Mr Johannes Kaesmacher, Department of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland; johannes.kaesmacher{at}insel.ch

Abstract

Background The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown.

Methods Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications.

Results Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0–90 days and for >90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction >0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86).

Conclusion Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups.

  • stroke
  • thrombectomy

Data availability statement

Data are available upon reasonable request. The data from the present study are not stored in a repository. The database is stored on a secured share point at the local comprehensive stroke center. Data are available as de-identified data. Data regarding the index ischemic stroke are derived from the local clinical database and data regarding the long term mortality are extracted from the Swiss Population Registry, which is actualized quarterly. The data are available for further use upon reasonable request to the principal investigators of this study (Johannes.kaesmacher@insel.ch or Urs.fischer@insel.ch). The original ethics protocol is also available upon reasonable request. Approval by the local ethic committee for further use of the data is required, if applicable.

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Data availability statement

Data are available upon reasonable request. The data from the present study are not stored in a repository. The database is stored on a secured share point at the local comprehensive stroke center. Data are available as de-identified data. Data regarding the index ischemic stroke are derived from the local clinical database and data regarding the long term mortality are extracted from the Swiss Population Registry, which is actualized quarterly. The data are available for further use upon reasonable request to the principal investigators of this study (Johannes.kaesmacher@insel.ch or Urs.fischer@insel.ch). The original ethics protocol is also available upon reasonable request. Approval by the local ethic committee for further use of the data is required, if applicable.

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Footnotes

  • Twitter @Morin91126916, @chris_kurmann, @FishingNeurons

  • Contributors MB contributed to conception and design, data acquisition, analysis and interpretation of the data, and writing of the publication. LW contributed to data acquisition, data interpretation, and critical revision of the manuscript for important intellectual content. CCK contributed to data acquisition, data interpretation, and critical revision of the manuscript for important intellectual content. MB contributed to analysis and interpretation of the data, and critical revision of the publication for important intellectual content. UF contributed to conception and design, critical revision of the publication for important intellectual content, and supervision. JK contributed to conception and design, analysis and interpretation of the data, writing of the publication, critical revision of the publication for important intellectual content, and supervision. All other authors contributed to interpretation of the data and critical revision of the manuscript for important intellectual content.

  • Funding This work was supported by the Swiss Academy of Medical Sciences (SAMS) within the framework of the Young Talents in Clinical Research Program (grant No YTCR 03/19) and grants provided by the Clinical Trials Unit Bern, University of Bern (grant No 84801869).

  • Competing interests UF reports grants during the conduct of the study from Medtronic, Stryker, and CSL Behring, unrelated to the submitted work. JG is a global principal investigator of STAR (Solitaire FR Thrombectomy for Acute Revascularisation), Clinical Event Committee member of the PROMISE study (Prospective, Multicenter, Observational, Single-Arm European Registry on the ACE Reperfusion Catheters and the Penumbra System in the Treatment of Acute Ischemic Stroke; Penumbra), and a principal investigator and consultant for the SWIFT DIRECT study (Solitaire With the Intention for Thrombectomy Plus Intravenous tPA Versus DIRECT Solitaire Stent-Retriever Thrombectomy in Acute Anterior Circulation Stroke; Medtronic) and receives Swiss National Science Foundation grants for magnetic resonance imaging in stroke. JK reports grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern during the conduct of the study. MA reports personal fees from Bayer, Bristol-Myers Squibb, Medtronic, Amgen, Daiichi Sankyo, Nestlé Health Sciences, Boehringer Ingelheim, and Covidien during the conduct of the study. TRM reports research support from the Bangerter Rhyner Foundation, Swiss National Foundation, and the Swiss Heart Foundation. MRH reports research support from the Bangerter Foundation, scientific advisory board honoraria from Amgen, and personal fees from Bayer.

  • 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.

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