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Ischemic stroke
Original research
Endovascular reperfusion of M2 occlusions in acute ischemic stroke reduced disability and mortality: ETIS Registry results
  1. Patricio Muszynski1,
  2. Mohammad Anadani2,3,
  3. Sébastien Richard4,
  4. Gaultier Marnat5,
  5. Romain Bourcier6,
  6. Igor Sibon7,
  7. Cyril Dargazanli8,
  8. Caroline Arquizan9,
  9. Benjamin Maïer10,
  10. Raphaël Blanc10,
  11. Bertrand Lapergue11,
  12. Arturo Consoli12,
  13. Francois Eugene13,
  14. Stephane Vannier14,
  15. Laurent Spelle15,
  16. Christian Denier16,
  17. Marion Boulanger17,
  18. Maxime Gauberti18,
  19. Suzana Saleme19,
  20. Francisco Macian20,
  21. Frédéric Clarençon21,22,
  22. Charlotte Rosso23,
  23. Olivier Naggara24,
  24. Guillaume Turc25,
  25. Ozlem Ozkul-Wermester26,
  26. Chrisanthi Papagiannaki27,
  27. Alain Viguier28,
  28. Christophe Cognard29,
  29. Anthony Le Bras30,
  30. Sarah Evain31,
  31. Valérie Wolff32,
  32. Raoul Pop33,
  33. Serge Timsit34,
  34. Jean-Christophe Gentric35,
  35. Frédéric Bourdain36,
  36. Louis Veunac37,
  37. Benjamin Gory1,38,
  38. Stephanos Nikolaos Finitsis39,40
  39. on behalf of the ETIS Registry Investigators
    1. 1Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
    2. 2Washington University School of Medicine in St Louis, St Louis, Missouri, USA
    3. 3Neurology, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA
    4. 4Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
    5. 5Interventional and Diagnostic Neuroradiology, CHU Bordeaux, Bordeaux, France
    6. 6Neuroradiology, University Hospital of Nantes, Nantes, France
    7. 7Neurology, Stroke Unit, CHU Bordeaux, Bordeaux, France
    8. 8Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
    9. 9Neurology, CHRU Gui de Chauliac, Montpellier, France
    10. 10Interventional Neuroradiology, Rothschild Foundation, Paris, France
    11. 11Neurology, Stroke Unit, Foch Hospital, Suresnes, France
    12. 12Diagnostic and Therapeutic Neuroradiology, Foch Hospital, Suresnes, France
    13. 13Neuroradiology, CHU Rennes, Rennes, France
    14. 14Neurology, Stroke Unit, CHU Rennes, Rennes, France
    15. 15Interventional Neuroradiolology, CHU Bicêtre, Le Kremlin-Bicêtre, France
    16. 16Neurology, Stroke Unit, CHU Bicêtre, Le Kremlin-Bicêtre, France
    17. 17Neurology, Stroke Unit, CHU Caen, Caen, France
    18. 18Neuroradiolology, CHU Caen, Caen, France
    19. 19Neuroradiology, CHU Limoges, Limoges, France
    20. 20Neurology, Stroke Unit, CHU Limoges, Limoges, France
    21. 21Sorbonne Université, Paris, France
    22. 22Neuroradiology, CHU Pitié-Salpêtrière, Paris, France
    23. 23Neurology, Stroke Unit, CHU Pitié-Salpêtrière, Paris, France
    24. 24Neuroradiology, Hôpital St Anne, Paris, France
    25. 25Neurology, Stroke Unit, Hôpital Saint Anne, Paris, France
    26. 26Neurology, Stroke Unit, CHU Rouen, Rouen, France
    27. 27Interventional Neuroradiolology, CHU Rouen, Rouen, France
    28. 28Neurology, Stroke Unit, CHU Toulouse, Toulouse, France
    29. 29Diagnostic and Therapeutic Neuroradiology, CHU Toulouse, Toulouse, France
    30. 30Radiology, CH Bretagne Atlantique, Vannes, France
    31. 31Neurology, Stroke Unit, CH Bretagne Atlantique, Vannes, France
    32. 32Stroke Unit, CHU Strasbourg, Strasbourg, France
    33. 33Interventional Neuroradiolology, CHU Strasbourg, Strasbourg, France
    34. 34Neurology, Stroke Unit, CHU Brest, Brest, France
    35. 35Interventionl Neuroradiolology, CHU Brest, Brest, France
    36. 36Neurology, Stroke Unit, CH Côte Basque, Bayonne, France
    37. 37Radiolology, CH Côte Basque, Bayonne, France
    38. 38IADI, INSERM U1254, Université de Lorraine, Nancy, France
    39. 39Neuroradiolology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
    40. 40Radiology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
    1. Correspondence to Professor Benjamin Gory, Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France; b.gory{at}chu-nancy.fr

    Abstract

    Background The predictors of successful reperfusion and the effect of reperfusion after endovascular treatment (EVT) for M2 occlusions have not been well studied. We aimed to identify predictors of successful reperfusion and the effect of reperfusion on outcomes of EVT for M2 occlusions in current practice.

    Methods Patients with acute ischemic stroke due to isolated M2 occlusions who were enrolled in the prospective multicenter Endovascular Treatment in Ischemic Stroke (ETIS) Registry in France between January 2015 and March 2020 were included. The primary outcome was a favorable outcome, defined as modified Rankin Scale (mRS) score of 0–2 at 90 days. Successful reperfusion was defined as an improvement of ≥1 points in the modified Thrombolysis In Cerebral Infarction score between the first and the last intracranial angiogram.

    Results A total of 458 patients were included (median National Institutes of Health Stroke Scale (NIHSS) score 14; 61.4% received prior intravenous thrombolysis). Compared with the non-reperfused patients, reperfused patients had an increased rate of excellent outcome (OR 2.3, 95% CI 0.98 to 5.36; p=0.053), favorable outcome (OR 2.79, 95% CI 1.31 to 5.93; p=0.007), and reduced 90-day mortality (OR 0.39, 95% CI 0.19 to 0.79; p<0.01). Admission NIHSS score was the only predictor of successful reperfusion. First-line strategy was not a predictor of successful reperfusion or favorable outcome, but the use of a stent retriever, alone or with an aspiration catheter, was associated with higher rates of procedural complications and 90-day mortality.

    Conclusions Successful reperfusion of M2 occlusions reduced disability and mortality. However, safety is a concern, especially if the procedure failed.

    • stroke
    • thrombectomy

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information. Endovascular Treatment in Ischemic Stroke (ETIS) Investigators.

    https://doi.org/10.1136/neurintsurg-2021-017380

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      Data availability statement

      All data relevant to the study are included in the article or uploaded as supplemental information. Endovascular Treatment in Ischemic Stroke (ETIS) Investigators.

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      Footnotes

      • PM and MA are joint first authors.

      • Twitter @patricioemusz

      • PM and MA contributed equally.

      • BG and SNF contributed equally.

      • Collaborators On behalf of the Endovascular Treatment in Ischemic Stroke (ETIS) Investigators: Rothschild Foundation: Michel Piotin, Raphael Blanc, Hocine Redjem, Simon Escalard, Jean-Philippe Dessilles, François Delvoye, Stanislas Smajda, Benjamin Maier, Hebert Solène, Mikael Mazighi, Mikael Obadia, Candice Sabben, Pierre Seners, Igor Raynouard, Ovide Corabianu, Thomas de Broucker, Eric Manchon, Guillaume Taylor, Malek Ben Maacha, Laurie-Anne Thion, Augustin Lecler, Julien Savatovsjy. Foch Hospital: Adrien Wang, Serge Evrard, Maya Tchikviladze, Nadia Ajili, Bertrand Lapergue, David WeisenburgerLile, Lucas Gorza, Géraldine Buard, Oguzhan Coskun, Arturo Consoli, Federico Di Maria, Georges Rodesh, Sergio Zimatore, Morgan Leguen, Julie Gratieux, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll, Sylvie Marinier. CHU Bordeaux: Gaultier Marnat, Florent Gariel, Xavier Barreau, Jérôme Berge, Patrice Menegon, Igor Sibon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles, François Rouanet, Thomas Tourdias, Jean-Sebastien Liegey, Pierre Briau, Nicolas Pangon.

        CHU Nantes: Romain Bourcier, Lili Detraz, Benjamin Daumas-Duport, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Hubert Desal, Benoît Guillon, Solène de Gaalon, Cécile Preterre. CHRU-Nancy: Benjamin Gory, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Romain, Tonnelet, Liang Liao, François Zhu, Emmanuelle Schmitt, Sophie Planel, Sébastien Richard, Lisa Humbertjean, Gioia Mione, Jean-Christophe Lacour, Nolwenn Riou-Comte, Gérard Audibert, Marcela Voicu, Lionel Alb, Marie Reitter, Madalina Brezeanu, Agnès Masson, Adriana Tabarna, Iona Podar, Sarah Guy, Fatiha Bechiri. CHU Limoges: Francisco Macian-Montoro, Suzanna Saleme, Charbel Mounayer, Aymeric Rouchaud, Laetitia Gimenez, Alexandre Cosnard.

        CHRU Gui de Chauliac: Vincent Costalat, Caroline Arquizan, Cyril Dargazanli, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand, Lucas Corti, Federico Cagnazzo, Adrien ter Schiphorst. CHU Rennes: Francois Eugene, Stéphane Vannier, Jean-Christophe Ferre, Hélène Raoult, Thomas Ronziere, Maria Lassale, Christophe Paya, Jean-Yves Gauvrit, Clément Tracol, Sophie Langnier-Lemercier, Axelle Maurice, Sabrina Cochennec, Mélanie Pinault.

        CHU Pitié-Salpétrière: Eimad Shotar, Nader Sourour, Stéphanie Lenck, Kévin Premat, Yves Samson Anne Léger, Sophie Crozier, Flore Baronnet, Sonia Alamowitch, Laure Bottin, Mathon Yger, Vincent Degos. CHU Kremlin-Bicêtre: Laurent Spelle, Christian Denier, Olivier Chassin, Vanessa Chalumeau, Jildaz Caroff, Olivier Chassin, Laura Venditti, Mariana Sarov, Nicolas Legris.

        Hôpital Saint Anne: Olivier Naggara, Wagih Ben Hassen, Grégoire Boulouis, Christine Rodriguez-Régent, Denis Trystram, Basile Kerleroux, Guillaume Turc, Pierre Seners, Valérie Domigo, Catherine Lamy, Julia Birchenall, Clothilde Isabel, François Lun.

        CHU Toulouse: Alain Viguier, Christophe Cognard, Anne Christine Januel, Jean-Marc Olivot, Louis Fontaine, Nicolas Raposo, Fabrice Bonneville, Jean François Albucher, Lionel Calviere, Jean Darcourt, Guillaume Bellanger, Philippe Tall. CHU Caen: Emmanuel Touze, Charlotte Barbier, Romain Schneckenburger, Marion Boulanger, Julien Cogez, Sophie Guettier, Maxime Gauberti.

        CHU Brest: Serge Timsit, Jean-Christophe Gentric, Julien Ognard, Francois Mathias Merrien. CHU Rouen: Ozlem Ozku Wermester, Evelyne Massardier, Chrysanthi Papagiannaki, Aude Triquenot, Margeaux Lefebvre. CH Bayonne: Frédéric Bourdain, Patricia Bernady, Laurent Lagoarde-Segot, Hélène Cailliez, Louis Veunac, David Higue. CHU Strasbourg: Valérie Wolff, Veronique Quenardelle, Valerie Lauer, Roxana Gheoca, Irene Pierre-Paul, Raoul Pop, Remy Beaujeux, Dan Mihoc, Monica Manisor, Julien Pottecher, Alain Meyer, Thiên-Nga Chamaraux-Tran. CH Vannes: Anthony Le Bras, Sarah Evain, Arnaud Le Guen.

      • Contributors Substantial contributions to the conception or design of the work: PM, MA, BG, SNF. Acquisition, analysis, and interpretation of the data for the work: PM, MA, SR, GM, IS, RB, CD, CA, BM, RB, BL, AC, SV, LS, CD, MB, MG, SS, FM, FC, CR, ON, GT, OW, CP, AV, CC, AL, SV, VW, RP, ST, JCG, FB, LV, FE, BG, SF. Drafting the work or revising it critically for important intellectual content: PM, MA, BG, SF.

      • 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 BL reports grants from Stryker, Penumbra, and Microvention.

      • 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.