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Original research
Thrombectomy for secondary distal, medium vessel occlusions of the posterior circulation: seeking complete reperfusion
  1. Lukas Meyer1,
  2. Christian Paul Stracke1,2,3,
  3. Marta Wallocha2,
  4. Gabriel Broocks1,
  5. Peter B Sporns1,4,
  6. Eike I Piechowiak5,
  7. Johannes Kaesmacher5,6,
  8. Christian Maegerlein7,
  9. Franziska Dorn8,
  10. Hanna Zimmermann8,
  11. Weis Naziri9,10,
  12. Nuran Abdullayev11,
  13. Christoph Kabbasch11,
  14. Daniel Behme12,13,
  15. Ala Jamous13,
  16. Volker Maus14,
  17. Sebastian Fischer14,
  18. Markus Möhlenbruch15,
  19. Charlotte Sabine Weyland15,
  20. Soenke Langner16,
  21. Dan Meila17,
  22. Milena Miszczuk18,
  23. Eberhard Siebert18,
  24. Stephan Lowens19,
  25. Lars Udo Krause20,
  26. Leonard LL Yeo21,22,
  27. Benjamin YQ Tan21,22,
  28. Anil Gopinathan21,23,
  29. Benjamin Gory24,25,
  30. Juan F Arenillas26,
  31. Pedro Navia27,
  32. Eytan Raz28,
  33. Maksim Shapiro28,
  34. Fabian Arnberg29,
  35. Kamil Zeleňák30,
  36. Mario Martínez-Galdámez31,
  37. Andreas Kastrup32,
  38. Panagiotis Papanagiotou33,34,
  39. Andre Kemmling9,10,
  40. Marios N Psychogios4,
  41. Tommy Andersson29,
  42. René Chapot2,
  43. Jens Fiehler1,
  44. Uta Hanning1
  45. On behalf of the TOPMOST Study Group
  1. 1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  2. 2Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
  3. 3Department of Interventional Neuroradiology, University Hospital Muenster, University Hospital Muenster, Muenster, Germany
  4. 4Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  5. 5Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland
  6. 6Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, Bern, Switzerland
  7. 7Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität, Munich, Germany
  8. 8Institute for Neuroradiology, Ludwig Maximilians University (LMU) Munich, Munich, Bayern, Germany
  9. 9Department of Neuroradiology, Westpfalz Hospital, Kaiserslautern, Rheinland-Pfalz, Germany
  10. 10Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
  11. 11Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
  12. 12Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
  13. 13Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Niedersachsen, Germany
  14. 14Department of Neuroradiology, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Nordrhein-Westfalen, Germany
  15. 15Department of Neuroradiology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
  16. 16Department of Neuroradiology, Rostock University Medical Center, Rostock, Mecklenburg-Vorpommern, Germany
  17. 17Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
  18. 18Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
  19. 19Department of Radiology, Klinikum Osnabrück GmbH, Osnabruck, Niedersachsen, Germany
  20. 20Department of Neurology, Klinikum Osnabrück GmbH, Osnabruck, Niedersachsen, Germany
  21. 21Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  22. 22Division of Neurology, Department of Medicine, National University Health System, Singapore
  23. 23Department of Diagnostic Imaging, National University Health System, Singapore
  24. 24Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
  25. 25Imagerie Adaptative Diagnostique et Interventionnelle, INSERM U1254, Université de Lorraine, Nancy, France
  26. 26Stroke Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
  27. 27Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
  28. 28Department of Radiology, NYU, New York, New York, USA
  29. 29Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
  30. 30Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
  31. 31Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
  32. 32Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
  33. 33Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
  34. 34Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
  1. Correspondence to Dr Lukas Meyer, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrabe, 20251 Hamburg, Germany; lu.meyer{at}


Background Whether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered.

Objective To investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO).

Methods TOPMOST (Treatment fOr Primary Medium vessel Occlusion STroke) is an international, retrospective, multicenter, observational registry of patients treated for distal cerebral artery occlusions. This study subanalysis endovascularly treated occlusions of the posterior cerebral artery in the P2 and P3 segment secondary preprocedural or periprocedural thrombus migration between January 2014 and June 2020. Technical feasibility was evaluated with the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Procedural safety was assessed by the occurrence of symptomatic intracranial hemorrhage (sICH) and intervention-related serious adverse events.

Results Among 71 patients with secondary posterior circulation DMVO who met the inclusion criteria, occlusions were present in 80.3% (57/71) located in the P2 segment and in 19.7% (14/71) in the P3 segment. Periprocedural migration occurred in 54.9% (39/71) and preprocedural migration in 45.1% (32/71) of cases. The first reperfusion attempt led in 38% (27/71) of all cases to mTICI 3. On multivariable logistic regression analysis, increased numbers of reperfusion attempts (adjusted odds ratio (aOR)=0.39, 95% CI 0.29 to 0.88, p=0.009) and preprocedural migration (aOR=4.70, 95% CI,1.35 to 16.35, p=0.015) were significantly associated with mTICI 3. sICH occurred in 2.8% (2/71).

Conclusion Thrombectomy for secondary posterior circulation DMVO seems to be safe and technically feasible. Even though thrombi that have migrated preprocedurally may be easier to retract, successful reperfusion can be achieved in the majority of patients with secondary DMVO of the P2 and P3 segment.

  • Stroke
  • Thrombectomy
  • Thrombolysis

Data availability statement

The data that support the findings of this study are available from the corresponding author after consultation with the participating centers and upon reasonable request.

Statistics from

Data availability statement

The data that support the findings of this study are available from the corresponding author after consultation with the participating centers and upon reasonable request.

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  • Collaborators Jan Gralla, MD; Pasquale Mordasini, MD: Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland. Christian Roth, MD; Maria Alexandrou, MD: Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany. Jorge Galván, MD; Miguel Schüller Arteaga MD:

    Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain. Maria Politi MD, Department for Interventional Neuroradiology, Henry Dunant Hospital, Athens, Greece.

  • Contributors LM, UH, and JF made substantial contributions to the conception and design of the work. Data acquisition was performed by all authors. LM and UH performed the data analysis. Interpretation of the data was done by LM, JF, CPS, UH, GB, and PP. LM drafted the manuscript and all other authors revised it critically for important intellectual content. All authors approved the final version to be published. They 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 manuscript 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 JF: research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; consultancy appointments; Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical; stock holdings for Tegus. PP: consultant for Penumbra and Ab Medica. AG: has served as proctor/consultant/speaker for Medtronic, Stryker, and Penumbra M. MM-G: consultant of Medtronic, Stryker, and Balt. FD: research support from Cerenovus; consultant for Cerus Endovascular, AB Medica, and Phenox; speaker honorary from Acandis, Cerenovus. JK reports grants from SAMW/Bangerter, grants from Swiss Stroke Society, and grants from Clinical Trial Unit Bern outside the submitted work. LLLY: consultant for Stryker and SeeMode; research support from National Medical Research Council (NMRC) Singapore and Ministry of Health (MOH); stock holdings for Cereflo. PBS: consultant/proctor for Balt, Acandis, Microvention. RC: consultant and/or proctor for BALT, Stryker, Microvention, Rapid Medical, Siemens Medical Systems. PN: consultant/proctor for Balt, Stryker, and Penumbra. KZ: support under the Operational Programme Integrated Infrastructure for the project: TENSION – complementary project, IMTS: 313011W875, co-financed by the European Regional Development Fund.

  • 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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