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Flow control in the middle cerebral artery during thrombectomy: the effect of anatomy, catheter size and tip location
  1. Michael Neidlin1,
  2. Ehsan Yousefian2,
  3. Claudio Luisi1,
  4. Thorsten Sichtermann2,
  5. Jan Minkenberg2,
  6. Dimah Hasan2,
  7. Hani Ridwan2,
  8. Ulrich Steinseifer1,
  9. Martin Wiesmann2,
  10. Omid Nikoubashman2
  1. 1Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Nordrhein-Westfalen, Germany
  2. 2Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Aachen, Nordrhein-Westfalen, Germany
  1. Correspondence to Professor Omid Nikoubashman, Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Aachen 52074, Nordrhein-Westfalen, Germany; onikoubashman{at}


Background Catheter size, location and circle of Willis anatomy impact the flow conditions during interventional stroke therapy. The aim of the study was to systematically investigate the influence of these factors on flow control in the middle cerebral artery by means of a computational model based on 100 patients with stroke who received endovascular treatment.

Methods The dimensions of the cervical and intracranial cerebral arteries of 100 patients who received endovascular mechanical thrombectomy for acute ischemic stroke were measured and a three-dimensional model of the circle of Willis was created based on these data. Flow control in the middle cerebral artery with variations in catheter size, catheter location and configurations of collateral vessels was determined using a computational model. A total of 48 scenarios were analyzed.

Results Flow reversal with a distal aspiration catheter alone was not possible in the internal carotid artery and only sometimes possible in the middle cerebral artery (14 of 48 cases). The Catalyst 7 catheter was more often successful in achieving flow reversal than Catalyst 5 or 6 catheters (p<0.001). In a full circle of Willis anatomy, flow reversal was almost never possible. The absence of one or more communicating arteries significantly influenced flow direction compared with the full anatomy with all communicating arteries present (p=0.028).

Conclusion Choosing the biggest possible aspiration catheter and locating it in the middle cerebral artery significantly increases the chances of successful flow control. Flow through the collaterals may impair the flow, and circle of Willis anatomy should be considered during aspiration thrombectomy.

  • Stroke
  • Thrombectomy

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors Data collection: EY, ON, DH and HR. Data evaluation and transfer: JM, TS. Establishment of the simulation model and performing the calculations: MN, CL. Evaluating and discussing the results: MW, ON and MN. Writing the original manuscript: ON and MN. Revising the manuscript: all authors. ON: acting as guarantor. All authors read and approved the final version of the manuscript.

  • Funding This study was funded by Stryker (Kalamazoo, Michigan, USA).

  • Competing interests None declared.

  • 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.