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Original research
Predictors of tissue infarction from distal emboli after mechanical thrombectomy
  1. Emily Fuller1,
  2. Juan Vivanco-Suarez2,
  3. Nicholas H Fain3,
  4. Cynthia B Zevallos2,
  5. Yujing Lu2,
  6. Santiago Ortega-Gutierrez4,
  7. Colin Derdeyn4
  1. 1Carver College of Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
  2. 2Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  3. 3Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  4. 4Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Colin Derdeyn, Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA; colin-derdeyn{at}


Background Distal embolization after endovascular thrombectomy (EVT) is common. We aimed to determine factors associated with tissue infarction in the territories of distal emboli.

Methods This is a retrospective cohort study of consecutive patients with anterior circulation large vessel occlusions who underwent EVT from 2015 to 2021. Patients with Thrombolysis In Cerebral Infarction (TICI) 2b reperfusion and follow-up imaging were identified. Baseline characteristics, procedural details, and imaging findings were reviewed. Primary outcome was categorized according to the occurrence of infarction at the territory of distal embolus on follow-up diffusion-weighted imaging MRI.

Results Of 156 subjects, 97 (62%) had at least one infarction in the territories at risk. Hypertension was significantly more prevalent in the infarct group (83% vs 53%, P=0.001). General anesthesia was more commonly used in the infarct group (60% vs 43%, P=0.037). The median number of distal emboli and diameter of the occluded vessel were similar. After adjusting for confounders, hypertension (aOR 4.73, 95% CI 1.81 to 13.25, P=0.002), higher blood glucose (aOR 1.01, 95% CI 1.00 to 1.03, P=0.023), and general anesthesia (aOR 2.75, 95% CI 1.15 to 6.84, P=0.025) were independently associated with infarction. The presence of angiographic leptomeningeal collaterals predicted tissue survival (aOR 0.13, 95% CI 0.05 to 0.33, P<0.001). 90-day modified Rankin scale (mRS) scores were worse for the infarction patients (mRS 0–2: infarct, 39% vs 55%, P=0.046).

Conclusions Nearly 40% of patients with TICI 2b had no tissue infarction in the territory of a distal embolus. The association of infarction with hypertension and general anesthesia suggests late or post-procedural blood pressure management could be a modifiable factor. Patients with poor leptomeningeal collaterals or hyperglycemia may benefit from further attempts at revascularization.

  • Stroke
  • Thrombectomy
  • Artery

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 EF, JV-S, NHF, and CBZ participated in data acquisition, editing figures and tables, and revision and final approval of the manuscript. YL participated in the data analysis of the study. CD and SO-G participated in the concept of the study, acquired the data, critically revised the manuscript, and approved the final work. CD is responsible for the overall content and is the guarantor of the entire work. He accepts full responsibility for the work and conduct of the study, had access to the data, and controlled the decision to publish.

  • 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 EF – none. JV-S – none. NHF – none. CBZ – none. YL – none. SO-G – grants: NIH-NINDS (R01NS127114-01, RO3NS126804-01), Stryker, Medtronic, Microvention, Methinks,; consulting fees: Medtronic, Stryker Neurovascular. CD – consulting: Penumbra (MIND and THUNDER trial DSMBs); NoNO (FRONTIER and ESCAPE-NEXT trial DSMBs).

  • 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.