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Ischemic stroke
Original research
Early stopping versus continued retrievals after failed recanalization: associated factors and implications for outcome
  1. Helge C Kniep1,
  2. Lukas Meyer1,
  3. Gabriel Broocks1,2,
  4. Matthias Bechstein1,
  5. Christian Heitkamp1,
  6. Laurens Winkelmeier1,
  7. Vincent Geest1,
  8. Tobias D Faizy3,
  9. Ludger Feyen4,5,6,
  10. Caspar Brekenfeld1,
  11. Fabian Flottmann1,
  12. Rosalie V McDonough1,7,
  13. Mate Maros8,9,
  14. Maximilian Schell10,
  15. Uta Hanning1,
  16. Goetz Thomalla10,
  17. Jens Fiehler1,
  18. Susanne Gellissen1
  19. for the German Stroke Registry - Endovascular Treatment (GSR-ET)
      1. 1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
      2. 2Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany
      3. 3Neuroendovascular Program, Department of Radiology, University Hospital Muenster, Muenster, Germany
      4. 4Department of Diagnostic and Interventional Radiology, HELIOS University Hospital Wuppertal, Wuppertal, Nordrhein-Westfalen, Germany
      5. 5Department of Diagnostic and Interventional Radiology, Helios Klinikum Krefeld, Krefeld, Germany
      6. 6Faculty of Health, School of Medicine, University Witten/Herdecke, Witten, Germany
      7. 7Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
      8. 8Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Baden-Württemberg, Germany
      9. 9Biomedical Informatics at the Center for Preventive Medicine and Digital Health (CPD-BW), Heidelberg University, Mannheim, Baden-Württemberg, Germany
      10. 10Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
      1. Correspondence to Helge C Kniep; H.kniep{at}uke.de

      Abstract

      Background Successful recanalization defined as modified Thrombolysis in Cerebral Infarction Score (mTICI) ≥2b is not achieved in 15%–20% of patients with acute ischemic stroke. This study aims to identify patient-specific factors associated with early stopping without successful recanalization. We hypothesized that the probability of the decision for early stopping during mechanical thrombectomy (MT) is higher in patients with an unfavorable prognosis.

      Methods All patients enrolled in the German Stroke Registry (GSR) between June 2015 and December 2021 were screened. Inclusion criteria were stroke in the anterior circulation and availability of relevant clinical data. For each retrieval attempt 1–3, patients with stopping and failed reperfusion (mTICI <2b) were compared with all patients with continued retrieval attempts using descriptive statistics and multivariable logistic regression.

      Results Our study included 2977 patients, 350 (12%) of which had early stopping. Higher pre-stroke Modified Rankin Scale (mRS) score (adjusted odds ratio (aOR) =1.20 (95% confidence interval (CI): 1.09; 1.32), P<0.001), higher age (aOR=1.01 (1.00; 1.02), P=0.017) and distal occlusions (aOR=1.93 (1.50; 2.47), P<0.001) as well as intraprocedural dissections/perforations (aOR=4.61 (2.95; 7.20), P<0.001) and extravasation (aOR=2.43 (1.55;3.82), P<0.001) were associated with early stopping. In patients with unsuccessful recanalization (n=622), the number of retrieval attempts (aOR=1.05 (0.94; 1.18), p=0.405) was not associated with unfavorable outcomes (90d-mRS>3).

      Conclusion The probability of early stopping was higher in patients with clinical conditions associated with: a) Favorable prognosis and assumed lower impact of recanalization success on functional status, such as distal occlusions; and b) Unfavorable prognosis, such as higher age and reduced pre-stroke functional status. Adverse events during the procedure increased the probability of early stopping. The number of recanalization attempts did not increase the risk of unfavorable outcome for patients with persistent occlusion, supporting the decision for continuation of retrieval attempts.

      • Stroke
      • Intervention
      • Technique

      Data availability statement

      Data may be obtained from a third party and are not publicly available. The data that support the findings of this study are available upon reasonable request after approval of the GSR-ET registry.

      https://doi.org/10.1136/jnis-2024-022157

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        Data availability statement

        Data may be obtained from a third party and are not publicly available. The data that support the findings of this study are available upon reasonable request after approval of the GSR-ET registry.

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        Footnotes

        • X @WinkelmeierMD, @VincentGeest, @rosevmcd, @Fie0815

        • Collaborators Joachim Röther (Asklepios Klinik Altona, Hamburg); Bernd Eckert (Asklepios Klinik Altona, Hamburg); Michael Braun (Bezirkskrankenhaus Günzburg); Gerhard F. Hamann (Bezirkskrankenhaus Günzburg); Eberhard Siebert (Charité –Benjamin Franklin und Campus Charité); Christian Nolte (Charité –Benjamin Franklin und Campus Charité); Sarah Zweynert (Charité - Campus Virchow Klinikum, Berlin); Georg Bohner (Charité - Campus Virchow Klinikum, Berlin); Jörg Berrouschot (Klinikum Altenburger Land); Albrecht Bormann (Klinikum Altenburger Land); Christoffer Kraemer (Klinikum Lüneburg); Hannes Leischner (Klinikum Lüneburg); Jörg Hattingen (KRH Klinikum Nordstadt Hannover); Martina Petersen (Klinikum Osnabrück); Florian Stögbauer (Klinikum Osnabrück); Boeckh-Behrens (Klinikum r.d.Isar); Silke Wunderlich (Klinikum r.d.Isar); Alexander Ludolph (Sana Klinikum Offenbach); Karl-Heinz Henn (Sana Klinikum Offenbach); Christian Gerloff (UKE Hamburg-Eppendorf); Jens Fiehler (UKE Hamburg-Eppendorf); Götz Thomalla (UKE Hamburg-Eppendorf); Asklepios Klinik Altona, Hamburg (UKE Hamburg-Eppendorf); Anna Alegiani (Asklepios Klinik Altona, Hamburg); Maximilian Schell (UKE Hamburg-Eppendorf); Arno Reich (Uniklinik RWTH Aachen); Omid Nikoubashman (Uniklinik RWTH Aachen); Franziska Dorn (Uniklinik Bonn); Gabor Petzold (Uniklinik Bonn); Jan Liman (Klinikum Nürnberg); Hendrik Schäfer (Uniklinik Frankfurt/ Main); Fee Keil (Uniklinik Frankfurt/ Main); Klaus Gröschel (Universitätsmedizin Mainz); Timo Uphaus (Universitätsmedizin Mainz); Peter Schellinger (Universitätsklinik Johannes Wesling Klinikum Minden); Jan Borggrefe (Universitätsklinik Johannes Wesling Klinikum Minden); Steffen Tiedt (Uniklinik München (LMU)); Lars Kellert (Uniklinik München (LMU)); Christoph Trumm (Uniklinik München (LMU)); Ulrike Ernemann (Universitätsklinik Tübingen); Sven Poli (Universitätsklinik Tübingen); Christian Riedel (Universitätsmedizin Göttingen); Marielle Sophie Ernst (Universitätsmedizin Göttingen).

        • Contributors Substantial contributions to the conception or design of the work: HK, LM, GB, MB, CH, LW, VG, TDF, SG. Acquisition, analysis, or interpretation of data for the work: LF, CB, FF, RVM, MM, MS, UH, GT, JF. Drafting the work: HK, SG. Critical revision for important intellectual content: HK, LM, GB, MB, CH, LW, VG, TDF, SG, LF, CB, FF, RVM, MM, MS, UH, GT, JF. Final approval of the version to be published: HK, LM, GB, MB, CH, LW, VG, TDF, SG, LF, CB, FF, RVM, MM, MS, UH, GT, JF. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: HK, LM, GB, MB, CH, LW, VG, TDF, SG, LF, CB, FF, RVM, MM, MS, UH, GT, JF. Guarantor of the integrity of the manuscript: HK, SG.

        • 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 HK and FF are consultants for Eppdata GmbH. HK is shareholder of Eppdata GmbH. GT received consultancy fees from Acandis, Boehringer Ingelheim, Bayer, and Portola, and fees as lecturer from Acandis, Alexion, Amarin, Bayer, Boehringer-Ingelheim, BMS/Pfizer, Daiichii Sankyo and Portola. He serves in the board of the TEA Stroke Study and of ESO. JF is consultant for Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche and Tonbridge. He serves on the advisory board of Stryker and Phenox. He is a stock holder of Tegus Medical, Eppdata and Vastrax. He serves as Associate Editor at JNIS.

        • 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.