Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke : A Multicenter Analysis

Fabian Flottmann, Gabriel Broocks, Tobias Djamsched Faizy, Rosalie McDonough, Lucas Watermann, Milani Deb-Chatterji, Götz Thomalla, Moriz Herzberg, Christian H Nolte, Jens Fiehler, Hannes Leischner, Caspar Brekenfeld, GSR investigators, Tobias Boeckh-Behrens, Silke Wunderlich, Arno Reich, Martin Wiesmann, Ulrike Ernemann, Till-Karsten Hauser, Eberhard Siebert, Sarah Zweynert, Georg Bohner, Alexander Ludolph, Karl-Heinz Henn, Waltraud Pfeilschifter, Marlis Wagner, Joachim Röther, Bernd Eckert, Jörg Berrouschot, Albrecht Bormann, Christian Gerloff, Elke Hattingen, Gabor Petzold, Sven Thonke, Christopher Bangard, Christoffer Kraemer, Martin Dichgans, Frank Wollenweber, Lars Kellert, Franziska Dorn, Moriz Herzberg, Marios Psychogios, Jan Liman, Martina Petersen, Florian Stögbauer, Peter Kraft, Mirko Pham, Michael Braun, Gerhard F Hamann, Andreas Kastrup, Christian Roth, Klaus Gröschel, Timo Uphaus, Volker Limmroth, Fabian Flottmann, Gabriel Broocks, Tobias Djamsched Faizy, Rosalie McDonough, Lucas Watermann, Milani Deb-Chatterji, Götz Thomalla, Moriz Herzberg, Christian H Nolte, Jens Fiehler, Hannes Leischner, Caspar Brekenfeld, GSR investigators, Tobias Boeckh-Behrens, Silke Wunderlich, Arno Reich, Martin Wiesmann, Ulrike Ernemann, Till-Karsten Hauser, Eberhard Siebert, Sarah Zweynert, Georg Bohner, Alexander Ludolph, Karl-Heinz Henn, Waltraud Pfeilschifter, Marlis Wagner, Joachim Röther, Bernd Eckert, Jörg Berrouschot, Albrecht Bormann, Christian Gerloff, Elke Hattingen, Gabor Petzold, Sven Thonke, Christopher Bangard, Christoffer Kraemer, Martin Dichgans, Frank Wollenweber, Lars Kellert, Franziska Dorn, Moriz Herzberg, Marios Psychogios, Jan Liman, Martina Petersen, Florian Stögbauer, Peter Kraft, Mirko Pham, Michael Braun, Gerhard F Hamann, Andreas Kastrup, Christian Roth, Klaus Gröschel, Timo Uphaus, Volker Limmroth

Abstract

Aim: In acute large vessel occlusions, endovascular therapy (EVT) achieves flow restoration in the majority of cases; however, EVT fails to achieve sufficient reperfusion in a substantial minority of patients. This study aimed to identify predictors of failed reperfusion.

Methods: In this study 2211 patients from the German Stroke Registry who received EVT for anterior circulation stroke were retrospectively analyzed. Failure of reperfusion was defined as thrombolysis in cerebral infarction (TICI) grades 0/1/2a, and sufficient reperfusion as TICI 2b/3. In 1629 patients with complete datasets, associations between failure of reperfusion and baseline clinical data, comorbidities, location of occlusion, and procedural data were assessed with multiple logistic regression.

Results: Failure of reperfusion occurred in 371 patients (16.8%) and was associated with the following locations of occlusion: cervical internal carotid artery (ICA, adjusted odds ratio, OR 2.01, 95% confidence interval, CI 1.08-3.69), intracranial ICA without carotid T occlusion (adjusted OR 1.79, 95% CI 1.05-2.98), and M2 segment (adjusted OR 1.86, 95% CI 1.21-2.84). Failed reperfusion was also associated with cervical ICA stenosis (>70% stenosis, adjusted OR 2.90, 95% CI 1.69-4.97), stroke of other determined etiology by TOAST (Trial of ORG 10172 in acute stroke treatment) criteria (e.g. nonatherosclerotic vasculopathies, adjusted OR 2.73, 95% CI 1.36-5.39), and treatment given outside the usual working hours (adjusted OR 1.41, 95% CI 1.07-1.86). Successful reperfusion was associated with higher Alberta stroke program early CT score (ASPECTS) on initial imaging (adjusted OR 0.85, 95% CI 0.79-0.92), treatment with the patient under general anesthesia (adjusted OR 0.72, 95% CI 0.54-0.96), and concomitant ICA stenting in patients with ICA stenosis (adjusted OR 0.20, 95% CI 0.11-0.38).

Conclusion: Several factors are associated with failure of reperfusion, most notably occlusions of the proximal ICA and low ASPECTS on admission. Conversely, stent placement in the proximal ICA was associated with reperfusion success.

Keywords: Endovascular treatment; Large-vessel occlusion; Mechanical thrombectomy; Registry study; Unsuccessful reperfusion.

Conflict of interest statement

G. Thomalla serves as a consultant or speaker for Acandis, Bayer Healthcare, Boehringer Ingelheim, BristolMyersSquibb/Pfizer, Covidien, Glaxo Smith Kline; served as a lead investigator of the WAKE-UP study; Principal Investigator of the THRILL study; received grants by the European Union (Grant No. 278276 und 634809) and Deutsche Forschungsgemeinschaft (SFB 936, Projekt C2). C.H. Nolte reports consulting and lecture fess from Boehringer Ingelheim, W.L. Gore and Associates, Bristol-Myers Squibb, Pfizer, and Sanofi, all outside of the submitted work. J. Fiehler served as a consultant for Acandis, Boehringer Ingelheim, Codman, Microvention, Sequent, Stryker. Speaker for Bayer Healthcare, Bracco, Covidien/ev3, Penumbra, Philips, Siemens. Received grants from Bundesministeriums für Wirtschaft und Energie (BMWi), Bundesministerium für Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft (DFG), European Union (EU), Covidien, Stryker (THRILL study), Microvention (ERASER study). F. Flottmann, G. Broocks, T.D. Faizy, R. McDonough, L. Watermann, M. Deb-Chatterji, M. Herzberg, H. Leischner and C. Brekenfeld declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Patient selection flow chart. TICI Thrombolysis in cerebral infarction, DSA digital subtraction angiography
Fig. 2
Fig. 2
Adjusted odds ratio estimates with 95% confidence intervals for failure of reperfusion (Thrombolysis in Cerebral Infarction [TICI] 0-2a). Results are derived from a logistic regression model, adjusted for confounders (age, sex, admission National Institutes of Health Stroke Scale [NIHSS] score, prestroke modified Rankin Scale [mRS] score, admission imaging Alberta stroke program early CT score [ASPECTS], comorbidities, application of i.v. thrombolysis, location of vessel occlusion, stroke etiology, and treatment out of daytime routine), and based on 1629 complete observations. ICA Internal carotid artery, M2 middle cerebral artery, M2 segment, EVT endovascular therapy

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