Original ArticleStentriever Thrombectomy Failure: A Challenge in Stroke Management
Introduction
Endovascular mechanical thrombectomy combined with intravenous thrombolysis has recently been shown to be superior to thrombolysis alone in the treatment of patients with acute ischemic stroke with large artery occlusion (LAO) of the anterior circulation.1 In particular, stentriever thrombectomy has been recommended as a first-line method for intra-arterial recanalization, although other thrombectomy or aspiration devices approved by local health authorities may be used at the discretion of the neurointerventionist if rapid, complete, and safe revascularization of the target vessel can be achieved.2 Stentriever thrombectomy does not guarantee a successful recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI], 2b-3) in all patients as already reported.3 In these cases, additional treatment with glycoprotein IIb/IIIa antagonists such as tirofiban and/or permanent stenting might represent a possible solution to achieve a better prognosis, because recanalization is known to be a strong predictor of good outcome in cerebral ischemia secondary to LAO.4 Glycoprotein IIb/IIIa inhibitors have been associated with increased risk of fatal intracerebral hemorrhage (ICH) and poor outcome,5 but not in all studies,6 and it has been shown that mechanical thrombectomy with stentrievers does not cause relevant endothelial damage.7 Permanent stenting has been suggested as another primary approach or as a rescue tool for recanalization of acute intracranial LAO,8, 9, 10 even though safety is an important issue here as well, because these procedures might increase the rates of symptomatic ICH and death. For this reason, we decided to conduct an observational study in patients with acute stroke caused by an anterior circulation LAO with the aim of investigating whether tirofiban and/or permanent stenting after mechanical thrombectomy failure are able to recanalize the occluded vessel and determine a better outcome without increasing mortality and ICH rates.
Section snippets
General Study Protocol
Patients consecutively admitted to the Stroke Unit of the University Hospital of Padua (Italy) from January 2014 to July 2016 for their first-ever acute ischemic stroke caused by anterior circulation LAO (defined as occlusion of the intracranial internal carotid artery [ICA] and/or middle cerebral artery [M1 segment and/or proximal M2 segment]) were prospectively assessed according to standardized diagnostic and therapeutic procedures as recommended by the European Stroke Organization,11
Results
During the study period, a total of 513 patients were hospitalized for their first-ever acute anterior circulation ischemic stroke, comprising 315 men (61.4%) and 198 women (38.6%), with a mean age of 71.5 ± 11.4 years. Among those with an anterior circulation LAO, 109 underwent stentriever thrombectomy either alone or in combination with intravenous thrombolysis, and a successful recanalization was achieved in 60 patients (55.0%). An intra-arterial infusion of tirofiban was administered after
Discussion
The main result of our study is that in patients with acute stroke with anterior circulation LAO refractory to stentriever thrombectomy, permanent stenting determined mTICI 2b-3 recanalization in 73.9% of cases with a better clinical outcome and a reduced mortality compared with the nonstent group, without an increase in symptomatic ICH.
Many (45%) of the patients in this study with acute ischemic stroke caused by anterior circulation LAO did not recanalize after stentriever thrombectomy either
Conclusions
According to our study, in patients with acute ischemic stroke caused by anterior circulation LAO and refractory to stentriever thrombectomy, permanent stenting seems to lead to a better clinical outcome and reduced mortality without an increase in ICH rate. Moreover, our results suggest that permanent stenting as a rescue treatment might be a therapeutic option also for elderly patients, given the positive impact of vessel recanalization in all age groups. In conclusion, permanent stenting
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Cited by (27)
Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy
2023, Journal of Stroke and Cerebrovascular DiseasesEfficacy and safety of tirofiban injection with intracranial stenting in early reocclusion due to intracranial atherosclerosis
2022, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementRescue Intracranial Stenting After Failed Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis
2019, World NeurosurgeryCitation Excerpt :Cornelissen et al.27 had no predetermined number of failed MT attempts, whereas Yoon et al.20 and Kim et al.24 required intra-arterial vasodilator delivery with persistent stenosis at 3–5 minutes prior to stenting. Interestingly, Baracchini et al.26 considered lesions appropriate for stenting when they were associated with calcified plaque or where lesions were deemed too distal for safe attempts at multiple MT passes because of a high risk of endothelial damage, dissection, or perforation. Overall, patients were older adults with a mean age of 66.6 years.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.