Mechanical thrombectomy in stroke patients with acute occlusion of the M1- compared to the M2-segment: Safety,efficacy,and clinical outcome

Abstract

Purpose

Endovascular treatment (ET) in occlusions of the M1- and proximal M2-segment of the middle cerebral artery (MCA) is an established procedure. In contrast, ET in distal M2-occlusions has not been sufficiently evaluated yet. The purpose of this study was to assess relevant parameters for clinical outcome, efficacy, and safety of patients undergoing ET in M1-, proximal M2-, and distal M2-occlusions.

Methods

One hundred seventy-four patients undergoing ET in acute ischemic stroke with an occlusion of the M1- or M2-segment of the MCA were enrolled prospectively. Non-parametric analysis of variance in 3-month mRS, TICI scale, and complication rates were performed with Kruskal–Wallis test between M1- and proximal and distal M2-occlusions. Subsequent pairwise group comparisons were calculated using Mann–Whitney U-tests. Binary logistic regression models were calculated for each occlusion site.

Results

There were no significant group differences in 3-month mRS, mTICI scale, or complication rates between M1- and M2-occlusions nor between proximal and distal M2-occlusions. Binary logistic regression in patients with M1-occlusions showed a substantial explanation of variance (NR²=0.35). NIHSS (p=0.009) and Maas Score as parameter for collateralization (p=0.01) appeared as significant contributing parameters. Binary logistic regression in M2-occlusions showed a high explanation of variance (NR²=0.50) of mRS but no significant factors.

Conclusions

Clinical outcome and procedural safety of patients with M2-occlusions undergoing ET are comparable to those of patients with M1-occlusions. Clinical outcome of patients with M1-occlusions undergoing ET is primarily influenced by the initial neurological deficit and the collateralization of the occlusions. By contrast, clinical outcome in patients with M2-occlusions undergoing ET is more multifactorial.

Keywords

endovascular treatment stroke M1-segment M2-segment clinical outcome

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References

Berkhemer

Fransen

Beumer

, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. New Engl Journal Medicine 2015; 372(1): 11–20.

Goyal

Demchuk

Menon

, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. New Engl Journal Medicine 2015; 372(11): 1019–1030.

Jovin

Chamorro

Cobo

, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med 2015; 372(24): 2296–2306.

Saver

Goyal

Bonafe

, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New Engl J Med 2015; 372(24): 2285–2295.

Nogueira

Jadhav

Haussen

, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New Engl Journal Medicine 2017; 378(1): 11–21.

Kaschner

M. G.

Weiss

Rubbert

, et al. One-year single-center experience with the Aperio thrombectomy device in large vessel occlusion in the anterior circulation: safety, efficacy, and clinical outcome. Neurol Sci 2019; 40(7): 1443–1451.

Campbell

Mitchell

Kleinig

, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. New Engl Journal Medicine 2015; 372(11): 1009–1018.

Salahuddin

Ramaiah

Slawski

, et al. Mechanical thrombectomy of M1 and M2 middle cerebral artery occlusions. J NeuroInterventional Surg 2018; 10(4): 330–334.

Humphries

Hoit

Doss

, et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J NeuroInterventional Surg 2015; 7(2): 90–94.

10.

Maus

Behme

Kabbasch

, et al. Maximizing First-Pass Complete Reperfusion with SAVE. Clin Neuroradiology 2018; 28(3): 327–338.

11.

Weiss

Kraus

Rubbert

, et al. Systematic evaluation of computed tomography angiography collateral scores for estimation of long-term outcome after mechanical thrombectomy in acute ischaemic stroke. Neuroradiology J 2019; 32(4): 277–286.

12.

Maas

Lev

, et al. Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 2009; 40(9): 3001–3005.

13.

Seker

Potreck

Möhlenbruch

, et al. Comparison of four different collateral scores in acute ischemic stroke by CT angiography. J NeuroInterventional Surg 2016; 8(11): 1116–1118.

14.

Von Kummer

Broderick

Campbell

BCV

, et al. The Heidelberg Bleeding Classification. Stroke 2015; 46(10): 2981–2986.

15.

Faul

Erdfelder

Buchner

, et al. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 2009; 41(4): 1149–1160.

16.

Wouters

Nysten

Thijs

, et al. Prediction of outcome in patients with acute ischemic stroke based on initial severity and improvement in the first 24 h. Front Neurol 2018; 9: 308.

17.

Seker

Pereira-Zimmermann

Pfaff

, et al. Collateral scores in acute ischemic stroke : a retrospective study assessing the suitability of collateral scores as standalone predictors of clinical outcome. Clin Neuroradiol 2019.

18.

Tomsick

Carrozzella

Foster

, et al. Endovascular therapy of M2 occlusion in IMS III: role of M2 segment definition and location on clinical and revascularization outcomes. Am J Neuroradiology 2017; 38(1): 84–89.

19.

Sheth

Jahan

Gralla

, et al. Time to endovascular reperfusion and degree of disability in acute stroke. Ann Neurology 2015; 78(4): 584–593.

20.

Ivan

Rubbert

Caspers

, et al. Mechanical thrombectomy in acute middle cerebral artery M2 segment occlusion with regard to vessel involvement. Neurol Sci 2020.

21.

Dorn

Stehle

Lockau

, et al. Endovascular treatment of acute intracerebral artery occlusions with the solitaire stent: single-centre experience with 108 recanalization procedures. Cerebrovasc Dis 2012; 34(1): 70–77.

22.

Flores

Tomasello

Cardona

, et al. Endovascular treatment for M2 occlusions in the era of stentrievers: a descriptive multicenter experience. J NeuroInterventional Surg 2015; 7(4): 234–237.

23.

Turk

Siddiqui

Fifi

, et al. Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial. The Lancet 2019; 393(10175): 998–1008.