Researchers examined data on 419 patients with acute ischemic stroke due to large vessel occlusion who were treated with mechanical thrombectomy and had successful recanalization. The study's main goal was determining if repeated clot retrieval attempts were associated with worse outcomes due to greater infarct growth and an increase in emboli to new territory within 24 hours.
"Previous studies showed that multiple clot retrieval attempts in mechanical thrombectomy for ischemic stroke are associated with lower rates of successful recanalization and have a detrimental effect on functional outcome," said lead study author Dr. Ben Hassen of Sainte-Anne Hospital and the University of Paris, in France.
"In this study we showed that this detrimental effect is due to an increased rate of emboli to new territory and higher infarct growth, explaining the poor functional outcome despite successful recanalization," Dr. Hassen said by email.
Overall, 224 patients had clot retrieval at one attempt, while 107 participants required two attempts, 49 patients needed three attempts, and 39 patients had four or more attempts.
Within 24 hours, 23 patients developed new emboli. In this group, two patients had a single clot retrieval attempt, three had two attempts, seven had three attempts, and 11 had four or more attempts.
In addition, the overall growth in the amount of brain damage within 24 hours was 14 milliliters. Average growth increased with each clot retrieval attempt, however, starting at 10 ml for a single attempt, 16 ml with two attempts, 21 ml for three attempts, and 25 ml for four or more attempts.
At three months, 57% of patients had little or no disability. With one clot retrieval attempt, 62% of patients had little or no disability, compared with 55% of patients who had two clot retrieval attempts, 49% who had three clot retrieval attempts, and 42% of patients with four or more attempts, according to the results published in Neurology.
One limitation of the study is that infarct growth could be affected by confounding factors such as the use of general anesthesia, time from onset to recanalization, and procedure times, as well as the specific thrombectomy device used for the procedure, the authors note. Another limitation is that there were too few patients to analyze five or more clot retrieval attempts separately.
"The outcome is still better if a patient recanalizes, even after more than one attempt," said Dr. Pierre Fayad, chief of the vascular neurology and stroke division at the University of Nebraska Medical Center in Omaha.
"Prospectively, it is hard to say when to stop trying," Dr. Fayad, who wasn't involved in the study, said by email. "It remains a matter of judgement based on the patient's age, pre-morbid functionality, co-morbid conditions, hemodynamic stability, size of the potential stroke, potential added value to trying harder in spite of risk."
SOURCE: https://bit.ly/3zVRXdW Neurology, online June 23, 2021.
By Lisa Rapaport
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