More clot retrieval attempts tied to hemorrhage risk in large vessel occlusion stroke
Click Here to Manage Email Alerts
During endovascular therapy for large vessel occlusion stroke, more than three attempts at clot retrieval was associated with elevated risk for symptomatic intracranial hemorrhage, regardless of procedure time, researchers reported.
According to a study published in Stroke, an Alberta Stroke Program Early CT Score (ASPECTS) of 8, 9 or 10 at admission was protective against symptomatic intracranial hemorrhage following endovascular therapy (EVT).
“From our analysis, we conclude that it is the number of retrieval attempts performed rather than the procedure time that is associated with higher risk of symptomatic intracranial hemorrhage,” Máté Elöd Maros, MD, MSc, senior radiology resident at the University Medical Center Hamburg-Eppendorf in Hamburg, Germany, and colleagues wrote. “The underlying mechanism for increased symptomatic intracranial hemorrhage with increasing number of retrieval attempts is beyond the scope of this study. However, it is obvious that any additional procedural step is associated with an additional complication risk. Additional stress on the intima by each aspiration and pulling maneuver might also weaken the vessel wall.”
The researchers analyzed 593 patients from the prospective German Stroke Registry (mean age, 72 years; 51% men) who underwent EVT for acute large vessel occlusion of the anterior circulation with known NIH Stroke Scale and ASPECTS at admission, final Thrombolysis in Cerebral Infarction (TICI) scores and a recorded number of retrieval attempts. The primary outcome was symptomatic intracranial hemorrhage and the secondary outcomes was any radiologically confirmed intracranial hemorrhage within the first 24 hours after EVT.
Retrieval attempts and hemorrhage risk
In the cohort, the median number of retrieval passes was two; symptomatic intracranial hemorrhage occurred in 4.4% of patients; and intracranial hemorrhage was identified by neuroimaging in 14.3% of patients.
After adjustment for age, NIH Stroke Scale and ASPECTS at admission, final TICI and time from symptom onset to flow restoration, researchers observed that more than three retrieval passes during EVT was the strongest predictor for symptomatic intracranial hemorrhage (OR = 3.61; 95% CI, 1.38-9.42; P = .0089).
Moreover, baseline ASPECTS of 8 to 9 (OR = 0.26; 95% CI, 0.07-0.89; P = .032) or 10 (OR = 0.21; 95% CI, 0.06-0.78; P = .02) was found to be a protective factor against symptomatic intracranial hemorrhage.
Researchers identified no significant relationship between any of the factors evaluated in this study and risk for radiographically confirmed intracranial hemorrhage within the first 24 hours after delivery of EVT; however, signs of estimated effects were consistent for all predictors.
‘When to terminate the procedure’
“A fundamental question in clinical practice in cases of persistent occlusion is when to terminate the procedure. The establishment of a definite cutoff threshold for the number of device passes is beyond the scope of this study, as the decision depends on the collective assessment of multiple factors (eg, patient age, clinical history, imaging features, technical difficulties, etc), all of which have to be weighed by the interventionalist,” the researchers wrote. “However, our findings could aid interventionalists in the decision to stop or continue a procedure by pointing to the increased risk of symptomatic intracranial hemorrhage with increasing retrieval attempts, particularly when considering the accompanying declining rate of TICI 2b/3 reperfusions.”
Collapse
Click Here to Manage Email Alerts