Study Finds First Pass Reperfusion Is Associated With Favorable Outcomes in Patients With Posterior Circulation Ischemic Stroke

May 27, 2021—A study by den Hartog et al found that first pass reperfusion (FPR) after endovascular treatment of posterior circulation ischemic stroke (PCS) was associated with favorable clinical outcomes. The results were published online ahead of print in Journal of NeuroInterventional Surgery.

Investigators used data from the MR CLEAN registry to assess the characteristics associated with FPR and evaluate the effect of FPR compared with multiple pass reperfusion (MPR) on clinical outcomes in patients with PCS. Patients were included if they were aged > 18 years with symptomatic occlusion of the vertebral, basilar, or posterior cerebral artery as confirmed by baseline CTA and underwent endovascular treatment between March 16, 2014 and December 31, 2018.

Patient imaging was assessed by an imaging core laboratory, and reperfusion grade was measured by the core lab based on final digital subtraction angiography using the expanded treatment in cerebral infarction (eTICI) scale. FPR was defined as a single pass of a device with no rescue treatment with intra-arterial thrombolytics, resulting in complete or near-complete reperfusion (eTICI 2C-3). MPR was defined as eTICI 2C-3 after > 1 pass or after one pass and rescue treatment with intra-arterial thrombolytics. No excellent perfusion was defined as eTICI < 2C independently of the number of passes.

The primary outcome was percent change in 24-hour (± 12 hours) National Institutes of Health Stroke Scale (NIHSS), and the secondary outcome was modified Rankin Scale (mRS) score at 3 months, both analyzed using linear regression.

The analysis included 224 patients with PCS; 45 (20%) had FPR, 47 (21%) had MPR, 90 (40%) had no excellent reperfusion, and 42 (19%) were allocated to the unclassified reperfusion group due to a missing number of attempts or eTICI score. No associations were found between patient, imaging, or treatment characteristics and FPR.

In multivariable analyses, FPR led to a reduction in 24-hour NIHSS score as compared with no FPR (–45%; 95% CI, –65% to –12%) and MPR (–14%; 95% CI, –51% to 49). Similarly, FPR led to more favorable mRS scale scores at 3 months as compared with no FPR (adjusted common odds ratio [acOR], 2.16; 95% CI, 1.23-3.79) and MPR (acOR, 1.50; 95% CI, 0.75-3.00). Procedure time was shorter for FPR as compared with no FPR. When adjustments included procedure time, there was still a benefit of FPR as compared with no FPR (–39%; 95% CI, –63% to –2%) and MPR (–6%; 95% CI, –53% to 89%), and the effect of FPR over MPR in mRS scale score was reduced (acOR, 1.19; 95% CI, 0.56-2.55).

As noted by the investigators, potential limitations of the study included (1) the fact that treatment of PCS differed between hospitals involved in the MR CLEAN registry because at the time of inclusion, there was no clear evidence of benefit of endovascular treatment over best medical management for basilar artery occlusion; and (2) assessment of eTICI score, which is less reliable in the posterior circulation because of interference with collateral flows, incomplete visualization of the perforating arteries to the brain stem, and the consideration of antegrade flow from the anterior circulation.

Based on these study data, FPR should be the target treatment for every patient undergoing endovascular treatment, the investigators concluded.