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Background Several variations of the combined thrombectomy technique for acute ischemic stroke using a stent retriever and aspiration catheter have been described. The aim of our study was to assess how the presence of the microcatheter and stent retriever affect the basic aspiration parameters, namely, flow rate and aspiration force, depending on their position within the aspiration catheter.Methods Two experimental set-ups were designed to assess changes in flow rate and aspiration force according to the position of the stent retriever and microcatheter within the aspiration catheter.Results The transition of the stent retriever and microcatheter from the distal to proximal position resulted in a progressive increase in the flow rate, but with no impact on aspiration force. Additionally, the size of the stent retriever had no significant effect on flow rate changes and the reduction in flow rate was related to the microcatheter diameter. Negative pressure generated inside the aspiration catheter impacted on its distal segment located beyond the radiopaque marker, thus leading to its partial collapse. As a consequence, the measured aspiration force was lower than the theoretical aspiration force level for all tested aspiration catheters.Conclusions In our experimental model, the position of the stent retriever and microcatheter within the aspirator catheter affected the flow rate, but not the aspiration force. Negative pressure generated within the aspiration catheter appeared to determine a partial collapse of the distal segment that resulted in a less effective aspiration force than the theoretical aspiration force level.

BackgroundVessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation.MethodsIn this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0–2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis.ResultsDuring 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation.ConclusionsIn our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.

Background Studies investigating endovascular therapy in vertebro-basilar stroke have led to controversial results in the past, but recent randomized trials seem to show an effectiveness superiority of endovascular therapy versus best medical treatment. However, uncertainty remains concerning many aspects of thrombectomy in acute basilar artery occlusion, notably technical considerations. This study compared the first-pass effect of direct thromboaspiration and combined thrombectomy in the setting of distal basilar occlusion.Methods An in-vitro experimental set-up was used, consisting of a vascular phantom model and thrombus analogs of different consistencies to mimic human clots. Thrombus analogs were injected into the model through the vertebral artery and flowed to the basilar distal third to mimic a distal basilar occlusion. Ten procedures were performed for each thrombus analog stiffness and technique (direct thromboaspiration versus combined thrombectomy).Results Direct thromboaspiration showed an overall first-pass effect rate of 83.3% (25/30) and was particularly effective for ultra-soft and soft clot analogs, but decreased for hard clot analogs. Combined thrombectomy had an overall first-pass effect rate of 56.7% (17/30). The effect rate for ultra-soft and soft clot analogs was 60% and 50% for hard clot analogs. In the softer clot analogs, the stent-retriever device used for the combined thrombectomies tended to deviate the clot analog from a co-axial trajectory with the aspiration catheter.Conclusions In the context of distal basilar occlusion, our in-vitro results showed that higher first-pass effect rates were achieved with direct thromboaspiration compared to combined thrombectomy in all types of thrombus analogs.

Background Bilateral and simultaneous occlusion of the anterior circulation is a rare event in patients with acute ischemic stroke. Although endovascular treatment is feasible and safe, the endovascular strategy to be used remains a subject of debate.Objective To assess the different endovascular strategies proposed for the treatment of a bilateral, simultaneous anterior circulation occlusion following acute ischemic stroke.Methods We present a retrospective study of the clinical and radiological records of all patients with a bilateral, simultaneous anterior circulation occlusion treated at our center between January 2019 and December 2022. Following the PRISMA guidelines, we also conducted a systematic review of the literature.Results Two patients with a bilateral and simultaneous middle cerebral artery occlusion were treated at our center during the study period. A TICI score ≥2b was obtained in 4 out of 4 occlusions. Modified Rankin Scale (mRS) at 90 days was 0 and 4, respectively. The literature review retrieved reports on 22 patients. The most frequent bilateral occlusion sites were internal carotid artery-middle cerebral artery. The clinical presentation was severe in most patients. A combined thrombectomy technique proved to have the highest number of first-pass recanalization. A TICI ≥2b was obtained in 95% of patients and an mRS ≤2 was found in 31.8% of patients.Conclusions In patients with bilateral and simultaneous occlusion of the anterior circulation, endovascular treatment using a combined technique appears to be rapid and effective. The clinical evolution of this patient population strongly depends on the severity of the onset symptoms.

Background Occlusions of the middle cerebral artery (MCA) M2 segments can be difficult to address with mechanical thrombectomy (MTB) using standard projections and this can affect the final recanalization. Three-dimensional rotational angiography (3D-RA) allows to obtain a 3D model of cerebral vessels in a few seconds and to determine the best two-dimensional (2D) projections to be selected to evaluate and treat cerebrovascular diseases, such as aneurysms or vascular malformations. We aimed to determine if 3D-RA could be applied also in MTB.Methods A retrospective review of two patient cohorts treated during two time periods of 12 months before and after the introduction of 3D-RA use at our institution for MTB in M2 occlusions. Analyses were conducted to compare the two groups for procedural characteristics, such as timing, recanalization rate and complications and clinical outcome.Results One hundred acute ischaemic stroke (AIS) patients (3D-RA group = 57; controls = 43) underwent MTB for an M2 occlusion during the two study periods. Recanalization rates were significantly higher in cases treated with 3D-RA. The mean 3D technique thrombectomy time was compared to that of non-3D cases (47 vs. 49 min, respectively).Conclusions Our findings showed that 3D-RA is a useful tool to select specific working projections to AIS patients presenting an M2 occlusion by improving final recanalization compared to standard projections, without increasing the overall procedural time.

Introduction: Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.Patients and methods: In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.Results: 459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0–2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, p= 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, p= 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, p= 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p< 0.001).Discussion and conclusion: Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.

Background and purpose A mechanical thrombectomy technique using a double stent retriever approach has been reported for the treatment of patients with acute ischemic stroke. The purpose of this study was to perform a benchtop evaluation of the mechanism of action and efficacy of a double-stent retriever approach compared to a single-stent retriever approach.Materials and methods In vitro, mechanical thrombectomy procedures were performed in a vascular phantom reproducing an M1-M2 occlusion with two different clot analog consistencies (soft and hard). We compared the double stent retriever approach to the single stent retriever approach and recorded the recanalization rate, distal embolization, and retrieval forces of each mechanical thrombectomy procedure.Results The double stent retriever approach achieved a higher recanalization rate and lower embolic complications compared to the single stent retriever approach. This seems to stem from two facts: the greater probability of targeting the correct artery with two stents in the case of bifurcation occlusion, and an improved clot capture mechanism using the double stent retriever approach. However, the double stent retriever was associated with an increased initial retrieval force.Conclusions In vitro evaluation of the mechanism of action of the double stent retriever provided explanations that appear to support the high efficacy of such an approach in patient cohorts and could help operators when selecting the optimal mechanical thrombectomy strategy in cases of arterial occlusions difficult to treat with a single stent retriever.

Background Focal vasospasm (FV) of the occluded vessel can occur during the endovascular treatment of acute ischemic stroke (AIS). Nimodipine is commonly used to treat vasospasm and can play a role in distinguishing it from artery narrowing due to iatrogenic dissection or residual clot. However, nimodipine administration can result in arterial hypotension and subsequent enlargement of the ischemic core.Objective To assess the efficacy of preventive and continuous vasoactive amine infusion to counterbalance nimodipine-induced hypotension.Methods We reviewed data from a prospective registry of patients treated for AIS between January 2019 and January 2022 who were administered nimodipine. All patients were equipped with an arterial cannula for invasive blood pressure measurement and given vasoactive amines preemptively before general anesthesia and throughout the procedure. Data obtained from invasive monitoring of mean arterial blood pressure (MABP) in a time-lapse of 25 min before and after nimodipine administration were analyzed.Results MABP significantly decreased after nimodipine administration but remained within the recommended range (81.79 ± 0.49 mmHg). Nimodipine was effective in reducing FV caused by stent retriever passage in 76.3% of cases. Furthermore, it proved valuable in diagnosing iatrogenic dissection (9.2%), residual clot (10.5%), or intracranial stenosis (4%).Conclusions Infusion of vasoactive amines effectively counteracted the intraarterial nimodipine effect, thus avoiding frank arterial hypotension during endovascular treatment. Nimodipine has been useful in differentiating the diagnosis of FV resulting from mechanical thrombectomy and other potential causes, such as iatrogenic dissection or residual clot.