Mechanical Thrombectomy in Perioperative Strokes
A Case–Control Study
Background and Purpose—Perioperative strokes (POS) are rare but serious complications for which mechanical thrombectomy could be beneficial. We aimed to compare the technical results and patients outcomes in a population of POS versus non-POS (nPOS) treated by mechanical thrombectomy.
Methods—From 2010 to 2017, 25 patients with POS (ie, acute ischemic stroke occurring during or within 30 days after a procedure) who underwent mechanical thrombectomy (POS group) were enrolled and paired with 50 consecutive patients with nPOS (control group), based on the occlusion’s site, National Institute of Health Stroke Scale, and age.
Results—Respectively, mean age was 68.3±16.6 versus 67.2±16.6 years (P=0.70), and median National Institute of Health Stroke Scale score at admission was 20 (interquartile range, 15–25) versus 19 (interquartile range, 17–25; P=0.79). Good clinical outcome (modified Rankin Scale score of 0–2 at 3 months) was achieved by 33.3% (POS) versus 56.5% (nPOS) of patients (P=0.055). Successful reperfusion (modified Thrombolysis In Cerebral Infarction score of ≥2b) was obtained in 76% (POS) versus 86% (nPOS) of cases (P=0.22). Mortality at 3 months was 33.3% in the POS group versus 4.2% (nPOS) (P=0.002). The rate of major procedural complications was 4% (POS) versus 6% (nPOS); none were lethal. Average time from symptoms’ onset to reperfusion was 4.9 hours (±2.0) in POS versus 5.2 hours (±2.6).
Conclusions—Successful reperfusion seems accessible in POS within a reasonable amount of time and with a good level of safety. However, favorable outcome was achieved with a lower rate than in nPOS, owing to a higher mortality rate.
Perioperative strokes (POS), defined as the occurrence of an acute ischemic stroke during or within 30 days after an intervention, remain rare complications, more frequently observed after neurological, cardiac, or vascular surgeries.1,2 Even with the best medical treatment, they are known to be associated with high mortality (≈25%3) and disability rates, especially in comparison to non-POS (nPOS).4–7 Recently, the management of acute ischemic stroke with large-vessel occlusion has been drastically modified, placing mechanical thrombectomy (MT) as the spearhead of the reperfusion strategy.8 Considering that intravenous thrombolysis is usually not a suitable option in a postoperative context, patients with POS caused by vascular occlusion are good candidates for MT. This study aimed to evaluate the technical results and the clinical outcome of patients with POS treated by MT in comparison to a pair-matched control population who underwent MT for nPOS.
Materials and Methods
Neither approval of the institutional review board nor patients’ informed consent was required by the ethics committee of our institution for retrospective analyses of patients records and imaging data.
We retrospectively reviewed our prospectively filled database of MTs performed between 2008 and 2017 and included all consecutive patients treated for POS.
The control group (nPOS group) was constituted of consecutive patients from the same database who underwent MT for nPOS. Each patient was matched (2:1) with patients from the POS group based on 3 parameters: occlusion site, National Institute of Health Stroke Score at admission, and age. For the constitution of the control group, the investigator was blinded to any other demographic parameters as well as angiographic and clinical results. The pairing was performed sequentially: the most important factor was the occlusion site, then the National Institute of Health Stroke Score at admission, and finally the age. Demographics and preprocedural details are displayed in Table 1. Patients’ selection and matching, pre- and post-procedural assessments are available in the online-only Data Supplement.
The main end point was the rate of good clinical outcome defined as a modified Rankin Scale score of ≤2 at 3 months. Secondary evaluation criteria included the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction9 score of 2b or 3) and the rate of major procedure-related complications.
Data analysis was performed using Epi Info™ 22.214.171.124 (Centers for Disease Control and Prevention, Atlanta, GA). Fisher exact test was used to compare frequencies, and comparison of means was performed using a Student t test or Wilcoxon test, depending on the data distribution. Results were considered statistically significant when P value<0.05.
Twenty-five consecutive patients were included in the POS group and paired with 50 nPOS patients. The vascular occlusions were the same in both groups: cervical internal carotid artery (n=1; 4%), basilar artery (n=3; 12%), M2 segment (n=3; 12%), terminal internal carotid artery (n=3; 12%), and M1 segment (n=15; 60%). In average, POS occurred 3.7 days (±5.8; range, 0–21) after the procedures. Procedural parameters, angiographic, and clinical outcomes are summarized in Table 2, and detailed results are available in the online-only Data Supplement.
Modified Rankin Scale at 3 months was not available in 1 POS case and 4 nPOS cases (P=0.46). Good clinical outcome was achieved by 33.3% (POS) versus 56.5% (nPOS) of patients (P=0.055). Successful reperfusion was obtained in 76% (POS) versus 86% (nPOS) of cases (P=0.22) and was always reached within 6 hours from symptoms’ onset in POS cases except in 5 (20%) patients.
Mortality at 3 months was 33.3% in the POS group versus 4.2% (nPOS) (P=0.002). After exclusion of the deceased patients, good clinical outcome at 3 months was achieved by 50% of POS patients. Mortality in neurosurgical patients was of 66.7% versus 28.6% (P=0.25) in the rest of the POS group.
Open surgeries are usually considered relative or absolute contraindications to intravenous thrombolysis depending on the surgical site and of the delay from surgery.1,10 Therefore, MT seems as the most reasonable way to achieve vascular recanalization. Although POS have been deeply described and discussed in large observational studies, the rate of POS with vascular occlusion potentially accessible for MT is lacking.
Just as in nPOS, MT is technically feasible, leading to successful reperfusion of the occluded vessel in 76% of cases with an acceptable degree of safety (Figure). A nonsignificant tendency toward a better outcome at 3 months was noted in patients from the control group owing to a superior mortality rate in the POS group. Possibly, the underlying diseases requiring surgeries in POS patients and their comorbidities (especially neurological and cardiovascular) may have worsened patients’ outcome. On the contrary, intravenous thrombolysis, which was never performed in the POS, may explain the better outcome observed in the nPOS group. In the presented series, POS after brain surgeries, regardless of the technical results, were associated with poorer outcomes (modified Rankin Scale score of 5 or 6 in all cases), suggesting that there is probably a proportion of patients who will not benefit from recanalization because of various underlying factors that may promote the ischemic injuries. But for patients who survive, MT, as part of the global management, may help to improve patients’ outcome.
MT is consistently and safely able to achieve reperfusion in acute ischemic stroke in the postoperative period, within a satisfactory amount of time. Despite a higher mortality rate in POS, good clinical outcome is still achievable in a substantial amount of patients; hence the importance of an accurate early assessment and an optimized periprocedural management in highly trained centers. Yet, this work merely gives an overview of MT’s potential in POS, which needs further investigations with larger series, to be able to identify patients who could potentially benefit the most from MT.
Dr Sourour is a consultant for Medtronic, Balt, and Microvention. F. Clarençon is a consultant for Balt, Medtronic, and Codman Neurovascular. The other authors report no conflicts.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.117.018033/-/DC1.
- Received May 26, 2017.
- Revision received August 18, 2017.
- Accepted September 14, 2017.
- © 2017 American Heart Association, Inc.
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