Deans' stroke musings: First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Wednesday, December 28, 2022

First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry

When you enter the ER you'll have to ask your doctor if they will guarantee a first pass success. Your responsibility!

First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry

Xianjun Huang https://orcid.org/0000-0003-2646-982X, Chu Chen, and Wen Sun sunwen_medneuro@163.comView all authors and affiliations

All Articles

https://doi.org/10.1177/17562864221139595

Abstract

Background:

Achieving rapid and complete vascular recanalization in patients with acute large vessel occlusion can significantly improve patients’ prognosis.

Objective:

We aimed to investigate the potential contribution of the first-pass effect (FPE) to the clinical outcome of patients with acute vertebrobasilar artery occlusion (VBAO).

Methods:

We retrospectively analyzed the data of patients who underwent endovascular thrombectomy (EVT) caused by VBAO in a multicentered retrospective registry dataset. FPE was defined as successful recanalization [modified thrombolysis in cerebral infarction (mTICI) 2b/3 as modified FPE (mFPE); mTICI 3 as true FPE (tFPE)] after one pass of the device without rescue therapy. The baseline characteristics and procedural and clinical outcomes were analyzed. Multivariate analysis was used to explore the predictors of FPE and the relationship between FPE and 90-day prognosis.

Results:

A total of 508 patients (age, 63.7 ± 13.1 years, male, 71.6%) were finally included, 29.9% (152/508) of whom achieved mFPE, and 21.1% (107/508) of whom achieved tFPE. FPE was significantly associated with improved clinical outcomes, regardless of mFPE [odds ratio (OR): 0.601, 95% confidence interval (CI): 0.370–0.977, p = 0.040] and tFPE (OR: 0.547, 95% CI: 0.318–0.940, p = 0.029). The use of contact aspiration, favorable collateral status, cardioembolic etiology, and basilar artery occlusion were statistically significant predictors of mFPE and tFPE, whereas hypertension was a negative predictor. Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) prior to EVT was a positive predictor of mFPE but not of tFPE.

Conclusion:

FPE was associated with significantly favorable outcomes in EVT patients with VBAO. The predictors of FPE include infarct etiology, the site of occlusion, collateral status, EVT strategies, and IV rt-PA bridging strategies.

Trial registration number:

URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.

Introduction

Posterior circulation stroke occurs in approximately one-fifth of all ischemic strokes,¹ which are supplied by the vertebrobasilar artery and result in severe disability or death in nearly two-thirds of patients.² Previously, several randomized controlled studies have shown that endovascular thrombectomy (EVT) was a safe and effective treatment for large vessel occlusion stroke (LVOS) in the anterior circulation up to 24 h from stroke onset.^3,4 However, among patients with stroke from vertebrobasilar artery occlusion (VBAO), EVT treatment showed inconsistent results. Previous clinical trials failed to show significant advantages over medical therapy.^5,6 However, the ATTENTION (EndovAscular TreaTmENT for acute basilar artery occlusION) study recently published at the European Stroke Conference showed that EVT was significantly better than medical therapy [an adjusted risk ratio of 2.1, 95% confidence interval (CI): 1.5–3.0]. One important reason was a significantly higher proportion of ‘futile’ reperfusion.⁷

Achieving successful reperfusion of the target vessel occlusion is critical for improving patients’ prognosis. However, reperfusion can be achieved in single or multiple passes.⁸ Multiple passes are associated with a prolonged procedure time and aggravated arterial endothelial injury.⁹ Therefore, the concept of the first-pass effect (FPE) or modified FPE (mFPE) was introduced, which implies that ideally, EVT should achieve successful reperfusion [modified thrombolysis in cerebral infarction (mTICI) 2b/3] after a single pass.^8,10 Several previous studies have investigated the clinical value and predictors of FPE in the treatment of EVT in patients with anterior circulation LVOS.^11,12 Furthermore, a recent study showed that first-pass mTICI 2b/3 reperfusion was the only treatment-related factor predictive of clinical outcome.¹² Therefore, it is important to identify the predictors associated with first-pass reperfusion in the posterior circulation stroke.¹³

To address this question, we conducted a study comparing the baseline characteristics and clinical outcomes of patients with FPE with those of the remainder of the cohort. The aim was to identify factors that may influence the achievement of FPE in EVT patients with VBAO and the relationship between FPE and prognosis.