Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 34,358 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective 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.
Showing posts with label first pass effect. Show all posts
Showing posts with label first pass effect. Show all posts
NOT GOOD ENOUGH! Survivors want 100% recovery! GET THERE!
Will you stop pushing your tyranny of low expectations? You'll want full recovery when you become the 1 in 4 per WHO that has a stroke! You better start that research now, or you'll be disabled like most of the 10 million yearly stroke survivors.
Rapid FP recanalization boosted stroke recovery, mainly due to shorter procedure times rather than full reperfusion success.
Researchers conducted a retrospective study published in July 2025 issue of Journal of Neurology to determine whether the benefits of first pass(FP)strokerecanalization were primarily associated with complete reperfusion or shorter procedure times.
They used data from 3,707 individuals with middle cerebral artery occlusion who achieved successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] 2b or higher), drawn from the German Stroke Registry (GSR) (2015–2021). A good functional outcome was defined as a modified Rankin Scale (mRS) score of ≤ 2 at 90 days. The mediation analysis was applied to assess how much complete reperfusion (mTICI 3) and reduced groin puncture contributed to recanalization time and outcome improvement.
The results showed that FP recanalization was linked to significantly better functional outcomes, with 46.9% of individuals in the FP group reaching a mRS score of ≤ 2 at 90 days, compared to 37.2% in those who underwent multiple thrombectomy attempts. Mediation analysis revealed that 14% of the benefit associated with FP recanalization was due to higher rates of complete reperfusion mTICI 3, while 37% was explained by shorter groin puncture to recanalization times.
Investigators concluded that the improved outcomes linked to FP recanalization were mainly driven by faster reperfusion rather than the extent of complete recanalization.
Well, which one got to 100% recovery? Oh you incompetently didn't measure that, did you? First pass effect is not something survivors care about, so why the fuck aren't you measuring survivor wants? Like 100% recovery?
The
optimal reperfusion technique in patients with isolated posterior
cerebral artery (PCA) occlusion is uncertain. We compared clinical and
technical outcomes with first‐line stent retriever (SR), contact
aspiration (CA), or combined techniques in patients with isolated PCA
occlusion.
Methods
This
international case–control study was conducted at 30 sites in Europe
and North America and included consecutive patients with isolated PCA
occlusion presenting within 24 hours of time last seen well from January
2015 to August 2022. The primary outcome was the first‐pass effect
(FPE), defined as expanded Treatment in Cerebral Infarction (TICI) 2c/3
on the first pass. Patients treated with SR, CA, or combined technique
were compared with multivariable logistic regression.
Results
There
were 326 patients who met inclusion criteria, 56.1% male, median age 75
(interquartile range 65–82) years, and median National Institutes of
Health Stroke Scale score 8 (5–12). Occlusion segments were PCA‐P1
(53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was
administered in 39.6%. First‐line technique was SR, CA, and combined
technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients,
respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively.
FPE was lower in patients treated with first‐line CA or combined
technique compared with SR (CA versus SR: adjusted odds ratio 0.45
[0.19–1.06]; P=0.07; combined versus SR: adjusted odds ratio 0.35 [0.016–0.80]; P=0.01).
There were lower odds of functional independence (modified Rankin scale
score 0–2) in the first‐line CA versus SR alone group (adjusted odds
ratio 0.52 [0.28–0.95]; P=0.04). FPE was associated with higher rates of favorable outcomes (modified Rankin scale score 0–2: 58% versus 43.4%; P=0.01; modified Rankin scale score 0–1: 36.6% versus 25.8%; P=0.05).
Overall, symptomatic intracranial hemorrhage was present in 5.6%
(18/326) and mortality in 10.9% (35/326) without difference between
first‐line technique.
Conclusion
In
patients with isolated PCA occlusion, SR was associated with a higher
rate of FPE compared with CA or combined techniques with no difference
in final successful reperfusion. Functional independence at 90 days was
more likely with first‐line SR compared with CA. FPE was associated with
better 90‐day clinical outcomes.
Until we get proper objectives like 100% recovery we get crapola
like this tyranny of low expectations; reperfusion. Survivors don't care
about reperfusion, that is just an intermediate step on the way to
recovery. And until we get survivors in charge researchers will not
change their habits to go after the only goal in stroke. 100% RECOVERY!
Endovascular
thrombectomy (EVT) is standard of care for acute ischemic stroke. Stent
assisted EVT with aspiration (SOLUMBRA) technique has remained a
mainstay approach. There is growing evidence that A Direct Aspiration
First Pass Technique (ADAPT) is a safe, efficient and effective approach
for EVT, offering several advantages. This study describes and reports
initial institutional experience in the use of a standardized scientific
based aspiration only technique: CANADAPT.
Methods
Single
center prospective cohort study was performed on consecutive patients
treated for large/medium vessel ischemic stroke with CANADAPT.
Intravenous thrombolytics were administered according to routine
practice, independent of the decision to proceed with EVT. A sequential
stepwise aspiration only technique was then applied, CANADAPT,
consisting of three maneuvers, A, B and C. The reperfusion success rate,
number of passes, use of rescue technique, complication rate and
procedural cost were determined.
Results
Twenty-two
patients were included in this case series representing M1 (17, 77%),
M1/2 (2, 9%), carotid-T (2, 9%) and basilar (1, 5%) occlusions. First
pass recanalization was achieved in 11 (50%) of patients. A further four
patients had successful reperfusion with a second pass of CANADAPT
(total 68% success rate). Only one patient had successful reperfusion
with the aspiration catheter at the clot interface (CANADAPT A). All
others required some withdrawal of the aspiration catheter for
reperfusion (CANADAPT B and C). Seven patients had SOLUMBRA rescue. Of
these, five patients (22% of total patients) had further successful
reperfusion. Overall median procedural time was 23 min for first
recanalization and 30 min for final recanalization. The cost per
procedure was $6630 ± 1069 for CANADAPT, and $13,530 ± 2706 for SOLUMBRA
techniques.
Conclusions
CANADAPT
represents a standardized scientific-based approach to aspiration only
thrombectomy intervention. This initial study demonstrates the safety,
efficiency and efficacy of this technique for use in EVT.
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.
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.
When you enter the emergency room you'll have to demand your doctor accomplish the thrombectomy in one pass or they better have followup protocols that restore functionality to the same that would have occurred in one pass.
The
first pass effect (FPE) is an independent predictor of functional
independence in patients with large vessel occlusion in anterior
circulation ischemic strokes. However, whether it predicts outcome in
posterior circulation large vessel occlusion (PC-LVO) is uncertain. We
aimed to study the frequency, characteristics, and predictors of FPE and
its association with clinical outcomes in PC-LVO.
Method:
We
performed an analysis from the prospective CICAT Registry. All patients
with PC-LVO who underwent endovascular therapy between January 2016 and
January 2020 were included. A centrally assessed clinical follow-up was
performed at 3 months by blinded investigators. FPE was defined as the
achievement of modified Thrombolysis In Cerebral Infarction 3 in a
single pass of the endovascular thrombectomy device, and multi-pass
effect (MPE) if it was achieved in more than one pass. A multivariable
analysis was performed to identify whether FPE is an independent
predictor of functional independence defined as a modified Rankin Score
of 0–2.
Results:
We
analyzed data from 265 patients in who FPE was achieved in 105 (39.6%).
Patients with FPE were more likely to achieve functional independence
compared to the non-FPE group (52.4% vs 25.1%, p < .001) and the MPE group (52.4% vs 26.7%, p
< .001). FPE was independently associated with functional
independence (adjusted odds ratio (aOR): 2.10, 95% confidence interval
(CI) 1.01-4.37) but MPE was not (aOR: 0.92, 95% CI 0.40-2.13).
Independent predictors of FPE were the use of direct aspiration, embolic
mechanism of stroke, and the absence of general anesthesia (GA) use.
Conclusions:
FPE
is an independent predictor of functional independence in PC-LVO and
was associated with a significantly better outcome than MPE.
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References
1. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38(3): 967–973.
With no reporting on 100% recovery you can't tell how good this is. Recanalization is an intermediate step that survivors don't give a shit about. Your reference to functional independence is just using your fucking tyranny of low expectations to justify failure.
Correspondence to Dr Ricardo A Hanel, Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA; rhanel@lyerlyneuro.com
Abstract
Background
The use of a balloon-guide catheter (BGC) in acute stroke treatment has
been widely adopted after demonstrating optimized procedure metrics and
outcomes. Initial technical constraints of previous devices included
catheter stiffness and smaller inner diameters. We aim to evaluate the
performance and safety of the Walrus BGC, a variable stiffness catheter
with a large bore 0.087 inch inner diameter (ID), via the the WICkED
study (Walrus Large Bore guide Catheter Impact on reCanalization first pass Effect anD outcomes).
Methods
This is a retrospective, site adjudicated, multicenter study on
consecutive patients with large vessel occlusion treated with the Walrus
BGC. Baseline characteristics, procedural outcomes and functional
outcomes were analyzed.
Results
A total of 338 patients met the inclusion criteria. The Walrus was
successfully tracked into distal vasculature and allowed therapeutic
device delivery in all but 3 cases (0.9%). Large aspiration catheters
≥0.070 inch ID were used in 71.9% of cases. Stent retriever thrombectomy
was used as the first-line modality in 59.2% and thromboaspiration in
40.8% of cases. The successful recanalization rate (modified treatment
in cerebral ischemia (mTICI) 2b/3) was 94.4%, with 64.8% of the patients
achieving mTICI 2b/3 after the first pass. The Walrus-related adverse
event rate was 0.6%, corresponding to two vessel dissections. Functional
independence was 50% (126/252) and mortality 25% (63/252). Unfavorable
outcomes were more likely in older patients, who had unsuccessful
reperfusion, longer procedure times, and a higher mean number of passes.
Conclusion
In acute ischemic stroke patients presenting with large vessel
occlusion, the Walrus BGC demonstrated excellent navigability and safety
profile, allowed the accommodation of leading large bore aspiration
catheters, and demonstrated high vessel recanalization rates.
So you are using the tyranny of low expectations: 'favorable outcome' ; to declare this a success? I consider it a complete fucking failure; nowhere close to 100% recovery and you show NO INTENT OF GETTING THERE. Damn it all; you should all be fired.
First‐pass
reperfusion (FPR) is associated with favorable outcome after
endovascular treatment. It is unknown whether this effect is independent
of patient characteristics and whether FPR has better outcomes compared
with excellent reperfusion (Expanded Thrombolysis in Cerebral
Infarction [eTICI] 2C‐3) after multiple‐passes reperfusion. We aimed to
evaluate the association between FPR and outcome with adjustment for
patient, imaging, and treatment characteristics to single out the
contribution of FPR.
Methods and Results
FPR
was defined as eTICI 2C‐3 after 1 pass. Multivariable regression models
were used to investigate characteristics associated with FPR and to
investigate the effect of FPR on outcomes. We included 2686 patients of
the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular
Treatment for Acute Ischemic Stroke in the Netherlands) Registry.
Factors associated with FPR were as follows: history of hyperlipidemia
(adjusted odds ratio [OR], 1.05; 95% CI, 1.01–1.10), middle cerebral
artery versus intracranial carotid artery occlusion (adjusted OR, 1.11;
95% CI, 1.06–1.16), and aspiration versus stent thrombectomy (adjusted
OR, 1.07; 95% CI, 1.03–1.11). Interventionist experience increased the
likelihood of FPR (adjusted OR, 1.03 per 50 patients previously treated;
95% CI, 1.01–1.06). Adjusted for patient, imaging, and treatment
characteristics, FPR remained associated with a better 24‐hour National
Institutes of Health Stroke Scale (NIHSS) score (−37%; 95% CI, −43% to
−31%) and a better modified Rankin Scale (mRS) score at 3 months
(adjusted common OR, 2.16; 95% CI, 1.83–2.54) compared with no FPR
(multiple‐passes reperfusion+no excellent reperfusion), and compared
with multiple‐passes reperfusion alone (24‐hour NIHSS score, (−23%; 95%
CI, −31% to −14%), and mRS score (adjusted common OR, 1.45; 95% CI,
1.19–1.78)).
Conclusions
FPR
compared with multiple‐passes reperfusion is associated with favorable
outcome,(But it wasn't 100% recovery,was it? So it wasn't favorable?) independently of patient, imaging, and treatment
characteristics. Factors associated with FPR were the experience of the
interventionist, history of hyperlipidemia, location of occluded artery,
and use of an aspiration device compared with stent thrombectomy.
Until we get proper objectives like 100% recovery we get crapola like this tyranny of low expectations; reperfusion. Survivors don't care about reperfusion, that is just an intermediate step on the way to recovery. And until we get survivors in charge researchers will not change their habits to go after the only goal in stroke. 100% RECOVERY!
Correspondence to Dr Ashutosh P Jadhav, Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; jadhav.library@gmail.com
Abstract
Background
First pass effect (FPE), defined as near-total/total reperfusion of the
territory (modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3)
of the occluded artery after a single thrombectomy attempt (single
pass), has been associated with superior safety and efficacy outcomes
than in patients not experiencing FPE.
Objective
To characterize the clinical features, incidence, and predictors of FPE
in the anterior and posterior circulation among patients enrolled in
the Trevo Registry.
Methods
Data were analyzed from the Trevo Retriever Registry. Univariate and
multivariable analyses were used to assess the relationship of patient
(demographics, clinical, occlusion location, collateral grade, Alberta
Stroke Program Early CT Score (ASPECTS)) and device/technique
characteristics with FPE (mTICI 2c/3 after single pass).
Results
FPE was achieved in 27.8% (378/1358) of patients undergoing anterior
large vessel occlusion (LVO) thrombectomy. Multivariable regression
analysis identified American Society of Interventional and Therapeutic
Neuroradiology (ASITN) levels 2–4, higher ASPECTS, and presence of
atrial fibrillation as independent predictors of FPE in anterior LVO
thrombectomy. Rates of modified Rankin Scale (mRS) score 0–2 at 90 days
were higher (63.9% vs 53.5%, p<0.0006), and 90-day mortality (11.4%
vs 12.8%, p=0.49) was comparable in the FPE group and non-FPE group.
Rate of FPE was 23.8% (19/80) among basilar artery occlusion strokes,
and outcomes were similar between FPE and non-FPE groups (mRS score 0–2,
47.4% vs 52.5%, p=0.70; mortality 26.3% vs 18.0%, p=0.43). Notably,
there were no difference in outcomes in FPE versus non-FPE mTICI 2c/3
patients.
Conclusion
Twenty-eight percent of patients undergoing anterior LVO thrombectomy
and 24% of patients undergoing basilar artery occlusion thrombectomy
experience FPE. Independent predictors of FPE in anterior circulation
LVO thrombectomy include higher ASITN levels, higher ASPECTS, and the
presence of atrial fibrillation.
You have got to be fucking kidding. Measuring COST RATHER THAN 100% RECOVERY! Do you really think survivors care about cost? Talk to them sometime, you are treating them, not your bottom line.
A study published in the British Medical Journal (BMJ)
has found that first-pass effect (FPE), restoring complete or near
complete reperfusion (modified Thrombolysis in Cerebral Infarction
[mTICI] 2c-[SM1] 3) in a single pass, used as an endovascular treatment
of acute ischaemic stroke, not only provides better clinical results,
but also lowers health costs. Researchers found a lower cost potential
per stroke patient annually, in every country studied.
The objective of the study was to assess the economic impact of
achieving complete or near complete reperfusion after FPE, compared with
the need for multiple passes to achieve the same level of reperfusion.
Study authors noted that, “Complete reperfusion of brain tissue is
the primary goal in treatment of acute ischaemic stroke. Rapid
revascularisation is vital as reduced time from symptom onset to
revascularisation is strongly correlated with improved clinical and
functional outcomes. Complete revascularisation with mechanical
thrombectomy, a cost-effective treatment for patients with acute stroke,
might require multiple passes, which prolongs procedure time and
increases the risk of arterial endothelial injury.”
The
analysis of revascularisation in ischaemic stroke with emboTrap study
(ARISE II study) is, a prospective, single-arm, international,
multicentre clinical trial, investigating the efficacy and safety of the
EmboTrap device (Cerenovus) in 227 treated patients. Patient level data
from the ARISE II study was used to conduct post hoc analyses
on patient outcomes. The target population were patients for whom mTICI
2c–3 was achieved (n=172). Therefore, the patients from this study were
split into two groups. The first was the FPE group, patients for whom
mTICI 2c–3 was achieved on the first pass. The second was the non-FPE
group:, patients who only achieved mTICI 2c–3 after multiple passes.
Data from the ARISE II study were used to establish baseline
characteristics, clinical outcomes, and healthcare resources for both
the FPE and non-FPE cohorts.
The researchers then used peer reviewed literature and public market
research reports to calculate the cost consequence of FPE or non-FPE
results, using a determinist approach from two different perspectives: ,
provider and payer. These data were country specific, looking at
healthcare systems in the USA, France, Germany, Italy, Spain, Sweden,
and the UK with two separate time horizons. The cost analysis was based
on total hospital length of stay (LOS), days in the intensive care unit,
standard bed days, and devices used during the procedure. This was
calculated for both FPE and non-FPE groups, which was then applied to
the country specific data, creating a cost estimate for both outcomes.
Finally, total costs per patient in an acute care setting were
calculated from a provider perspective.
From the ARISE II study, researchers found that 76% of patients
received complete or near complete reperfusion; among these, 53% were in
the FPE group. Investigators reported that a higher proportion of
patients in the FPE group achieved good or functional outcomes compared
with the non-FPE group. Additionally, patients in the FPE group required
only a single EmboTrap device, whereas 35% of patients in the non-FPE
group required at least one additional device.
With regard to cost, researchers found that FPE led to potential
per-patient cost savings in every country studied (US$6575 for the USA,
€1560 [US$1833] for France, €2202 [US$2587] for Germany, €2901 [US$3409]
for Italy, €4548 [US$5343] for Spain, Kr 29 468 [US$3364] for Sweden,
and £1751 [US$2285] for the UK. Furthermore, achieving FPE led to
potential per-patient annual care cost savings in the first year after
stroke in every country studied (US$4116 for the USA, €2131 [US$2503]
for France, €701 [US$823] for Italy, Kr 13 333 for Sweden [US$1522], and
£2132 [US$2783] for the UK.
Lead author of the study Osama Zaidat (Mercy Saint Vincent Medical
Center, Toledo, USA), commented, “This article showed that in patients
who achieved FPE with the EmboTrap clot retrieval Device, not only
achieved a better clinical outcome with single attempt vessel opening,
but also resulted were also associated with significant cost saving.
This should focus the future clinical research and technical innovation
on identifying the best approach, devices, and clot features that would
lead to this important target.”
Background
The first-pass effect (FPE) has emerged as a key metric for efficacy in
mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on
non-contrast head CT (NCCT) indicates a higher clot content of red blood
cells.
Objective To assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT.
Methods
A prospective MT database was reviewed for consecutive patients with
anterior circulation large vessel occlusion stroke who underwent
thrombectomy with stent retriever (SR) or contact aspiration (CA) as
first-line therapy between January 2012 and November 2018. Pretreatment
NCCT scans were evaluated for the presence of HDVS. The primary outcome
was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The
primary analysis was the interaction between HDVS and thrombectomy
modality on FPE. Secondary analyses aimed to evaluate the predictors of
FPE.
Results
A total of 779 patients qualified for the analysis. HDVS and FPE were
reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The
presence of HDVS significantly modified the effect of thrombectomy
modality on FPE (p=0.01), with patients with HDVS having a significantly
higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11
(95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a
numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR
0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to
1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to
3.47), p=0.005) were independent predictors of FPE in the overall
population.
Conclusion
Our data suggest that patients with HDVS may have a better response to
SRs than CA for the FPE. Larger confirmatory prospective studies are
warranted.
Zaidat
OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, et al.
First Pass Effect: A New Measure for Stroke Thrombectomy Devices. Stroke. 2018
Currently, the American Heart Association/American Stroke Association
recommends mechanical thrombectomy as the standard of care for acute
stroke patients with proximal artery occlusions. Multiple studies have
shown complete or near-complete reperfusion achieved in a timely manner
leads to improved clinical outcomes and reduced adverse effects;
however, complete reperfusion is achieved in <50% of cases, and often
requires many thrombectomy attempts and the use of multiple devices.
This not only delays time to achieve recanalization, but also incurs
additional risk of vessel spasm, injury, and rupture. Design improvement
of mechanical thrombectomy devices, particularly the advent of stent
retrievers, has improved recanalization rates and decreased the
complication rates leading to this notion that achieving complete
revascularization with a single pass should be the new angiographic
goal.
In the March 2018 issue of Stroke, Zaidat et al introduced
and evaluated a new metric for thrombectomy devices, the first pass
effect (FPE). They studied FPE with the Solitaire FR device within a
large cohort of patients from the North American Solitaire Acute Stroke
(NASA) Registry database from March 2012 to February 2013 at 24 North
American medical centers. They defined FPE as: (1) single pass/use of
the device; (2) complete revascularization of the large vessel occlusion
and its downstream territory (Modified Thrombolysis in Cerebral
Infarction [mTICI] 3); and (3) no use of rescue therapy. They reported
clinical and angiographic outcomes of patients between FPE and non-FPE
populations.
Three hundred fifty-four patients were included in the NASA registry,
out of which 25.1% achieved FPE. The study demonstrated that the FPE
patients had significantly better 90-day clinical outcomes than those in
the non-FPE population (mRS score <=2 61.3% versus 35.3%; P=0.01;
odds ratio, 1.7; 95% confidence interval, 1.1–2.7). 90-day mortality
rate (16%) and symptomatic intracranial hemorrhage rate (5.6%) was
significantly lower in the FPE group compared with the non-FPE cohort.
Predictors of achieving FPE were the use of balloon guided catheters,
whereas the ICA terminus occlusion predicted failure to achieve FPE.
Despite these interesting findings, this study had several
limitations. First, the study was not designed to study FPE rather
report an observation from their registry. Secondly, the study had a
small number of patients treated with the combined aspiration and stent
retriever thrombectomy or aspiration-first approach, making it hard to
distinguish the effect of this combination approach vs. FPE only. The
authors hinted at the potential benefit of the aspiration-first approach
in achieving rapid and high rate of FPE from a single attempt, but left
it to future studies to address this. Nevertheless, Dr. Zaidat’s study
findings reiterate the importance of early and complete reperfusion in
acute ischemic stroke patients and establish FPE as a potential
benchmark to measure the angiographic efficacy and a possible surrogate
for clinical efficacy for emerging thrombectomy devices.
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