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Angiographic Microcirculatory Obstructions Distal to Occlusion Signify Poor Outcome after Endovascular Treatment for Acute Ischemic Stroke

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Abstract

The success of endovascular therapies depends on a number of factors including flow dynamics proximal and distal to the occlusion. The evaluation of antegrade flow distal to the occluded segment is currently a readily available, yet unexplored, option during stentriever-mediated thrombectomy. In this study, we retrospectively evaluated presence of contrast stasis and absence of capillary blush on angiograms obtained by selective injections into the distal site of occlusive thrombi, prior to deployment of stentrievers, in patients undergoing endovascular treatment for acute MCA occlusion. The role of this novel angiographic strategy assessing distal antegrade flow in predicting procedural and clinical outcome was compared to previously defined, prognostic angiographic characteristics. A total of 7 (21%) out of 34 patients had contrast stasis and lack of capillary blush downstream to the injection site. None of these patients with angiographic features suggestive of microcirculatory obstructions achieved a satisfactory outcome in terms of reperfusion (TICI grade 2B–C) and clinical outcome (90-day mRS 0–2), while the corresponding figures were 78% (p < 0.001) and 48% (p = 0.029), respectively, among patients with substantial capillary filling. These findings highlight the potentially detrimental impact of impaired microcirculatory flow on tissue and clinical outcome after recanalization/reperfusion efforts in acute ischemic stroke.

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Authors and Affiliations

  1. Department of Neurology, Faculty of Medicine, Hacettepe University, 06100 Sihhiye, Ankara, Turkey

    Ethem Murat Arsava & Mehmet Akif Topcuoglu

  2. Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey

    Anil Arat & Ahmet Peker

  3. Department of Neurology, Faculty of Medicine, and Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey

    Muge Yemisci & Turgay Dalkara

Authors
  1. Ethem Murat Arsava
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  2. Anil Arat
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  3. Mehmet Akif Topcuoglu
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  4. Ahmet Peker
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  5. Muge Yemisci
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  6. Turgay Dalkara
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Correspondence to Ethem Murat Arsava.

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Conflict of Interest

Dr. Arsava has received speaker honoraria from Bayer Healthcare, Pfizer, and Numil Advanced Medical Nutrition. He has served on scientific advisory boards for Nutricia and Numil Advanced Medical Nutrition. Drs. Arat, Topcuoglu, Peker, Yemisci, Dalkara declare they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was waived due to the retrospective nature of the study, yet informed consent was obtained from all individual participants or their caregivers for the endovascular procedures performed within the context of the study as part of the standard clinical care.

Electronic supplementary material

Video files e1 and e2: Lateral projections of selective injections performed from the distal site of the occlusive thrombi in two different patients (images were obtained at a frame rate of 3 frames/sec). Impeded flow in second and third order intracranial arteries with diminished capillary blush is suggestive of microcirculatory obstructions in the first patient (video e1); the use of narrow window settings better demonstrate the lack of capillary blush in the second part of the movie. In contrast, rapid opacification and substantial capillary blush is observed in the other patient with satisfactory microcirculatory flow (video e2)

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Arsava, E.M., Arat, A., Topcuoglu, M.A. et al. Angiographic Microcirculatory Obstructions Distal to Occlusion Signify Poor Outcome after Endovascular Treatment for Acute Ischemic Stroke. Transl. Stroke Res. 9, 44–50 (2018). https://doi.org/10.1007/s12975-017-0562-2

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  • DOI: https://doi.org/10.1007/s12975-017-0562-2

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