RT Journal Article SR Electronic T1 Refractory Stroke Thrombectomy: Prevalence, Etiology, and Adjunctive Treatment in a North American Cohort JF American Journal of Neuroradiology JO Am. J. Neuroradiol. FD American Society of Neuroradiology SP 1258 OP 1263 DO 10.3174/ajnr.A7124 VO 42 IS 7 A1 R.N. Abdalla A1 D.R. Cantrell A1 A. Shaibani A1 M.C. Hurley A1 B.S. Jahromi A1 M.B. Potts A1 S.A. Ansari YR 2021 UL http://www.ajnr.org/content/42/7/1258.abstract AB BACKGROUND AND PURPOSE: Acute stroke intervention refractory to mechanical thrombectomy may be due to underlying vessel wall pathology including intracranial atherosclerotic disease and intracranial arterial dissection or recalcitrant emboli. We studied the prevalence and etiology of refractory thrombectomy, the safety and efficacy of adjunctive interventions in a North American–based cohort.MATERIALS AND METHODS: We performed a multicenter, retrospective study of refractory thrombectomy, defined as unsuccessful recanalization, vessel reocclusion in <72 hours, or required adjunctive antiplatelet glycoprotein IIb/IIIa inhibitors, intracranial angioplasty and/or stenting to achieve and maintain reperfusion. Clinical and imaging criteria differentiated etiologies for refractory thrombectomy. Baseline demographics, cerebrovascular risk factors, technical/clinical outcomes, and procedural safety/complications were compared between refractory and standard thrombectomy groups. Multivariable logistic regression analysis was performed to determine independent predictors of refractory thrombectomy.RESULTS: Refractory thrombectomy was identified in 25/302 cases (8.3%), correlated with diabetes (44% versus 22%, P = .02) as an independent predictor with OR = 2.72 (95% CI, 1.05–7.09; P = .04) and inversely correlated with atrial fibrillation (16% versus 45.7%, P = .005). Refractory etiologies were secondary to recalcitrant emboli (20%), intracranial atherosclerotic disease (60%), and/or intracranial arterial dissection (44%). Four (16%) patients were diagnosed with early vessel reocclusion, and 21 patients underwent adjunctive salvage interventions with glycoprotein IIb/IIIa inhibitor infusion alone (32%) or intracranial angioplasty and/or stenting (52%). There were no significant differences in TICI 2b/3 reperfusion efficacy (85.7% versus 90.9%, P = .48), symptomatic intracranial hemorrhage rates (0% versus 9%, P = .24), favorable clinical outcomes (39.1% versus 48.3%, P = .51), or mortality (13% versus 28.3%, P = .14) versus standard thrombectomy.CONCLUSIONS: Refractory stroke thrombectomy is encountered in <10% of cases, independently associated with diabetes, and related to underlying vessel wall pathology (intracranial atherosclerotic disease and/or intracranial arterial dissection) or, less commonly, recalcitrant emboli. Emergent salvage interventions with glycoprotein IIb/IIIa inhibitors or intracranial angioplasty and/or stenting are safe and effective adjunctive treatments.AISacute ischemic strokeDACdistal access catheterELVOemergent large-vessel occlusionGPIglycoprotein IIb/IIIa inhibitorsIADintracranial arterial dissectionICADintracranial atherosclerotic diseasesICHsymptomatic intracranial hemorrhage