Elsevier

World Neurosurgery

Volume 132, December 2019, Pages e235-e245
World Neurosurgery

Original Article
Rescue Intracranial Stenting After Failed Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.wneu.2019.08.192Get rights and content

Background

Up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0–1 after mechanical thrombectomy (MT). Furthermore, underlying intracranial atherosclerotic disease, particularly when associated with >70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. The aim of this study was to systematically review the procedural and clinical outcomes in patients with failed MT and high failure risk MT. We also explored differences between patients receiving acute rescue stenting compared with medical management alone.

Methods

A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications from their date of inception until October 2018. Studies including adult patients with acute ischemic stroke because of emergent large vessel occlusion with failed (mTICI score 0–1) or high failure risk MT within the anterior circulation who underwent rescue stenting were included. A systematic review and meta-analysis of proportions was performed.

Results

Rescue intracranial stenting after failed MT or high failure risk MT results in improved clinical outcomes compared with patients without stenting (48.5% vs. 19.7%, respectively; P < 0.001), without an increase in the rate of symptomatic intracranial hemorrhage, despite additional use of antiplatelet agents (9.7% vs. 14.1%, respectively; P = 0.04).

Conclusions

In patients who fail initial attempts at MT or are high risk for acute reocclusion, rescue intracranial stenting could be considered with the aim to improve functional outcomes. Antiplatelet agents do not increase the risk of hemorrhage in these patients.

Introduction

Stroke is a leading cause of morbidity and mortality worldwide.1 Cerebral reperfusion with mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) because of emergent large vessel occlusion.2, 3, 4, 5, 6, 7, 8, 9, 10 MT is effective across different patient subgroups including elderly patients, those who are ineligible for intravenous thrombolysis (IV tPA), and patients with tandem occlusions.6 Recent trials have demonstrated efficacy of MT in selected patients with delayed presentation of up to 24 hours postictus.11, 12

However, up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0–1 after MT.6 Failed MT may relate to thrombus burden, etiology, and/or endothelial injury during MT. Underlying intracranial atherosclerotic disease, particularly when associated with >70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. Recent observational studies suggest that this cohort of patients with failed and high failure risk MT may benefit from rescue stenting with more favorable clinical outcomes demonstrated after this treatment compared with medical management alone.13, 14, 15

The aims of this study were to systematically review the procedural and clinical outcomes in patients with failed and high failure risk MT, and to explore differences between patients receiving acute rescue stenting compared with medical management alone.

Section snippets

Literature Search Strategy

This study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.16, 17 A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications using Medical Subject Headings and general search terms from their date of inception until October 2018. The search strategy used a combination of the following terms: “stroke,” “middle cerebral

Search Strategy

A total of 4599 articles were identified through a comprehensive search of relevant databases. After removal of duplicates, 3344 articles were available for title and abstract screening. After removal of irrelevant articles based on title and abstract screening, 50 were retrieved for full-text analysis. Figure 1 outlines the search strategy following PRISMA guidelines, including reasons for exclusion after full-text review. Twelve studies were identified with a total of 530 patients who

Discussion

The results from this systematic review and meta-analysis suggest a significant benefit in clinical outcome to performing rescue stenting in patients with failed and high failure risk MT, without an increase in the rate of sICH, despite additional use of antiplatelet agents. There was also a numerically lower mortality in patients who received rescue stenting. Figure 5 demonstrates and highlights the use of intracranial angioplasty and stenting using the Wingspan device in a patient with a high

Conclusions

This meta-analysis suggests that rescue stenting is safe and efficacious in patients presenting with AIS in the setting of failed MT or with high-risk MT, with significant improvement in clinical outcomes and no corresponding risk of sICH. However, current data are limited to relatively small retrospective studies and should be cautiously interpreted. The data are not generalizable to all patients, given the variability in the underlying etiology of the failed MT therapy, and given the

References (35)

  • B.C. Campbell et al.

    Endovascular therapy for ischemic stroke with perfusion-imaging selection

    N Engl J Med

    (2015)
  • M. Goyal et al.

    Randomized assessment of rapid endovascular treatment of ischemic stroke

    N Engl J Med

    (2015)
  • T.G. Jovin et al.

    Thrombectomy within 8 hours after symptom onset in ischemic stroke

    N Engl J Med

    (2015)
  • T. Leslie-Mazwi et al.

    ELVO: an operational definition

    J Neurointerv Surg

    (2018)
  • K.W. Muir et al.

    Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial

    J Neurol Neurosurg Psychiatry

    (2017)
  • J.L. Saver et al.

    Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke

    N Engl J Med

    (2015)
  • R.G. Nogueira et al.

    Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct

    N Engl J Med

    (2018)
  • Cited by (0)

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    View full text