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Resident PGY 2
Henry Ford Hospital
Background: Mechanical endovascular reperfusion therapy (MER) has become the standard of care for treatment of large vessel occlusion (LVO) acute ischemic strokes (AIS) with expansion of treatment window to 24 hours from LNW. Nearly 25% of all stroke patients have a recurrent event within 5 years. Intravenous alteplase use in AIS patients with recent ischemic stroke history is often restricted due to the risk of intracranial hemorrhage, however this may not apply for MER. Bouslama et al found no statistically significant differences in the reperfusion rates, hemorrhagic complications, clinical outcomes, and mortality between patients who underwent repeated thrombectomy (RT) and those who had a single thrombectomy. Methods:This was a retrospective case series study of the endovascular database for patients who underwent RT in our institution from March 2016 till March 2018. Demographic data, clinical presentation, imaging, procedural data and clinical outcomes were evaluated. Results:Of the total 145 patients with AIS that received MER, 8 (5.5%) RT occurred in 5 patients. Mean age was 67 ± 21 years. Four of the five patients were females. All five patients achieved successful reperfusion (TICI 2b-3). Three patients underwent one RT, one had two RT, and one had three RT. The average time between consecutive MER (8 total periods) was 106 days. The time between the first to last MER for each patient ranged from 3 days to 2 years. All patients were optimized on their medical therapy after the first stroke. Four of the five patients (80%) had RT in the same vascular territory. One patient had post-procedure focal high-grade stenosis after the 3rd intervention in the same artery that was treated later with elective angioplasty. One RT was complicated with fatal intracranial hemorrhage due to late presentation despite presence of large area of penumbra. 3 months MRS was 2. Conclusion: In patients presented with recurrent LVO, RT appears to be effective and relatively safe. Based on the available literature, prior MER should not discourage aggressive treatment that may potentially lead to a good clinical outcome. It is unclear if prior MER therapies cause endothelial injury leading to a predilection for local in-situ thrombus or denovo stenosis formation predisposing to re-occlusions. The risk of reperfusion injury in a recently infarcted territory should be weighted carefully when considering as hemorrhagic complications remain possible.
Mohamed, Ghada A.; Arshad, Khadija; Affan, Muhammad; Ismail, Mohammed; Alsrouji, Owais; Miller, Daniel J; Kole, Maximillian K; and Marin, Horia, "Recurrent Thrombectomy in Patients with Prior Mechanical Endovascular Revascularization: A Single Center Experience" (2019). Clinical Research. 30.