Thrombolysis in Cerebral Infarction 2b Reperfusions: To Treat or to Stop?

Kaesmacher, Johannes; Ospel, Johanna M.; Meinel, Thomas R.; Boulouis, Grégoire; Goyal, Mayank; Campbell, Bruce C V; Fiehler, Jens; Gralla, Jan; Fischer, Urs (2020). Thrombolysis in Cerebral Infarction 2b Reperfusions: To Treat or to Stop? Stroke, 51(11), pp. 3461-3471. American Heart Association 10.1161/STROKEAHA.120.030157

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In patients undergoing mechanical thrombectomy, achieving complete (Thrombolysis in Cerebral Infarction 3) rather than incomplete successful reperfusion (Thrombolysis in Cerebral Infarction 2b) is associated with better functional outcome. Despite technical improvements, incomplete reperfusion remains the final angiographic result in 40% of patients according to recent trials. As most incomplete reperfusions are caused by distal vessel occlusions, they are potentially amenable to rescue strategies. While observational data suggest a net benefit of up to 20% in functional independence of incomplete versus complete reperfusions, the net benefit of secondary improvement from Thrombolysis in Cerebral Infarction 2b to 3 reperfusion might differ due to lengthier procedures and delayed reperfusion. Current strategies to tackle distal vessel occlusions consist of distal (microcatheter) aspiration, small adjustable stent retrievers, and administration of intra-arterial thrombolytics. While there are promising reports evaluating those techniques, all available studies show relevant limitations in terms of selection bias, single-center design, or nonconsecutive patient inclusion. Besides an assessment of risks associated with rescue maneuvers, we advocate that the decision-making process should also include a consideration of potential outcomes if complete reperfusion would successfully be achieved. These include (1) a futile angiographic improvement (hypoperfused territory is already infarcted), (2) an unnecessary angiographic improvement (the patient would not have developed infarction if no rescue maneuver was performed), and (3) a successful rescue maneuver with clinical benefit. Currently there is paucity of data on how these scenarios can be predicted and the decision whether to treat or to stop in a patient with incomplete reperfusion involves many unknowns. To advance the status quo, we outline current knowledge gaps and avenues of potential research regarding this clinically important question.

Item Type:

Journal Article (Review Article)

Division/Institute:

04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic, Interventional and Paediatric Radiology
04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic and Interventional Neuroradiology
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology

UniBE Contributor:

Kaesmacher, Johannes; Meinel, Thomas Raphael; Gralla, Jan and Fischer, Urs

Subjects:

600 Technology > 610 Medicine & health

ISSN:

1524-4628

Publisher:

American Heart Association

Language:

English

Submitter:

Martin Zbinden

Date Deposited:

12 Oct 2020 09:50

Last Modified:

27 Oct 2020 01:41

Publisher DOI:

10.1161/STROKEAHA.120.030157

PubMed ID:

32993461

Uncontrolled Keywords:

decision-making endovascular reperfusion stroke thrombectomy

BORIS DOI:

10.7892/boris.146903

URI:

https://boris.unibe.ch/id/eprint/146903

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