Impact of Procedure Time on First Pass Effect in Mechanical Thrombectomy for Anterior Circulation Acute Ischemic Stroke

Andrew B Koo; Benjamin C Reeves; Daniela Renedo; Ilko L Maier; Sami Al Kasab; Pascal Jabbour; Joon-Tae Kim; Stacey Q Wolfe; Ansaar Rai; Robert M Starke; Marios-Nikos Psychogios; Amir Shaban; Adam Arthur; Shinichi Yoshimura; Hugo Cuellar; Jonathan A Grossberg; Ali Alawieh; Daniele G Romano; Omar Tanweer; Justin Mascitelli; Isabel Fragata; Adam Polifka; Joshua Osbun; Roberto Crosa; Min S Park; Michael R Levitt; Waleed Brinjikji; Mark Moss; Travis Dumont; Richard Williamson Jr; Pedro Navia; Peter Kan; Alejandro M Spiotta; Kevin N Sheth; Adam de Havenon; Charles C Matouk

doi:10.1227/neu.0000000000002900

Impact of Procedure Time on First Pass Effect in Mechanical Thrombectomy for Anterior Circulation Acute Ischemic Stroke

Neurosurgery. 2024 Mar 14. doi: 10.1227/neu.0000000000002900. Online ahead of print.

Authors

Andrew B Koo¹, Benjamin C Reeves¹, Daniela Renedo¹, Ilko L Maier², Sami Al Kasab³, Pascal Jabbour⁴, Joon-Tae Kim⁵, Stacey Q Wolfe⁶, Ansaar Rai⁷, Robert M Starke⁸, Marios-Nikos Psychogios⁹, Amir Shaban¹⁰, Adam Arthur¹¹, Shinichi Yoshimura¹², Hugo Cuellar¹³, Jonathan A Grossberg¹⁴, Ali Alawieh¹⁴, Daniele G Romano¹⁵, Omar Tanweer¹⁶, Justin Mascitelli¹⁷, Isabel Fragata¹⁸, Adam Polifka¹⁹, Joshua Osbun²⁰, Roberto Crosa²¹, Min S Park²², Michael R Levitt²³, Waleed Brinjikji²⁴, Mark Moss²⁵, Travis Dumont²⁶, Richard Williamson Jr²⁷, Pedro Navia²⁸, Peter Kan²⁹, Alejandro M Spiotta³, Kevin N Sheth³⁰, Adam de Havenon³⁰, Charles C Matouk¹

Affiliations

¹ Department of Neurosurgery, Yale University, New Haven , Connecticut , USA.
² Department of Neuroradiology, University Medical Center Göttingen, Göttingen , Germany.
³ Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston , South Carolina , USA.
⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia , Pennsylvania , USA.
⁵ Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju , Korea.
⁶ Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem , North Carolina , USA.
⁷ Department of Neuroradiology, West Virginia School of Medicine, Morgantown , West Virginia , USA.
⁸ Department of Neurosurgery, University of Miami Health System, Miami , Florida , USA.
⁹ Department of Diagnostic and Interventional Neuroradiology, University of Basel, Basel , Switzerland.
¹⁰ Department of Neurology, The University of Iowa, Iowa City , Iowa , USA.
¹¹ Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis , Tennessee , USA.
¹² Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya , Hyogo , Japan.
¹³ Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport , Louisiana , USA.
¹⁴ Department of Neurosurgery, Emory University, Atlanta , Georgia , USA.
¹⁵ Department of Radiology, Aou S. Giovanni di Dio e Ruggi d'Aragona, Salerno , Italy.
¹⁶ Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA.
¹⁷ Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio , Texas , USA.
¹⁸ Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon , Portugal.
¹⁹ Department of Neurosurgery, University of Florida, Gainesville , Florida , USA.
²⁰ Department of Neurosurgery, Washington University, St. Louis , Missouri , USA.
²¹ Department of Neurosurgery, Medica Uruguaya, Montevideo , Uruguay.
²² Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA.
²³ Department of Neurosurgery, University of Washington, Seattle , Washington , USA.
²⁴ Department of Radiology, Mayo Clinic in Minnesota, Rochester , Minnesota , USA.
²⁵ Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville , Arkansas , USA.
²⁶ Department of Neurosurgery, University of Arizona, Tucson , Arizona , USA.
²⁷ Department of Neurosurgery, Allegheny Hospital, Pittsburgh , Pennsylvania , USA.
²⁸ Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid , Spain.
²⁹ Department of Neurosurgery, University of Texas Medical Branch, Galveston , Texas , USA.
³⁰ Department of Neurology, Yale University, New Haven , Connecticut , USA.

PMID: 38483158
DOI: 10.1227/neu.0000000000002900

Abstract

Background and objectives: First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT).

Methods: A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation.

Results: A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable.

Conclusion: FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.