Prolonged intracranial catheter dwell time exacerbates penumbral stress and worsens stroke thrombectomy outcomes

Ali M Alawieh; Sameh Samir Elawady; Youssef M Zohdy; Reda M Chalhoub; Conor Cunningham; Brian M Howard; C Michael Cawley; Daniel Barrow; Feras Akbik; Aqueel Pabaney; Frank C Tong; Sami Al Kasab; Pascal Jabbour; Nitin Goyal; Adam S Arthur; Fazeel Siddiqui; Shinichi Yoshimura; Min S Park; Waleed Brinjikji; Charles Matouk; Daniele G Romano; David Altschul; Richard Williamson; Mark Moss; Reade Andrew De Leacy; Mohamad Ezzeldin; Peter Kan; Michael R Levitt; Ramesh Grandhi; Justin R Mascitelli; Jonathan A Grossberg; Alejandro M Spiotta; Stroke Thrombectomy and Aneurysm Registry (STAR)

doi:10.1136/jnis-2024-022271

Prolonged intracranial catheter dwell time exacerbates penumbral stress and worsens stroke thrombectomy outcomes

J Neurointerv Surg. 2024 Nov 14:jnis-2024-022271. doi: 10.1136/jnis-2024-022271. Online ahead of print.

Authors

Ali M Alawieh^#¹, Sameh Samir Elawady^#², Youssef M Zohdy³, Reda M Chalhoub², Conor Cunningham⁴, Brian M Howard⁵, C Michael Cawley⁶, Daniel Barrow^{7

8}, Feras Akbik⁹, Aqueel Pabaney³, Frank C Tong¹⁰, Sami Al Kasab¹¹, Pascal Jabbour¹², Nitin Goyal¹³, Adam S Arthur^{14

15}, Fazeel Siddiqui¹⁶, Shinichi Yoshimura¹⁷, Min S Park¹⁸, Waleed Brinjikji¹⁹, Charles Matouk²⁰, Daniele G Romano²¹, David Altschul²², Richard Williamson²³, Mark Moss²⁴, Reade Andrew De Leacy²⁵, Mohamad Ezzeldin^{26

27}, Peter Kan²⁸, Michael R Levitt²⁹, Ramesh Grandhi³⁰, Justin R Mascitelli³¹, Jonathan A Grossberg³², Alejandro M Spiotta³³; Stroke Thrombectomy and Aneurysm Registry (STAR)

Affiliations

¹ Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
² Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Neurosurgery, Emory University, Atlanta, Georgia, USA.
⁴ Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁵ Neurological Surgery, Emory University, Atlanta, Georgia, USA.
⁶ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
⁷ Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
⁸ Emory University School of Medicine, Atlanta, Georgia, USA.
⁹ Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁰ Department of Neurosurgery, School of Medicine, Atlanta, Georgia, USA.
¹¹ Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
¹² Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹³ Semmes Murphey Foundation, Memphis, Tennessee, USA.
¹⁴ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹⁵ Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹⁶ University of Michigan Health-West, Wyoming, Michigan, USA.
¹⁷ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
¹⁸ University of Virginia, Charlottesville, Virginia, USA.
¹⁹ Radiology, Mayo Clinic, Rochester, Minnesota, USA.
²⁰ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²¹ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
²² Albert Einstein College of Medicine, Bronx, New York, USA.
²³ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
²⁴ Washington Regional Medical Center, Fayetteville, Arkansas, USA.
²⁵ Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA.
²⁶ Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA.
²⁷ Neuroendovascular surgery, HCA Houston, Houston, Texas, USA.
²⁸ Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
²⁹ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
³⁰ University of Utah Health, Salt Lake City, Utah, USA.
³¹ Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA.
³² Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA jonathan.a.grossberg@emory.edu.
³³ Med Univ S Carolina, Charleston, South Carolina, USA.

^# Contributed equally.

PMID: 39542713
DOI: 10.1136/jnis-2024-022271

Abstract

Background: The duration of mechanical thrombectomy (MT) is a negative predictor of outcomes in acute ischemic stroke (AIS), yet the precise mechanisms are unclear. We investigated whether the placement of large-bore catheters intracranially reduces blood flow to the ischemic penumbra and diminishes the efficacy of MT.

Methods: We investigated the impact of different catheter sizes on flow through the intracranial circulation using an in vitro model. Data from a multicenter international registry of AIS patients undergoing MT between January 2016 and December 2023 were reviewed. Intracranial procedure time (icPT) from catheter placement to thrombectomy completion was analyzed using propensity score (PS) matched analysis of patients with successful recanalization achieved in <30 min versus ≥30 min (n=1006/group). Primary outcome was modified Rankin Scale (mRS) score at 90 days (mRS 0-2 favorable). Secondary outcomes included mortality, symptomatic intracranial hemorrhage (sICH), and need for craniectomy.

Results: Using our flow model, we demonstrated a significant reduction in middle cerebral artery and anterior cerebral artery blood flow with the use of larger caliber catheters in the internal carotid artery. Controlling for covariates in 3318 patients, longer icPT predicted lower odds of 90-day favorable outcome (adjusted odds ratio (aOR) 0.87, P<0.01), increased mortality (aOR 1.03, P<0.01), higher decompressive craniectomy rates (aOR 1.07, P<0.01), and increased sICH (aOR 1.07, P<0.01). Each additional 10 mins of icPT correlated with a 13% decrease in recanalization success. The impact of icPT on outcomes was consistent regardless of recanalization success, though catheter size influenced effects. Reduced intraprocedural blood pressure worsened icPT's effects.

Conclusions: This study is the first to demonstrate the risks associated with the duration of catheter use during MT and to propose strategies to mitigate these risks in AIS.

Keywords: Stroke.