Prognostic Value of Thrombus Volume and Interaction With First-Line Endovascular Treatment Device Choice
Authors: van Voorst Henk , Bruggeman Agnetha A.E. , Andriessen Jurr , Hoving Jan W. , Konduri Praneeta R. , Yang Wenjin , Kappelhof Manon , Arrarte Terreros Nerea , Roos Yvo B.W.E.M. , van Zwam Wim H. , van der Lugt Aad , van der Hoorn Anouk , Boiten Jelis , Roosendaal Stefan , Jenniskens Sjoerd , Caan Matthan W.A. , Marquering Henk A. , Emmer Bart J. , Majoie Charles B.L.M. , Dippel Diederik W.J. , van Oostenbrugge Robert J. , Vos Jan Albert , Jansen Ivo G.H. , Mulder Maxim J.H.L. , Goldhoorn Robert- Jan B. , Compagne Kars C.J. , Brouwer Josje , den Hartog Sanne J. , Hinsenveld Wouter H. , Dippel Diederik W.J. , Roozenbeek Bob , van Es Adriaan C.G.M. , Coutinho Jonathan M. , Schonewille Wouter J. , Vos Jan Albert , Wermer Marieke J.H. , van Walderveen Marianne A.A. , Staals Julie , van Oostenbrugge Robert J. , Hofmeijer Jeannette , Martens Jasper M. , Lycklama à Nijeholt Geert J. , de Bruijn Sebastiaan F. , van Dijk Lukas C. , van der Worp H. Bart , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Vries J. , de Kort Paul L.M. , van Tuijl Julia , Peluso Jo P. , Fransen Puck , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Uyttenboogaart Maarten , Eschgi Omid , Bokkers Reinoud P.H. , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Yo Lonneke S.F. , den Hertog Heleen M. , Sturm Emiel J.C. , Brouwers Paul J.A.M. , Lycklama à Nijeholt Geert J. , van Walderveen Marianne A.A. , Sprengers Marieke E.S. , van den Berg René , Yoo Albert J. , Beenen Ludo F.M. , Postma Alida A. , van der Kallen Bas F.W. , van den Wijngaard Ido R. , van Es Adriaan C.G.M. , Martens Jasper M. , Yo Lonneke S.F. , Vos Jan Albert , Bot Joost , van Doormaal Pieter-Jan , Meijer Anton , Ghariq Elyas , Bokkers Reinoud P.H. , van Proosdij Marc P. , Krietemeijer G. Menno , Peluso Jo P. , Boogaarts Hieronymus D. , Lo Rob , Gerrits Dick , Dinkelaar Wouter , Appelman Auke P.A. , Hammer Bas , Pegge Sjoert , Vinke Saman , Dippel Diederik W.J. , van Oostenbrugge Robert J. , Lycklama à Nijeholt Geert J. , Vos Jan Albert , Schonewille Wouter J. , Hofmeijer Jeannette , Martens Jasper M. , van der Worp H. Bart , Lo Rob H. , van Oostenbrugge Robert J. , Hofmeijer Jeannette , Flach H. Zwenneke , Lingsma Hester F. , el Ghannouti Naziha , Sterrenberg Martin , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , Simons Michelle , Vossers Marjolein , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , Messchendorp Gert , Nicolaij Nynke , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert Maureen , Verheesen Sabrina , Jeurrissen D. , Bos Erna , Drabbe Yvonne , Sandiman Michelle , Aaldering Nicoline , Zweedijk Berber , Vervoort Jocova , Ponjee Eva , Romviel Sharon , Kanselaar Karin , Barning Denn , Venema Esmee , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R.M. , Muijres Daan , de Jong Anouk , Berkhemer Olvert A. , Boers Anna M.M. , Huguet J. , Groot P.F.C. , Mens Marieke A. , van Kranendonk Katinka R. , Treurniet Kilian M. , Tolhuisen Manon L. , Alves Heitor , Weterings Annick J. , Kirkels Eleonora L.F. , Voogd Eva J.H.F. , Schupp Lieve M. , Collette Sabine , Groot Adrien E.D. , LeCouffe Natalie E. , Prasetya Haryadi , Ramos Lucas A. 
Published: March 2023

Background:
A larger thrombus in patients with acute ischemic stroke might result in more complex endovascular treatment procedures, resulting in poorer patient outcomes. Current evidence on thrombus volume and length related to procedural and functional outcomes remains contradicting. This study aimed to assess the prognostic value of thrombus volume and thrombus length and whether this relationship differs between first-line stent retrievers and aspiration devices for endovascular treatment.

Methods:
In this multicenter retrospective cohort study, 670 of 3279 patients from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) for endovascularly treated large vessel occlusions were included. Thrombus volume (0.1 mL) and length (0.1 mm) based on manual segmentations and measurements were related to reperfusion grade (expanded Treatment in Cerebral Infarction score) after endovascular treatment, the number of retrieval attempts, symptomatic intracranial hemorrhage, and a shift for functional outcome at 90 days measured with the reverted ordinal modified Rankin Scale (odds ratio >1 implies a favorable outcome). Univariable and multivariable linear and logistic regression were used to report common odds ratios (cORs)/adjusted cOR and regression coefficients (B/aB) with 95% CIs. Furthermore, a multiplicative interaction term was used to analyze the relationship between first-line device choice, stent retrievers versus aspiration device, thrombus volume, and outcomes.

Results:

Thrombus volume was associated with functional outcome (adjusted cOR, 0.83 [95% CI, 0.71–0.97]) and number of retrieval attempts (aB, 0.16 [95% CI, 0.16–0.28]) but not with the other outcome measures. Thrombus length was only associated with functional independence (adjusted cOR, 0.45 [95% CI, 0.24–0.85]). Patients with more voluminous thrombi had worse functional outcomes if endovascular treatment was based on first-line stent retrievers (interaction cOR, 0.67 [95% CI, 0.50–0.89];
P
=0.005; adjusted cOR, 0.74 [95% CI, 0.55–1.0];
P
=0.04).

Conclusions:
In this study, patients with a more voluminous thrombus required more endovascular thrombus retrieval attempts and had a worse functional outcome. Patients with a lengthier thrombus were less likely to achieve functional independence at 90 days. For more voluminous thrombi, first-line stent retrieval compared with first-line aspiration might be associated with worse functional outcome.