Clot evaluation and distal embolization risk during mechanical thrombectomy in anterior circulation stroke

Clot features along with patients' clinical features may influence thrombus compactness predisposing at distal embolization during thrombectomy. The aim of this study was to evaluate thrombus features assessed by radiological and histopathological analysis along with patient-related features to predict distal embolization during thrombectomy.

We performed a retrospective analysis of a prospectively maintained dataset of a tertiary stroke center inclusive of all cases of endovascular treatment for acute ischemic stroke involving anterior circulation occlusion. All patients underwent head and neck CT-angiography (CTA) at baseline. Patients were enrolled if thrombus material was suitable for histopathologic analyses.

A total of 327 patients underwent mechanical thrombectomy between March 2017 and May 2020. Among them, 133 (40.7%) had thrombus material suitable for histopathological analysis but 11 patients were excluded due to posterior circulation occlusion. A total of 122 patients were included in the analysis. A distal embolism was documented in 27 patients (28.4%). Multivariable analysis with distal embolism as dependent variable showed an adjusted OR of 2.64 (95%CI: 0.9-7.73; p-value: 0.08) for anticoagulant therapy, an adjusted OR of 1.38 (95%CI: 1.01-1.91; p-value 0.05) each 5-mm increasing of thrombus length at CTA. No association was found with age, sex, thrombolysis and first thrombectomy technique used.

The combined effect of anticoagulant therapy and thrombus length may have a potentially harmful effect on reperfusion during mechanical recanalization, causing distal embolization and this aspect should be taken into account in patient's risk assessment and when planning treatment strategy.