What predicts poor outcome after successful thrombectomy in early time window?

2021 ◽  
pp. neurintsurg-2021-017946
Author(s):  
Jean-Marc Olivot ◽  
Jeremy J Heit ◽  
Mikael Mazighi ◽  
Nicolas Raposo ◽  
Jean François Albucher ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Time Window ◽  
Independent Predictor ◽  
Early Time ◽  
National Institutes Of Health ◽  
Multivariable Logistic Regression Analysis ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Poor Outcome

BackgroundHalf of the patients with large vessel occlusion (LVO)-related acute ischemic stroke (AIS) who undergo endovascular reperfusion are dead or dependent at 3 months. We hypothesize that in addition to established prognostic factors, baseline imaging profile predicts outcome among reperfusers.MethodsConsecutive patients receiving endovascular treatment (EVT) within 6 hours after onset with Thrombolysis In Cerebral Infarction (TICI) 2b, 2c and 3 revascularization were included. Poor outcome was defined by a modified Rankin scale (mRS) 3–6 at 90 days. No mismatch (NoMM) profile was defined as a mismatch (MM) ratio ≤1.2 and/or a volume <10 mL on pretreatment imaging.Results187 patients were included, and 81 (43%) had a poor outcome. Median delay from stroke onset to the end of EVT was 259 min (IQR 209–340). After multivariable logistic regression analysis, older age (OR 1.26, 95% CI 1.06 to 1.5; p=0.01), higher National Institutes of Health Stroke Scale (NIHSS) (OR 1.15, 95% CI 1.06 to 1.25; p<0.0001), internal carotid artery (ICA) occlusion (OR 3.02, 95% CI 1.2 to 8.0; p=0.021), and NoMM (OR 4.87, 95% CI 1.09 to 22.8; p=0.004) were associated with poor outcome. In addition, post-EVT hemorrhage (OR 3.64, 95% CI 1.5 to 9.1; p=0.04) was also associated with poor outcome.ConclusionsThe absence of a penumbra defined by a NoMM profile on baseline imaging appears to be an independent predictor of poor outcome after reperfusion. Strategies aiming to preserve the penumbra may be encouraged to improve these patients’ outcomes.

scholarly journals Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Jacob R. Morey ◽  
Xiangnan Zhang ◽  
Naoum Fares Marayati ◽  
Stavros Matsoukas ◽  
Emily Fiano ◽  
...  
Keyword(s):  
Scale Score ◽  
Time Window ◽  
Early Time ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Late Time ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and Purpose: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model. Methods: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale. Results: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model ( P <0.01). In the late window, outcomes were similar (35% versus 41%; P =0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window ( P <0.01) and 5.0 and 11.0 in the late window ( P =0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model ( P <0.01) and similar in the late window ( P =0.41). Conclusions: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03048292.

Predictors and impact of hemorrhagic transformations after endovascular thrombectomy in patients with acute large vessel occlusions

2018 ◽  
Vol 11 (5) ◽  
pp. 469-473 ◽  
Author(s):  
Yu Bin Lee ◽  
Woong Yoon ◽  
Yun Young Lee ◽  
Seul Kee Kim ◽  
Byung Hyun Baek ◽  
...  
Keyword(s):  
Lower Risk ◽  
Independent Predictor ◽  
Hemorrhagic Transformation ◽  
Large Vessel ◽  
Regression Analyses ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Poor Outcome ◽  
Male Sex

BackgroundPredictors and impact of hemorrhagic transformation (HT) after thrombectomy remain to be elucidated.ObjectiveTo investigate the independent predictors and impact of each hemorrhagic infarction (HI) and parenchymal hematoma (PH) after thrombectomy in patients with acute stroke due to intracranial large vessel occlusion (LVO).Materials and methodsWe retrospectively reviewed data from 400 patients with acute LVO who underwent thrombectomy. Logistic regression analyses were performed to determine independent predictors of HI and PH on post-treatment CT scans. Associations between HT and poor outcome (modified Rankin Scalescore ≥3) at 90 days were analyzed.ResultsHT was observed in 98 patients (62 HIs (15.5%) and 36 PHs (9%)). Independent predictors of HI were male sex, atrial fibrillation, and time from symptom onset to groin puncture. Hyperlipidemia (OR=0.221, 95% CI 0.064 to 0.767, P=0.017) and successful reperfusion (OR=0.246, 95% CI 0.093 to 0.651, P=0.005) were independently associated with a lower chance of PH, while hypertension (OR=2.260, 95% CI 1.014 to 5.035, P=0.046) and longer procedure duration (OR=1.046, 95% CI 1.016 to 1.077, P=0.003) were independently associated with a higher chance of PH. Only PH (OR=10.154, 95% CI 3.260 to 31.632, P<0.001) was an independent predictor of poor outcome.ConclusionsPH is independently associated with poor outcome, whereas HI does not predict outcome after thrombectomy in patients with acute LVO. Our findings suggest that rapid and successful reperfusion is essential to prevent PH in patients undergoing thrombectomy for acute LVO. In addition, our study suggests that hyperlipidemia is associated with a lower risk of PH in such patients.

Effect of Occlusion Site on the Safety and Efficacy of Intravenous Alteplase Before Endovascular Thrombectomy: A Prespecified Subgroup Analysis of DIRECT-MT

Stroke ◽  
2021 ◽  
Author(s):  
Yu Zhou ◽  
Pengfei Xing ◽  
Zifu Li ◽  
Xiaoxi Zhang ◽  
Lei Zhang ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Intravenous Alteplase

Background and Purpose: Recent trials showed thrombectomy alone was comparable to bridging therapy in patients with anterior circulation large vessel occlusion eligible for both intravenous alteplase and endovascular thrombectomy. We performed this study to examine whether occlusion site modifies the effect of intravenous alteplase before thrombectomy. Methods: This is a prespecified subgroup analysis of a randomized trial evaluating risk and benefit of intravenous alteplase before thrombectomy (DIRECT-MT [Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals]). Among 658 randomized patients, 640 with baseline occlusion site information were included. The primary outcome was the score on the modified Rankin Scale at 90 days. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by occlusion location (internal carotid artery versus M1 versus M2). We report the adjusted common odds ratio for a shift toward better outcome on the modified Rankin Scale after thrombectomy alone compared with combination treatment adjusted for age, the National Institutes of Health Stroke Scale score at baseline, the time from stroke onset to randomization, the modified Rankin Scale score before stroke onset, and collateral score per the DIRECT-MT statistical analysis plan. Results: The overall adjusted common odds ratio was 1.08 (95% CI, 0.82–1.43) with thrombectomy alone compared with combination treatment, and there was no significant treatment-by-occlusion site interaction ( P =0.47). In subgroups based on occlusion location, we found the following adjusted common odds ratios: 0.99 (95% CI, 0.62–1.59) for internal carotid artery occlusions, 1.12 (95% CI, 0.77–1.64) for M1 occlusions, and 1.22 (95% CI, 0.53–2.79) for M2 occlusions. No treatment-by-occlusion site interactions were observed for dichotomized modified Rankin Scale distributions and successful reperfusion (extended thrombolysis in Cerebral Infarction score ≥2b) before thrombectomy. Differences in symptomatic hemorrhage rate were not significant between occlusion locations (internal carotid artery occlusion: 7.02% in bridging therapy versus 7.14% for thrombectomy alone, P =0.97; M1 occlusion: 5.06% versus 2.48%, P =0.22; M2 occlusion: 9.09% versus 4.76%; P =0.78). Conclusions: In this prespecified subgroup of a randomized trial, we found no evidence that occlusion location can inform intravenous alteplase decisions in endovascular treatment eligible patients directly presenting at endovascular treatment capable centers. Future studies are needed to confirm our findings. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03469206.

Association between age and outcomes following thrombectomy for anterior circulation emergent large vessel occlusion is determined by degree of recanalisation

2018 ◽  
Vol 11 (2) ◽  
pp. 114-118 ◽  
Author(s):  
Mahesh V Jayaraman ◽  
Thomas Kishkovich ◽  
Grayson L Baird ◽  
Morgan L Hemendinger ◽  
Eric L Tung ◽  
...  
Keyword(s):  
Older Patients ◽  
Internal Carotid ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Single Centre ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Improved Outcomes ◽  
The Relationship

BackgroundOlder patients undergoing thrombectomy for emergent large vessel occlusion have worse outcomes. However, complete or near-complete reperfusion (modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2 c/3) is associated with improved outcomes compared with partial recanalisation (mTICI 2b).ObjectiveTo examine the relationship between outcomes and age separately for the mTICI 2c/3, 2b and 0-2a groups in patients undergoing thrombectomy for anterior circulation emergent large vessel occlusion.MethodsRetrospective review of 157 consecutive patients undergoing thrombectomy at a single centre with an occlusion of the internal carotid artery (ICA), M1 or proximal M2 segments of the middle cerebral artery (MCA). Angiograms were graded in a blinded fashion. Patients were divided into three groups: mTICI 0-2a, mTICI 2b, and mTICI 2c/3. Demographics and workflow parameters were compared. Outcomes at 90 days were compared as a function of age, using both the conventional modified Rankin scale (mRs) and utility weighted mRs (UWmRs).ResultsThere were 72, 61 and 24 patients in the mTICI 2c/3, 2b and 0-2a groups, respectively. Outcomes were significantly worse with increasing age for the mTICI 2b group, but not for the mTICI 0-2a and 2c/3 groups (P=0.0002). With increasing age, outcomes of the mTICI 2b group approached those of the mTICI 0-2a group. However, outcomes of the mTICI 2c/3 groups were similar for all ages. This association was present for both the original mRs and UWmRs.ConclusionIncreasing age was associated with worse outcomes for those with partial (mTICI 2b) recanalisation, not in patients with complete (mTICI 2c/3) recanalisation.

scholarly journals Sensitivity of prehospital stroke scales for different intracranial large vessel occlusion locations

2021 ◽  
pp. 239698732110158
Author(s):  
Martijne HC Duvekot ◽  
Esmee Venema ◽  
Hester F Lingsma ◽  
Jonathan M Coutinho ◽  
H Bart van der Worp ◽  
...  
Keyword(s):  
Prospective Observational Study ◽  
Internal Carotid ◽  
Clinical Findings ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Scale Scores ◽  
Mr Clean

Introduction Prehospital stroke scales have been proposed to identify stroke patients with a large vessel occlusion to allow direct transport to an intervention centre capable of endovascular treatment (EVT). It is unclear whether these scales are able to detect not only proximal, but also more distal treatable occlusions. Our aim was to assess the sensitivity of prehospital stroke scales for different EVT-eligible occlusion locations in the anterior circulation. Patients and methods The MR CLEAN Registry is a prospective, observational study in all centres that perform EVT in the Netherlands. We included adult patients with an anterior circulation stroke treated between March 2014 and November 2017. We used National Institutes of Health Stroke Scale scores at admission to reconstruct previously published prehospital stroke scales. We compared the sensitivity of each scale for different occlusion locations. Occlusions were assessed with CT angiography by an imaging core laboratory blinded to clinical findings. Results We included 3021 patients for the analysis of 14 scales. All scales had the highest sensitivity to detect internal carotid artery terminus occlusions (ranging from 0.21 to 0.97) and lowest for occlusions of the M2 segment (0.08 to 0.84, p-values < 0.001). Discussion and conclusion: Although prehospital stroke scales are generally sensitive for proximal large vessel occlusions, they are less sensitive to detect more distal occlusions.

scholarly journals General Anesthesia Versus Conscious Sedation and Local Anesthesia During Thrombectomy for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (7) ◽  
pp. 2036-2044 ◽  
Author(s):  
Manuel Cappellari ◽  
Giovanni Pracucci ◽  
Stefano Forlivesi ◽  
Valentina Saia ◽  
Sergio Nappini ◽  
...  
Keyword(s):  
General Anesthesia ◽  
Scale Score ◽  
Local Anesthesia ◽  
Functional Outcomes ◽  
Randomized Clinical Trials ◽  
Conscious Sedation ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose: As numerous questions remain about the best anesthetic strategy during thrombectomy, we assessed functional and radiological outcomes in stroke patients treated with thrombectomy in presence of general anesthesia (GA) versus conscious sedation (CS) and local anesthesia (LA). Methods: We conducted a cohort study on prospectively collected data from 4429 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Results: GA was used in 2013 patients, CS in 1285 patients, and LA in 1131 patients. The rates of 3-month modified Rankin Scale score of 0–1 were 32.7%, 33.7%, and 38.1% in the GA, CS, and LA groups: GA versus CS: odds ratios after adjustment for unbalanced variables (adjusted odds ratio [aOR]), 0.811 (95% CI, 0.602–1.091); and GA versus LA: aOR, 0.714 (95% CI, 0.515–0.990). The rates of modified Rankin Scale score of 0–2 were 42.5%, 46.6%, and 52.4% in the GA, CS, and LA groups: GA versus CS: aOR, 0.902 (95% CI, 0.689–1.180); and GA versus LA: aOR, 0.769 (95% CI, 0.566–0.998). The rates of 3-month death were 21.5%, 19.7%, and 14.8% in the GA, CS, and LA groups: GA versus CS: aOR, 0.872 (95% CI, 0.644–1.181); and GA versus LA: aOR, 1.235 (95% CI, 0.844–1.807). The rates of parenchymal hematoma were 9%, 12.6%, and 11.3% in the GA, CS, and LA groups: GA versus CS: aOR, 0.380 (95% CI, 0.262–0.551); and GA versus LA: aOR, 0.532 (95% CI, 0.337–0.838). After model of adjustment for predefined variables (age, sex, thrombolysis, National Institutes of Health Stroke Scale, onset-to-groin time, anterior large vessel occlusion, procedure time, prestroke modified Rankin Scale score of <1, antiplatelet, and anticoagulant), differences were found also between GA versus CS as regards modified Rankin Scale score of 0–2 (aOR, 0.659 [95% CI, 0.538–0.807]) and GA versus LA as regards death (aOR, 1.413 [95% CI, 1.095–1.823]). Conclusions: GA during thrombectomy was associated with worse 3-month functional outcomes, especially when compared with LA. The inclusion of an LA arm in future randomized clinical trials of anesthesia strategy is recommended.

Association of Multiple Passes during Mechanical Thrombectomy with Incomplete Reperfusion and Lesion Growth

2021 ◽  
pp. 1-9
Author(s):  
Marie Luby ◽  
José G. Merino ◽  
Rachel Davis ◽  
Saeed Ansari ◽  
Marc Fisher ◽  
...  
Keyword(s):  
Reperfusion Injury ◽  
Mechanical Thrombectomy ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Neurological Improvement ◽  
Multiple Pass ◽  
Lesion Growth

<b><i>Introduction:</i></b> Despite complete recanalization by mechanical thrombectomy, abnormal perfusion can be detected on MRI obtained post-endovascular therapy (EVT). The presence of residual perfusion abnormalities post-EVT may be associated with blood-brain barrier breakdown in response to mechanical disruption of the endothelium from multiple-pass thrombectomy. We hypothesize that multiple-pass versus single-pass thrombectomy is associated with a higher rate of residual hypoperfusion and increased lesion growth at 24 h. <b><i>Materials and Methods:</i></b> For this analysis, we included patients presenting to one of two stroke centers between January 2015 and February 2018 with an acute ischemic stroke within 12 h from symptom onset if they had a large vessel occlusion of the anterior circulation documented on magnetic resonance angiography or CTA, baseline MRI pre-EVT with imaging evidence of hypoperfusion, underwent EVT, and had a post-EVT MRI with qualitatively interpretable perfusion-weighted imaging data at 24 h. MRI <i>T</i><sub>max</sub> maps using a time delay threshold of &#x3e;6 s were used to quantitate hypoperfusion volumes. Residual hypoperfusion at 24 h was solely defined as <i>T</i><sub>max</sub> volume &#x3e;10 mL with &#x3e;6 s delay. Complete recanalization was defined as modified treatment in cerebral infarction visualized on angiography at EVT completion. Hyperintense acute reperfusion injury marker was assessed on post-EVT pre-contrast fluid-attenuated inversion recovery at 24 h. Major early neurological improvement was defined as a reduction of the admission National Institutes of Health Stroke Scale by ≥8 points or a score of 0–1 at 24 h. Good functional outcome was defined as 0–2 on the modified Rankin Scale on day 30 or 90. <b><i>Results:</i></b> Fifty-five patients were included with median age 67 years, 58% female, 45% Black/African American, 36% White/Caucasian, median admission National Institutes of Health Stroke Scale 19, large vessel occlusion locations: 71% M1, 14.5% iICA, 14.5% M2, 69% treated with intravenous recombinant tissue plasminogen activator. Of these, 58% had multiple-pass thrombectomy, 39% had residual perfusion abnormalities at 24 h, and 64% had severe hyperintense acute reperfusion injury marker at 24 h. After adjusting for complete recanalization, only multiple-pass thrombectomy (odds ratio, 4.3 95% CI, 1.07–17.2; <i>p</i> = 0.04) was an independent predictor of residual hypoperfusion at 24 h. Patients with residual hypoperfusion had larger lesion growth on diffusion-weighted imaging (59 mL vs. 8 mL, <i>p</i> &#x3c; 0.001), lower rate of major early neurological improvement (24% vs. 70%, <i>p</i> = 0.002) at 24 h, and worse long-term outcome based on the modified Rankin Scale at 30 or 90 days, 5 versus 2 (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Our findings suggest that incomplete reperfusion on post-EVT MRI is present even in some patients with successful recanalization at the time of EVT and is associated with multiple-pass thrombectomy, lesion growth, and worse outcome. Future studies are needed to investigate whether patients with residual hypoperfusion may benefit from immediate adjunctive therapy to limit lesion growth and improve clinical outcome.

Tandem stents thrombectomy as a rescue treatment for refractory large vessel occlusions

2020 ◽  
Vol 13 (1) ◽  
pp. 33-38
Author(s):  
Haowen Xu ◽  
Shanling Peng ◽  
Tao Quan ◽  
Yongjie Yuan ◽  
Zibo Wang ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Good Clinical Outcome ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Rescue Treatment

BackgroundMechanical thrombectomy with a stent retriever (SR) and/or aspiration is the 'gold standard' for the treatment of acute ischemic stroke due to large vessel occlusion (LVO). However, sometimes clots may not be retrievable with a single SR alone or combined with aspiration.ObjectiveTo assess the safety and efficacy of a novel tandem stents thrombectomy (TST) technique as a rescue treatment for acute LVO that is refractory to conventional attempts.MethodsAll patients treated with the TST technique as rescue treatment after failure of conventional attempts were retrospectively reviewed. The postprocedural angiographic and clinical outcome, including modified Thrombolysis in Cerebral infarction (mTICI) grade, National Institutes of Health Stroke Scale (NIHSS) score, and modified Rankin Scale (mRS) score, was assessed.ResultsNine patients (mean age, 65.2 years; median NIHSS score 18) with middle cerebral artery M1 segment (n=6) and terminal internal carotid artery (n=3) occlusions were included in the study. The TST technique was performed as a rescue treatment after unsuccessful stent thrombectomy alone (four cases) and stent thrombectomy plus aspiration (five cases). Successful recanalization (mTICI 2b/3) was achieved in all patients. No procedure-related complications occurred except reversible vasospasms were observed in three patients and one patient developed hemorrhage transformation after the procedure, but was asymptomatic. Three patients had good clinical outcome (mRS score 0–2 at 90 days). Two patients (22.2%) died.ConclusionsThe TST technique seems to be a safe and effective rescue treatment for acute LVO that is refractory to conventional attempts.

Clot imaging characteristics predict first pass effect of aspiration—first approach to thrombectomy

2021 ◽  
pp. 159101992110191
Author(s):  
Muhammad Waqas ◽  
Weizhe Li ◽  
Tatsat R Patel ◽  
Felix Chin ◽  
Vincent M Tutino ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Validation Cohort ◽  
Area Under The Curve ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Imaging Characteristics ◽  
First Pass ◽  
Sensitivity Specificity ◽  
Youden’S Index

Background The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. Methods We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). Results Patients ( n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65–46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8–29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84–7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55–29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden’s index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728–0.904, P < 0.001). In a validation cohort ( n = 30), sensitivity, specificity, positive and negative predictive value of a score of 6–10 were 72.7%, 73.6%, 61.5% and 82.3%. Conclusions Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.

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