Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy: A Case Series and Systematic Review.

BACKGROUND: Arterial perforation is a potentially serious complication during endovascular thrombectomy. PURPOSE: Our aim was to describe interventional approaches after arterial perforation during endovascular thrombectomy and to determine whether reperfusion remains associated with favorable outcome despite this complication. DATA SOURCES: Data from consecutive patients with acute stroke undergoing endovascular thrombectomy were retrospectively collected between 2015 to 2020 from a single-center cohort, and a systematic review was performed using PubMed, EMBASE, and Ovid MEDLINE up to June 2020. STUDY SELECTION: Articles reporting functional outcome after arterial perforation during endovascular thrombectomy were selected. DATA ANALYSIS: Functional outcomes of patients achieving successful reperfusion (TICI 2b/3) were compared with outcomes of those with unsuccessful reperfusion in our single-center cohort. We then summarized the literature review to describe interventional approaches and outcomes after arterial perforation during endovascular thrombectomy. DATA SYNTHESIS: In our single-center cohort, 1419 patients underwent endovascular thrombectomy, among whom 32 (2.3%) had vessel perforation and were included in the analysis. The most common hemostatic strategy was watchful waiting (71% of cases). Patients with successful reperfusion had a higher proportion of favorable 90-day mRS scores (60% versus 12.5%; P = .006) and a lower mortality rate (13.3% versus 56.3%, P = .01) than patients without successful reperfusion. Thirteen articles were included in the systematic review. Successful reperfusion also appeared to be associated with better outcomes. LIMITATIONS: Given the low number of published reports, we performed only a descriptive analysis. CONCLUSIONS: Arterial perforation during endovascular thrombectomy is rare but is associated with high mortality rates and poor outcome. However, successful reperfusion remains correlated with favorable outcome in these patients.

Exophthalmos following mechanical thrombectomy for anterior circulation stroke: A retrospective study and review of literature.

BACKGROUND: Anecdotal cases of exophthalmos after acute mechanical thrombectomy have been described. We sought to estimate the incidence in a large cohort of patients with acute anterior circulation stroke treated with mechanical thrombectomy. Secondarily, we aimed to evaluate the underlying mechanism and to differentiate it on imaging from other pathology with similar clinical orbital features. METHODS: Between November 2016 and November 2018, we performed a retrospective single-center study of 250 patients who underwent anterior circulation mechanical thrombectomy. Development of exophthalmos was independently evaluated by two readers on preprocedure and 24-h postprocedure non-contrast cerebral CT. RESULTS: In the mechanical thrombectomy cohort, six individuals (2.4%) developed interval ipsilateral exophthalmos at 24 h. Of these, at least two patients developed clinical symptoms. There was almost perfect agreement between assessments of the two readers (Cohen's kappa = 0.907 (95% confidence interval: 0.726, 1.000)). In two patients, there was delayed ophthalmic artery filling on digital subtraction angiography. None of the patients had features of a direct carotid-cavernous fistula. CONCLUSIONS: Exophthalmos is not uncommon after mechanical thrombectomy (2.4%). The underlying mechanism is difficult to confirm, but it is most likely due to orbital ischemia from hypoperfusion or distal emboli.