Importance of First Pass Reperfusion in Endovascular Stroke Care - Insights From Thrombectomy and Aneurysm Registry (STAR)

Background: Mechanical thrombectomy has become the first-line treatment strategy for patients with large-vessel occlusion strokes. Often >1 thrombectomy maneuver is necessary to achieve reperfusion. A first-pass (FP) effect with improved functional outcomes after mechanical thrombectomy has been described. Aim of the present study is to investigate the FP effect in a large, international, multicenter stroke database. Methods: Patients who underwent mechanical thrombectomy for large-vessel occlusion stroke in the anterior cerebral circulation between January 2014 and January 2021 and achieved complete reperfusion were identified from the STAR (Stroke Thrombectomy and Aneurysm Registry). We compared functional outcomes of patients with FP (defined as modified treatment in cerebral ischemia score 3 after a single thrombectomy maneuver) versus multiple-pass complete reperfusion (defined as modified treatment in cerebral ischemia 3 after >= 1 thrombectomy maneuver). Results: A total of 1481 patients with anterior circulation large-vessel occlusion stroke and successful recanalization were included in the analysis. FP complete recanalization was achieved in 778 patients versus 703 patients with multiple-pass complete reperfusion. Patients with FP complete recanalization had higher Alberta Stroke Programme Early CT [Computed Tomography] Score at baseline (9 [7-10] versus 8 [7-10]; P=0.002), were less likely to be men (47% versus 51%; P=0.078) and to have intracranial internal carotid artery occlusions (14% versus 27%), as well as more likely to have M1/M2 occlusions (86% versus 73%; P<0.001), diabetes (28% versus 24%; P=0.076), and atrial fibrillation (37% versus 32%; P=0.064). FP complete recanalization (odds ratio [OR], 1.49; P=0.026), lower age (OR, 0.966; P<0.010), lower prestroke modified Rankin scale score (OR, 0.601; P<0.001), diabetes (OR, 0.612; P=0.014), and higher Alberta Stroke Programme Early CT Score (OR, 1.183; P<0.001) were independent predictors of favorable functional outcome (defined as modified Rankin scale score <= 2). In a subgroup analysis, the effect of FP complete reperfusion on favorable outcome was only detectable in patients with M1 occlusions (OR, 1.667; P=0.045). Predictors for FP reperfusion success were lower National Institutes of Health Stroke Scale score at baseline (OR, 0.980; P=0.020) and M1 occlusions (OR, 1.990; P<0.001). Conclusions: This analysis of a large, multicenter stroke database confirms the importance of FP reperfusion in endovascular stroke care.