Background: Endovascular therapy has been proven effective for the treatment of large vessel occlusion strokes (LVOS). However, the feasibility and potential benefits of repeat thrombectomy for recurrent stroke is unclear. We aim to report our experience with repeat thrombectomy for recurrent LVOS. Methods: We reviewed our prospectively collected endovascular database for patients who underwent repeated mechanical thrombectomy. Baseline characteristics, procedural data and outcomes were evaluated. Patients with repeat thrombectomy were compared to patients with single thrombectomy. For patients with repeat thrombectomy, imaging and procedural variables were compared between first and last procedures. Results: Out of 697 patients treated within the study period, 15 patients (2%) had repeat thrombectomies (14 treated twice and one thrice). The mean age was 63 ± 15 years and 40% were males. The median time between the first and last procedure was 18 (1-278) days. Cardioembolism (66%) was the most common etiology, followed by intracranial atherosclerosis (13%) and large vessel atherosclerosis (6%). At 90 days after the last thrombectomy, 60% of patients achieved a modified Rankin Scale score of 0-2 and 20% were deceased. There were no statistically significant differences in demographics, stroke severity, time from last known normal to puncture, reperfusion rates, hemorrhagic complications, good clinical outcomes and mortality between patients who underwent repeat thrombectomy and those who had a single thrombectomy. Conclusion: In properly selected patients suffering recurrent LVOS, repeated mechanical thrombectomy appears to be feasible and safe. A previous thrombectomy should not discourage aggressive treatment as these patients may achieve similar rates of good clinical outcomes as those who undergo single thrombectomy.

Keywords:
Acute stroke, Cerebral ischemia, Recurrent event, Thrombectomy, Outcomes
1.
Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Davalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millan M, Davis SM, Roy D, Thornton J, Roman LS, Ribo M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES collaborators: Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723-1731.
2.
Mohan KM, Wolfe CD, Rudd AG, Heuschmann PU, Kolominsky-Rabas PL, Grieve AP: Risk and cumulative risk of stroke recurrence: a systematic review and meta-analysis. Stroke 2011;42:1489-1494.
3.
Sauer R, Huttner HB, Breuer L, Engelhorn T, Schellinger PD, Schwab S, Kohrmann M: Repeated thrombolysis for chronologically separated ischemic strokes: a case series. Stroke 2010;41:1829-1832.
4.
Yoo HS, Kim YD, Lee HS, Song D, Song TJ, Kim BM, Kim DJ, Kim DI, Heo JH, Nam HS: Repeated thrombolytic therapy in patients with recurrent acute ischemic stroke. J Stroke 2013;15:182-188.
5.
Qureshi AI, Malik AA, Freese M, Thompson MJ, Khan AA, Suri MF: Readministration of intravenous alteplase in acute ischemic stroke patients: case series and systematic review. Am J Emerg Med 2015;33:307.e1-4.
6.
Cappellari M, Tomelleri G, Carletti M, Bovi P, Moretto G: Intravenous thrombolysis on early recurrent cardioembolic stroke: ‘Dr Jekyll' or ‘Mr Hyde'? Blood Coagul Fibrinolysis 2012;23:78-81.
7.
Lee Y, Yi H, Kim BM, Kim DJ, Kim SH, Nam HS, Heo JH, Kim YD: Recurrent cardioembolic stroke treated successfully with repeated mechanical thrombectomy within the acute index stroke period. J Clin Neurol 2015;11:275-278.
8.
Laible M, Mohlenbruch M, Hacke W, Bendszus M, Ringleb PA, Rizos T: Repeated intra-arterial thrombectomy within 72 hours in a patient with a clear contraindication for intravenous thrombolysis. Case Rep Vasc Med 2015;2015:872817.
9.
Suzuki S, Kidwell CS, Starkman S, Saver JL, Duckwiler G, Vinuela F, Ovbiagele B: Use of multimodal MRI and novel endovascular therapies in a patient ineligible for intravenous tissue plasminogen activator. Stroke 2005;36:e77-e79.
10.
Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Marks MP, Prabhakaran S, Kallmes DF, Fitzsimmons BF, Mocco J, Wardlaw JM, Barnwell SL, Jovin TG, Linfante I, Siddiqui AH, Alexander MJ, Hirsch JA, Wintermark M, Albers G, Woo HH, Heck DV, Lev M, Aviv R, Hacke W, Warach S, Broderick J, Derdeyn CP, Furlan A, Nogueira RG, Yavagal DR, Goyal M, Demchuk AM, Bendszus M, Liebeskind DS; Cerebral Angiographic Revascularization Grading (CARG) Collaborators; STIR Revascularization working group; STIR Thrombolysis in Cerebral Infarction (TICI) Task Force: Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013;44:2650-2663.
11.
Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Hoxter G, Mahagne MH, et al: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017-1025.
12.
Sulter G, Steen C, De Keyser J: Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999;30:1538-1541.
13.
Pexman JH, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, Hu WY, Buchan AM: Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001;22:1534-1542.
14.
Smith WS, Lev MH, English JD, Camargo EC, Chou M, Johnston SC, Gonzalez G, Schaefer PW, Dillon WP, Koroshetz WJ, Furie KL: Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA. Stroke 2009;40:3834-3840.
15.
Fugate JE, Rabinstein AA: Absolute and relative contraindications to IV rt-PA for acute ischemic stroke. Neurohospitalist 2015;5:110-121.
16.
Pechlaner C, Knapp E, Wiedermann CJ: Hypersensitivity reactions associated with recombinant tissue-type plasminogen activator and urokinase. Blood Coagul Fibrinolysis 2001;12:491-494.
17.
Rudolf J, Grond M, Prince WS, Schmulling S, Heiss WD: Evidence of anaphylaxy after alteplase infusion. Stroke 1999;30:1142-1143.
18.
Arboix A, Alio J: Cardioembolic stroke: clinical features, specific cardiac disorders and prognosis. Curr Cardiol Rev 2010;6:150-161.
19.
Sacco RL, Kargman DE, Gu Q, Zamanillo MC: Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke 1995;26:14-20.
20.
Arenillas JF, Molina CA, Chacon P, Rovira A, Montaner J, Coscojuela P, Sanchez E, Quintana M, Alvarez-Sabin J: High lipoprotein (a), diabetes, and the extent of symptomatic intracranial atherosclerosis. Neurology 2004;63:27-32.
© 2016 S. Karger AG, Basel
2016
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.