First pass effect in patients with large core infarcts undergoing mechanical thrombectomy: subgroup analysis of the prospective international ASSIST registry

Haydn Hoffman; Salvador Miralbes; Bharath Naravetla; Alejandro M Spiotta; Christian Loehr; Mario Martínez-Galdámez; Ryan A McTaggart; Luc Defreyne; Pedro Vega; Osama O Zaidat; Lori Lyn Price; David S Liebeskind; Markus A Möhlenbruch; Rishi Gupta; Nitin Goyal; ASSIST Investigators

doi:10.1136/jnis-2024-022532

First pass effect in patients with large core infarcts undergoing mechanical thrombectomy: subgroup analysis of the prospective international ASSIST registry

J Neurointerv Surg. 2025 Jan 8:jnis-2024-022532. doi: 10.1136/jnis-2024-022532. Online ahead of print.

Authors

Haydn Hoffman¹, Salvador Miralbes², Bharath Naravetla³, Alejandro M Spiotta⁴, Christian Loehr⁵, Mario Martínez-Galdámez^{6

7}, Ryan A McTaggart⁸, Luc Defreyne⁹, Pedro Vega¹⁰, Osama O Zaidat¹¹, Lori Lyn Price¹², David S Liebeskind¹³, Markus A Möhlenbruch¹⁴, Rishi Gupta¹⁵, Nitin Goyal¹⁶; ASSIST Investigators

Collaborators

ASSIST Investigators:
Salvador Miralbes, Marc Viles, Rebeca Bermejo, Ángel Calleja, Bharath Naravetla, Aniel Majjhoo, Mahmoud Rayes, Onishchuk Valentyna, Tanya Mosley Gardner, Emily Paschal, Stephanie Bruma, Marci Roberts, Alejandro Spiotta, Jonathan Lena, Kimberly Kicielinski, Sami Al Kasab, Emily Infinger, Melza Van Roijen, Meredith Robinson, Christian Loehr, Stephan Bossmann, Jan Oliver Kuhnt, Axel Schaefer, Andreea Cioltan, Johanna Zabel, Christian Dynak, Jan Peter Püttmann, Markus Möhlenbruch, Christian Herweh, Christian Ulfert, Johannes Pfaff, Alexander Hubert, Alexander Mohr, Leonie Jestaedt, Jessica Jesser, Dominik Vollherbst, Faith Seker, Tim Hilgenfeld, Susanne Bonekamp, Sabine Johnson, Jenny Frech, Lukas Diebold, Gabriele Neureither, Mario Martínez-Galdámez, Miguel Arturo Schüller, Jorge Galván, Mercedes De Lera, Carlos Castañeda, Javier Rodríguez, Rishi Gupta, Ahmad Khaldi, William Humphries, Stephanie Rowe, Lauryn Taylor, Martha Kelly, Ryan McTaggart, Mahesh Jayaraman, Richard Haas, Radmehr Torabi, Wendy Smith, Gina Merola, Susan Foley, Luc Defreyne, Elisabeth Dhondt, Peter Vanlangenhove, Laurens Hermie, Lynn Huyck, Lien Van Cauwenberghe, Pedro Vega, Eduardo Murias, Juan Chaviano, Jose Maria Jimenez, Marios-Nikos Psychogios, Ioannis Tsogkas, Peter Sporns, Kristine Blackham, Alex Brehm, Antonin Krajina, Ondrej Renc, Eva Vitkova, Vendelin Chovanec, Jan Raupach, Miroslav Lojik, Woong Yoon, Byung Hyun Baek, Eugene Kim, Osama Zaidat, Saif Bushnaq, Bader Alenzi, Nicholas Liaw, Eugene Lin, Varun Chaubal, Alyssa Bickley, Ronda White, India Bass, Amy Krueger, Cynthia Upham, Ansaar Rai, Sohyun Boo, Abdul Tarabishy, Gerard Deib, Rachel Gregis, Abdul Alhalak, Jennifer Domico, Antonio Pitrone, Orazio Buonomo, Agostino Tessitore, Nicola Milazzo, Mariano Velo, Antonio Caragliano, Andrea Calzoni, Sergio Lucio Vinci, Dong Hoon Lee, Seung Yoon Song, Ho Jun Yi, Jae Hoon Sung, Narae Kwon, Lucio Castellan, Laura Malfatto, Nicola Mavilio, Giancarlo Salsano, Bruno Del Sette, Guido Bigliardi, Maria Luisa Dell'Acqua, Laura Vandelli, Giuseppe Borzì, Ludovico Ciolli, Livio Icchetto, Riccardo Ricceri, Francesca Rosafio, Stefano Vallone, Stefania Maffei, Luis López Ibor, Manuel Moreu, Santiago Rosati, Carlos Gomez-Escalonilla, Clemens Schirmer, Itay Melamed, Gregory Weiner, Oded Goren, Christoph Griessenauer, Shamsher Dalal, Karissa Graham, Katherine Freedman, Angela Whitmire, Chelsie Derr, Shahram Majidi, Christopher Kellner, Paul Singh, Johanna Fifi, Hazem Shoirah, Reade DeLeacy, Tomoyoshi Shigematsu, Pouria Moshayedi, Krisztina Moldovan, Gregory Lock, Thomas Oxley, Benjamin Rapoport, Jacopo Scaggiante, Mais Al Kawaz, Sukaina Davdani, Emily Fiano, Armand Harb, Serina Deeb, Geert Vanhooren, Sofie De Blauwe, Olivier Deryck, Bruno Bergmans, Tybault Hollanders, Heleen Parmentier, Ludo Vanopdenbosch, Kristof Verhoeven, Melissa Cambron, Johan Ghekiere, Annelies Van Dycke, Isaline Demarcin, Louise Adams, Robin Bouttelgier, Lisa Van Doeselaer, Charlotte Vanden Berghe, Arne Hostens, Louise De Temmerman, Valérie Schotte, Heleen Couckuyt, Julie Derous, Charlotte Rüther, Monika Probst, Tobias Boeckh-Behrens, Kornelia Kreiser, Christian Maegerlein, Silke Wunderlich Kirschke, Maria Bauer, Timo Krings, Patrick Nicholson, Ronit Agid, Alex Kostynskyy, James Jaffe, Chris Neal, Dharati Trivedi, Thomas Wolfe, Kessarin Panichpisal, Glen Pollock, Sudeepta Dandapat, Kavit Shah, Genevieve Kuchinsky, Samantha Goedde, Payton Tepp, Kristopher Rowe, Gary Dennison, Batul Dhariwala, Kaite McPolin, Tonya Hollrith, Bradley Bohnstedt, Marissa Lowe, Lauren Snyder, Jean-Christophe Gentric, Julien Ognard, Lorena Nico, Géraldine Viard, Eduardo Bárcena, Fernando Ostos, Federico Ballenilla, Jorge Campollo, Pedro Saura, Miriam Fernandez Gomez, David Altschul, Neil Haranhali, Seon-Kyu Lee, Richard Zampolin, Allan Brook, Aureliana Toma, Lavinia Williams, Lei Feng, Kuo Chao, Catherine Lui, Ashima Sharma, Vanessa Audea, Nathalie Sanchez, Marissa Barron, Demetrius Lopes, Joshua Billingsley, Khaled Asi, Kiffon Keigher, Bridget Cantrell, Gina Barbaglia, Eric Leadley, Molly Bake, Abigail Walters, Linda Jiang, Pavan Murty, Arth Srivastava, Nicholas Armijo, Gina Littlejohn, Sherri Velez, Nicole Hannigan, Kathleen Hesse, Lucian Maidan, Geroge Luh, Danielle Hornbuckle, Sharon Bluemel, Jose Luis Caniego, Juan Vega, Rafael González, Conrad Liang, Mazen Noufal, Valerie Wyman, Ashima Sharma, Vanessa Audea, Ali Malek, Nils Mueller-Kronast, Dennys Reyes, Juan Ramos, Muneer Hassan, Jennafer Hallquist, Natasha Molina, Sandra Ripper-Brown, Charity Denson, Marianne Torres-Malaga, Fawaz Al-Mufti, Chirag Ghandhi, Justin Santarelli, Gurmeen Kaur, Christeena Kurian, Jared Cooper, Haris Kamal, Katarina Dakay, Divya Viswanathan, Monique Carrero-Tagle, Kevin Clare, Bridget Nolan, Lucas Elijovich, Adam Arthur, Daniel Hoit, Violiza Inoa, Christopher Nickele, David Dornbos, Nitin Goyal, Jeremy Peterson, Radmehr Torabi, Daniel Heiferman, Kendrick Johnson, Stephanie Wilson, Amanda Nolte, Stephanie Corder, Valorie Horner, Kamal Lotay, Stefan Rohde, Olaf Adamczewski, Stephan Schwarz, Gernot Reimann, Rachid El Mouden, Ines Gaedke, Kristina Hauptmann, Torsten Döring, Bettina Zoeller, Paolo Machi, Gianmarco Bernava, Andrea Rosi, Jeremy Hofmeister, Michel Muster, Malvina Destro, Hoang Duong, Andrey Lima, Brijesh Mehta, Doris Alaby, Joy Sessa

Affiliations

¹ Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA [email protected].
² Department of Neuroradiology, Hospital Universitari Son Espases, Palma de Mallorca, Spain.
³ McLaren Regional Medical Center, Flint, Michigan, USA.
⁴ Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁵ Department of Radiology and Neuroradiology, Klinikum Vest GmbH, Recklinghausen, Germany.
⁶ Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
⁷ Department of Interventional Neuroradiology, Hospital La Luz, Quironsalud, Madrid, Spain.
⁸ Rhode Island Hospital, Providence, Rhode Island, USA.
⁹ Department of Interventional Neuroradiology, University Hospital Ghent, Ghent, Belgium.
¹⁰ Department of Radiology, Hospital Universitario Central de Asturias, Oviedo, Spain.
¹¹ Department of Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA.
¹² Department of Clinical Affairs, Stryker Neurovascular, Fremont, California, USA.
¹³ Department of Neurology, UCLA, Los Angeles, California, USA.
¹⁴ Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany.
¹⁵ WellStar Medical Group, Marietta, Georgia, USA.
¹⁶ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.

PMID: 39778929
DOI: 10.1136/jnis-2024-022532

Abstract

Background: Studies have described a first pass effect (FPE) where patients with successful recanalization after one pass experience better outcomes. Few studies have evaluated this in patients with large core infarctions.

Objective: To determine whether patients with large core infarcts undergoing mechanical thrombectomy in which first pass reperfusion is achieved experience improved outcomes compared with those who undergo more than one pass.

Methods: The ASSIST Registry, a prospective, global, multicenter registry of patients with anterior circulation large vessel occlusion (LVO) undergoing mechanical thrombectomy was used. Adults with internal carotid artery/M1/M2 occlusions and preprocedural Alberta Stroke Program Early CT Score (ASPECTS) <6 were included. The variable of interest was number of thrombectomy passes (dichotomized to 1 or >1) performed for the target occlusion. The primary outcome was 90-day good functional outcome defined as modified Rankin Scale (mRS) score 0-3.

Results: 150 patients with a mean age of 66 years were included. Most patients had ASPECTS of 4 (33%) or 5 (59%). 77 patients (51%) underwent one pass. Compared with patients with one pass, those with more than one pass had significantly lower odds of good functional outcome (OR=0.44, 95% CI 0.21 to 0.93; P=0.03). More than one pass was not significantly associated with 90-day mRS score 0-2 (OR=0.46, 95% CI 0.15 to 1.43; P=0.17) or mortality (OR=2.03, 95% CI 0.81 to 5.08; P=0.13). FPE (one pass eTICI≥2c) and modified FPE (one pass extended thrombolysis in cerebral infarction ≥2b50) were not significantly associated with 90-day mRS 0-3, mortality, or symptomatic intracranial hemorrhage.

Conclusion: This analysis suggests that use of multiple passes is associated with worse outcomes in patients with large core infarcts.

Keywords: Stroke; Thrombectomy.