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Publications

Journal Article Ahead of print

PubMed: 42417042 DOI: 10.1161/STROKEAHA.125.054852

MAD-MT Score: A Tool to Optimize Patient Selection for Mechanical Thrombectomy in Distal Vessel Occlusions.

Stroke

Authors: Huanwen Chen, Dhairya A Lakhani, Hamza Adel Salim, Marco Colasurdo, Vivek Yedavalli, Basel Musmar, Nimer Adeeb, Davide Simonato, Yan-Lin Li, Muhammed Amir Essibayi, Orabi Hajjeh, Nils Henninger, Sri Hari Sundararajan, Anna Luisa Kühn, Jane Khalife, Sherief Ghozy, Fulvio Zaccagna, James T Grist, Luca Scarcia, Leonard L L Yeo, Benjamin Y Q Tan, Robert W Regenhardt, Jeremy J Heit, Aymeric Rouchaud, Jens Fiehler, Sunil Sheth, Ajit S Puri, Christian Dyzmann, Leonardo Renieri, João Pedro Filipe, Pablo Harker, Răzvan Alexandru Radu, Mohamad Abdalkader, Piers Klein, Takahiro Ota, Ashkan Mowla, Kareem El Naamani, Pascal Jabbour, Arundhati Biswas, Frédéric Clarençon, James E Siegler, Thanh N Nguyen, Ricardo Varela, Amanda Baker, David Altschul, Nestor R Gonzalez, Markus A Möhlenbruch, Vincent Costalat, Benjamin Gory, Christian Paul Stracke … and 18 other authors

Affiliations

  • Division of Neurointerventional Surgery, Department of Neurosurgery, University of Maryland Medical Center, Baltimore (H.C. D.G.).
  • Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown (D.A.L.).
  • Division of Neuroradiology, Department of Radiology, Johns Hopkins Medical Center, Baltimore, MD (H.A.S. V.Y.).
  • Department of Neuroradiology, MD Anderson Medical Center, Houston, TX (H.A.S. O.H. M.W.).
  • Department of Interventional Radiology, Oregon Health and Science University, Portland (M.C.).
  • Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (B.M. K.E.N. P.J.).
  • Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge (N.A.).
  • Department of Neuroradiology, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, Oxford University Hospitals NHS Foundation Trust (D.S. Y.-L.L. M.F.).
  • Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Laboratory, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (M.A.E. A. Baker, D.A.).
  • Department of Neurology, University of Massachusetts Chan Medical School, Worcester (N.H.).
  • Department of Endovascular Neurosurgery and Neuroradiology, Rutgers New Jersey Medical School, Newark (S.H.S.).
  • Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K. A.S.P.).
  • Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ (J.K. J.E.S. H.S.).
  • Nuffield Department of Primary Care Health Sciences and Department for Continuing Education, University of Oxford, United Kingdom. (EBHC Program) (S.G.).
  • Oxford Centre for Clinical Magnetic Resonance Research (F.Z. J.T.G.), University of Oxford, United Kingdom.
  • Department of Neuroradiology, Henri Mondor Hospital, Creteil, France (L.S. E.K.).
  • Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (L.L.L.Y. B.Y.Q.T.).
  • Division of Neurology, Department of Medicine, National University Hospital, Singapore (B.Y.Q.T.).
  • Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston (R.W.R. A.B.P. A.A.D.).
  • Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA (J.J.H.).
  • Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252 (A.R.).
  • Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.).
  • Department of Neurology, UTHealth McGovern Medical School, Houston, TX (S.S.).
  • Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Germany (C.D.).
  • Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy (L.R.).
  • Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Portugal. (J.P.F.).
  • Department of Neurology, University of Cincinnati Medical Center, OH (P.H.).
  • Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, France (R.A.R. V.C.).
  • Departments of Radiology and Neurology, Boston Medical Center, MA (M.A. P.K. T.N.N.).
  • Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Japan (T.O.).
  • Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles (A.M.).
  • Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla (A. Biswas).
  • Department of Neuroradiology, Pitié-Salpêtrière Hospital, GRC BioFast, Sorbonne University, Paris VI, France (F.C.).
  • Department of Neurology (R.V.), Centro Hospitalar Universitário do Porto, Portugal.
  • Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.R.G.).
  • Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Germany (M.A.M.).
  • Department of Interventional Neuroradiology, Nancy University Hospital, France (B.G.).
  • INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France (B.G.).
  • Interventional Neuroradiology Section, Department of Radiology, University Medical Center Münster, Germany. (C.P.S.).

Abstract

BACKGROUND

Endovascular thrombectomy (EVT) for distal and medium vessel occlusion stroke remains uncertain. We aimed to develop a medium and distal mechanical thrombectomy score integrating clinical need and procedural risk to guide patient selection.

METHODS

This retrospective cohort analysis used an international distal and medium vessel occlusion stroke registry spanning the study period of 2017 to 2023. Patients with acute distal and medium vessel occlusion stroke who received medical management (MM) or EVT across 37 stroke centers were included, and those with baseline modified Rankin Scale score of ≥3 or those with missing covariable data were excluded. Multivariable logistic regression identified predictors of poor functional outcome (modified Rankin Scale score >2 at 90 days) in the MM cohort and predictors of EVT failure/complications in the EVT cohort. Predictors of poor outcome on MM were assigned positive weights (clinical need); predictors of EVT failure/harm were assigned negative weights (procedural risk). The medium and distal mechanical thrombectomy score summed these weighted points. Interaction analysis assessed the heterogeneity of EVT effect by score.

RESULTS

A total of 1217 patients were identified, and 1007 were included (EVT: 822, MM: 185; median age 73 years; 41% female). Higher National Institutes of Health Stroke Scale score (+1 per point) and lack of intravenous thrombolysis (+7) predicted poor MM outcomes. In the EVT cohort, older age (-1 per 15 years above 25), absence of hypertension (-2), and absence of atrial fibrillation (-2) predicted failure/complications. The medium and distal mechanical thrombectomy score (range -8 to 49) significantly modified EVT effect versus MM (P interaction=0.048). In high-score patients (≥15; n=293), EVT yielded a better 90-day modified Rankin Scale score than MM (median, 3 versus 4; P=0.009). Conversely, in low-score patients (<15; n=710), EVT yielded a worse modified Rankin Scale score (median, 2 versus 1; P=0.014).

CONCLUSIONS

The medium and distal mechanical thrombectomy score is a pragmatic tool that identifies patients with distal and medium vessel occlusion most likely to benefit from EVT while minimizing risk, supporting patient-centered decisions and future trial design.

MeSH

Ischemic Stroke, Stroke, Absenteeism, Angiography, Subarachnoid Hemorrhage, Cerebrovascular Disorders, Thrombectomy, Prognosis