Intracranial Vessel Perforation during Thrombectomy: Prevalence, Outcomes, and Ongoing Research

Thrombectomy has revolutionized patient care in acute ischemic stroke, but it is an invasive procedure and contains inherent risks. One of the most dreaded complications of thrombectomy is intracranial vessel perforation with subsequent active bleeding. Recently, the topic has gained interest and a few publications have reported on the key characteristics of this complication. Here is a quick summary:

• Periprocedural vessel perforation is reported to occur in 1-6% of procedures and was more frequent in distal/medium vessel occlusion thrombectomy as compared to large vessel occlusion thrombectomy^1–4.
• Periprocedural vessel perforation is a severe complication which is associated with poor functional outcome and high mortality^1,2,4. The largest retrospective cohort studies report that survival at 90 days is around 50%.

But how relevant is this complication? In 2020, approximately 70.000 thrombectomies have been performed in the European region⁵. If we accept the assumptions of a risk of vessel perforation of 2% per thrombectomy and an associated mortality of 50%, this would roughly lead to an estimated number of 700 fatalities in association with vessel perforation during thrombectomy in 2020 in Europe. We need to keep in mind that several randomized controlled trials and the corresponding individual patient data meta-analyses have shown the benefit of thrombectomy in several distinct patient groups. However, trials assessing if thrombectomy may also benefit patients with distal / medium vessel occlusions or low NIHSS are still ongoing. Since these patients differ from the HERMES meta-analysis cohort regarding their natural course of disease, a severe periprocedural complication might be even more impactful in these patients.

Are there any research projects going on about this? Yes: the PeRforation EVents during ENdovascular Therapy (PREVENT) registry gathers clinical data and imaging of patients with vessel perforation during thrombectomy as well as of matched thrombectomy patients without vessel perforation. The registry aims to identify risk factors of vessel perforation and to provide a helpful classification as well as recommendations on management of active bleeding and on continuation vs abortion of thrombectomy. Please contact prevent@usb.ch for more information.

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References

1. Schulze-Zachau V, Brehm A, Ntoulias N, et al. Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy. Journal of NeuroInterventional Surgery. Epub ahead of print 31 July 2023. DOI: 10.1136/jnis-2023-020531.
2. Schulze-Zachau V, Rommers N, Ntoulias N, et al. “Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis”. European Stroke Journal 2024; 23969873241272542.
3. Vega P, Murias E, Jimenez JM, et al. First-line Double Stentriever Thrombectomy for M1/TICA Occlusions. Clin Neuroradiol 2022; 32: 971–977.
4. Dmytriw AA, Musmar B, Salim H, et al. Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study. European Stroke Journal 2024; 23969873231219412.
5. Aguiar de Sousa D, Wilkie A, Norrving B, et al. Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020. European Stroke Journal 2023; 8: 618–628.

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