Impact of first pass effect in endovascular treatment of large core stroke: a post-hoc analysis of the ANGEL-ASPECT trial

Xianjun Huang; Dapeng Sun; Thanh N Nguyen; Yuesong Pan; Mengxing Wang; Mohamad Abdalkader; Osama O Zaidat; Ning Ma; Feng Gao; Dapeng Mo; Zhongrong Miao; Xiaochuan Huo; Zhiming Zhou; ANGEL-ASPECT study group

doi:10.1136/jnis-2024-021728

Impact of first pass effect in endovascular treatment of large core stroke: a post-hoc analysis of the ANGEL-ASPECT trial

J Neurointerv Surg. 2024 Jun 24:jnis-2024-021728. doi: 10.1136/jnis-2024-021728. Online ahead of print.

Authors

Xianjun Huang^#¹, Dapeng Sun^#², Thanh N Nguyen³, Yuesong Pan^{2

4}, Mengxing Wang⁴, Mohamad Abdalkader³, Osama O Zaidat⁵, Ning Ma², Feng Gao², Dapeng Mo², Zhongrong Miao², Xiaochuan Huo⁶, Zhiming Zhou⁷; ANGEL-ASPECT study group

Collaborators

ANGEL-ASPECT study group:
Miao Zhongrong, Ren Zeguang, Vitor Mendes Pereira, Huo Xiaochuan, Tong Xu Ma Gaoting, Zhang Xuelei, Sun Dapeng, Liu Zhenqiang, Yang Ming, Zhang Yupeng, Nie Ximing, Wei Na, Yang Bo, Meng Xia, Pan Yuesong, Wang Anxin, Liu Liping, Wang Yilong, Wang Yongjun, Ji Xunming, Liu Xinfeng, Dong Qiang, Xu Anding, Yang Qingwu, Geng Xiaokun, Zhang Shiyong, Zhou Zhiming, Chen Wenhuo, Wang Yizhou, Liao Geng, Liu Yajie, Ling Wentong, Xu Guodong Li Tong, Gui Liqiang, Zhang Jiangang Li Tianxiao, Ju Dongsheng, Zhao Junfeng, Shi Haibin, Pen Ya, Liu Yan, Shi Hongchao, Wu Jin, Ding Yasuo, Song Weigen, Li Di, Jiang Changchun, Zhu Qiyi, Han Hongxing, Wang Guoqing, Song Cunfeng, L I Weirong Zhao Jing, Bi Yong, Zheng Hongbo, Luo Jun, Wei Ming Li Jinglun, Guo Zaiyu, Yin Congguo, Wang En, Liu Shudong, Cai Chuwei, Zhang Meng, Cai Xueli, Nan Guangxian, Zhang Liyong, Yang Hua, Sun Yaxuan, Xu Na, Yang Xinguang, Yuan Guangxiong, Dai Linzhi, Huang Wenguo, Gao Zongen, Shi Qing, Tang Yufeng, Yue Wencan, Wen Changming

Affiliations

¹ Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China.
² Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
³ Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA.
⁴ China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
⁵ Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio, USA.
⁶ Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China neuro_depar@hotmail.com huoxiaochuan@126.com.
⁷ Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China neuro_depar@hotmail.com huoxiaochuan@126.com.

^# Contributed equally.

PMID: 38914460
DOI: 10.1136/jnis-2024-021728

Abstract

Background: The first-pass effect (FPE) is linked to better safety and efficacy prognosis in patients with small- to- moderate sized ischemic infarctions. We evaluated the incidence, prognosis, and predictors of FPE in patients with large core infarctions (LCIs).

Methods: We conducted a post-hoc analysis of data from the Trial of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT). The FPE was defined as a successful recanalization (expanded Thrombolysis in Cerebral Infarction (eTICI) 2 c/3, and eTICI 2b-3 as modified FPE (mFPE)) after one pass. The primary outcome was clinical functional independence, and the secondary outcomes were independent ambulation, assessed by the modified Rankin Scale (mRS) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) defined by the Heidelberg bleeding classification, any intracranial hemorrhage (ICH), and death within 90 days of stroke onset.

Results: Of the 226 patients in the study, FPE and mFPE were achieved in 33 (14.6%) and 82 (36.3%) patients, respectively. Patients with FPE exhibited shorter onset-to-puncture times (adjusted odds ratio [OR] 0.915; 95% confidence interval [CI]: 0.84 to 0.996), and patients with mFPE were older (OR 1.039; 95% CI: 1.005 to 1.075). mFPE was significantly associated with favorable outcomes (modified Rankin score [mRS] 0-2: OR 2.64; 95% CI: 1.37 to 5.07; mRS 0-3: OR 3.31; 95% CI: 1.73 to 6.33). FPE tended to improve outcomes (mRS 0-3: OR 2.24; 95% CI: 0.92 to 4.97; p=0.08). ICH rates (OR 0.60; 95% CI: 0.34 to 1.05; p=0.07) and 90-day deaths (OR 0.57; 95% CI: 0.30 to 1.09; p=0.09) tended to decrease in patients who achieved mFPE but not in patients who achieved FPE.

Conclusions: In the ANGEL-ASPECT trial, patients who achieved mFPE had a higher rate of independent ambulation and functional independence, and the rates of any ICH and 90-day death tended to decrease.

Keywords: Stroke; Thrombectomy.