Proposed achievable levels of dose and impact of dose-reduction systems for thrombectomy in acute ischemic stroke: an international, multicentric, retrospective study in 1096 patients

Eur Radiol. 2019 Jul;29(7):3506-3515. doi: 10.1007/s00330-019-06062-6. Epub 2019 Mar 22.


Background: International dose reference levels are lacking for mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusions. We studied whether radiation dose-reduction systems (RDS) could effectively reduce exposure and propose achievable levels.

Materials and methods: We retrospectively included consecutive patients treated with thrombectomy on a biplane angiography system (BP) in five international, high-volume centers between January 2014 and May 2017. Institutional Review Board approvals were obtained. Technical, procedural, and clinical characteristics were assessed. Efficacy, safety, radiation dose, and contrast load were compared between angiography systems with and without RDS. Multivariate analyses were adjusted according to Bonferroni's correction. Proposed international achievable cutoff levels were set at the 75th percentile.

Results: Out of the 1096 thrombectomized patients, 520 (47%) were treated on a BP equipped with RDS. After multivariate analysis, RDS significantly reduced dose-area product (DAP) (91 vs 140 Gy cm2, relative effect 0.74 (CI 0.66; 0.83), 35% decrease, p < 0.001) and air kerma (0.46 vs 0.97 Gy, relative effect 0.63 (CI 0.56; 0.71), 53% decrease, p < 0.001) with 75th percentile levels of 148 Gy cm2 and 0.73 Gy, respectively. There was no difference in contrast load, rates of successful recanalization, complications, or clinical outcome.

Conclusion: Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety. The respective thresholds of 148 Gy cm2 and 0.73 Gy represent achievable levels that may serve to optimize current and future radiation exposure in the setting of acute ischemic stroke treatment. As technology evolves, we expect these values to decrease.

Key points: • Internationally validated achievable levels may help caregivers and health authorities better assess and reduce radiation exposure of both ischemic stroke patients and treating staff during thrombectomy procedures. • Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety in the setting of acute ischemic stroke due to large vessel occlusion.

Keywords: Patient safety; Stroke; Thrombectomy.

Publication types

  • Multicenter Study

MeSH terms

  • Acute Disease
  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Brain Ischemia / diagnosis
  • Brain Ischemia / surgery*
  • Carotid Artery, Internal / diagnostic imaging
  • Carotid Artery, Internal / surgery*
  • Female
  • Fluoroscopy / methods*
  • Humans
  • Ischemia
  • Male
  • Middle Aged
  • Radiation Dosage
  • Radiation Exposure / standards*
  • Radiation Injuries / prevention & control*
  • Retrospective Studies
  • Surgery, Computer-Assisted / methods*
  • Thrombectomy / methods*
  • Young Adult