Need for refining successful revascularization in endovascular treatment of acute ischemic stroke: Data from  real-world

Carvalho, Andreia; Santos, Telma; Cunha, André Mallemont; Gregório, Tiago; Paredes, Ludovina; Costa, Henrique; Castro, Sérgio; Ribeiro, Manuel; Veloso, Miguel; Barros, Pedro

doi:10.1016/j.jns.2017.10.013

Cited by 15 publications

(9 citation statements)

References 18 publications

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“…Our study demonstrated that the effect of mTICI-3 reperfusion was not significantly modified by patients' baseline characteristics such as age, sex, NIHSS score, ASPECTS, and target occlusion location among patients www.nature.com/scientificreports www.nature.com/scientificreports/ with anterior circulation occlusion. Previous studies have reported the effect of complete reperfusion on outcomes [4][5][6][7][8][9][10][11][12][22][23][24] , but the heterogeneity of this effect according to patients' characteristics has not been fully investigated. Although the superiority of mTICI-3 reperfusion did not reach statistical significance in some subgroups, presumably due to insufficient power, our findings provide further support for the importance of achieving mTICI-3 reperfusion regardless of the baseline characteristics.…”

Section: Discussionmentioning

confidence: 99%

Futile complete recanalization: patients characteristics and its time course

Kitano

Todo

Yoshimura

et al. 2020

Sci Rep

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As the goal of mechanical thrombectomy is shifting toward mTICI-3 rather than mTICI-2b, we sought to clarify the limitation of the effect of mTICI-3. A post-hoc analysis of a registry of large-vessel occlusion stroke from 46 centers was conducted. Among 2,420 registered patients, 725 patients with anterior circulation occlusion who achieved successful reperfusion were analyzed. We compared outcomes between patients with mTICI-3 and mTICI-2b, and investigated how the effect of mTICI-3 changed according to baseline characteristics and time course. The proportion of patients with favorable outcomes (mRS 0-2 at day 90) was higher among patients with mTICI-3 compared to those with mTICI-2b (adjusted OR, 2.10; 95% CI, 1.49-2.97). There was no heterogeneity in the effect of mTICI-3 with respect to age, neurological deficit, alteplase use, occluded vessels, or infarct size. mTICI-3 was associated with favorable outcomes when the puncture-to-reperfusion time was <80 minutes (adjusted OR, 2.28; 95% CI, 1.52-3.41), but not when the puncture-to-reperfusion time was ≥80 minutes. A significant heterogeneity was found in the effect of mTICI-3 reperfusion across the puncture-toreperfusion time subgroups (p for interaction = 0.025). Until when operators should continue the procedure after mTICI-2b has been achieved, needs to be studied.

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Section: Discussionmentioning

confidence: 99%

Futile complete recanalization: patients characteristics and its time course

Kitano

Todo

Yoshimura

et al. 2020

Sci Rep

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“…Clinical trials have shown the superiority of intravenous thrombolysis plus mechanical thrombectomy (IVT + MT) versus IVT alone in acute stroke due to intracranial large-vessel occlusion (LVO) [1][2][3][4][5][6][7]. MT indeed increases the rate of optimal reperfusion, which is known to be the best predictor of independence after any revascularization treatment [8,9].…”

Section: Introductionmentioning

confidence: 99%

Predictive factors of functional independence after optimal reperfusion in anterior circulation ischaemic stroke with indication for intravenous thrombolysis plus mechanical thrombectomy

Riou‐Comte

Guillemin

Gory

et al. 2020

Euro J of Neurology

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Background and purpose: Intravenous thrombolysis plus mechanical thrombectomy (IVT + MT) is the best current management of acute stroke due to large-vessel occlusion and results in optimal reperfusion for most patients. Nevertheless, some of these patients do not subsequently achieve functional independence. The aim was to identify baseline factors associated with 3-month independence after optimal reperfusion and to validate a prediction model. Methods: All consecutive patients with intracranial anterior large-vessel occlusion, with indication for IVT + MT and achieving optimal reperfusion (defined as modified Treatment in Cerebral Ischaemia score 2b-3), from the THRACE trial and the ETIS registry, were included in order to identify a prediction model. The primary outcome was 3-month independence [modified Rankin Scale (mRS) score ≤ 2]. Multivariate inferences invoked forward logistic regression, multiple imputation and bootstrap resampling. Predictive performance was assessed by c-statistic. Model validation was conducted on patients from the ASTER trial. Results: Amongst 139 patients (mean age 65.5 years; 54.3% female), predictors of 3-month mRS ≤ 2 (n = 82) were younger age [odds ratio 0.62 per 10year increase; 95% confidence interval (CI) 0.53-0.72] and higher Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (odds ratio 1.65 per 1-point increase; 95% CI 1.47-1.86) with c-statistic 0.77. Model validation (n = 104/181 patients with 3-month mRS ≤ 2) demonstrated a moderate discrimination (c-statistic 0.74; 95% CI 0.66-0.81) combining age and ASPECTS. The validation model was improved by the adjunction of three candidate variables that were found to be predictors. Addition of baseline National Institutes of Health Stroke Scale (NIHSS) score, history of vascular risk factor and onset-to-reperfusion time significantly improved discrimination (c-statistic 0.85; 95% CI 0.83-0.87). Conclusions: After optimal reperfusion, younger age, higher ASPECTS, lower NIHSS score, shorter onset-to-reperfusion time and absence of vascular risk factor were predictive of independence and could help to guide patient management.

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“…Since 2013, and based on these assumptions, mTICI has been accepted as the stan- dard scale and mTICI 2b and mTICI 3 grades as successful revascularization [1]. However, mTICI 2b grade encompasses a wide range of revascularization states (from just over 50% reperfusion of the vessel territory to complete reperfusion but slow contrast filling), with differences in clinical outcomes between mTICI 2b and mTICI 3 grades recently demonstrated by our group [4] and by other reports [2,3,5]. Thus, it may partially justify the dissociation of approximately 15-30% between angiographic successful revascularization and good outcome rates verified in clinical trials [6,[10][11][12][13][14].…”

Section: Discussionmentioning

confidence: 83%

“…Details relative to revascularization procedures and follow-up evaluations can be seen in the "Methods" section of our prior study [4].…”

Section: Methodsmentioning

confidence: 99%

“…Although mTICI 2b and mTICI 3 grades have been equally accepted as successful revascularization, this cutoff has been questioned since the magnitude of benefit derived from each of these angiographic scores does not seem to be equivalent [2][3][4][5]. We previously showed that patients with mTICI 3 grade had significant better efficacy and safety outcomes than mTICI 2b patients and suggested that the definition of successful revascularization should be redefined [4]. In 2014, Goyal et al [6] proposed an adaptation of the mTICI scale that includes a 2c grade (near complete perfusion, except for slow flow or small emboli in a few distal cortical vessels), in a way to restrain the large heterogeneity of revascularization states of mTICI 2b group.…”

Section: Introductionmentioning

confidence: 99%

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Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

et al. 2018

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Background: A 2013 consensus statement recommended the use of the modified Treatment In Cerebral Ischemia (mTICI) scale to evaluate angiographic revascularization after endovascular treatment (EVT) of acute ischemic stroke due to its higher inter-rater agreement and capacity of clinical outcome prediction. The current definition of successful revascularization includes the achievement of grades mTICI 2b or 3. However, mTICI 2b grade encompasses a large heterogeneity of revascularization states, and prior studies suggested that the magnitude of benefit derived from mTICI 2b and mTICI 3 does not seem to be equivalent. In a way to restrain the referred heterogeneity, Goyal et al. [J Neurointerv Surg 2014; 6: 83–86] proposed a revised mTICI scale that includes a 2c grade (rTICI). Methods: Retrospective analysis of prospectively collected data from consecutive cases of EVT for anterior circulation large-vessel occlusion, performed between January 2015 and July 2017. Patients with mTICI 2b or 3 grades were reclassified according to the rTICI scale, and the outcomes between the 3 revascularization grades (rTICI 2b, 2c, 3) compared. Results: Our study population of 226 patients (64 rTICI 2b, 30 rTICI 2c, 132 rTICI 3) has a mean age of 71 years, 48.2% males, median baseline NIHSS of 16 (13–19) and ASPECTS of 8 (7–9). The 3 revascularization grades are represented by homogeneous populations. Logistic regression analysis showed statistically significant higher rates of functional independence at 3 months (65.9 vs. 50.0%; adjusted OR 0.39, 95% CI 0.18–0.86), with lower rates of mortality (8.3 vs. 15.6%; adjusted OR 3.54, 95% CI 1.14–10.97) and intracranial hemorrhage (ICH) in rTICI 3 than 2b groups. When comparing rTICI 3 with 2c groups, there were only statistically significant differences in the total ICH rate (8.3 vs. 26.7%; adjusted OR 7.08, 95% CI 1.80–27.82) but not in symptomatic ICH. Conclusions: These results corroborate the scarce prior findings suggesting that patients with rTICI 2c grade should be reported separately, since they have similar outcomes to rTICI 3, and better than rTICI 2b patients. Therefore, we suggest resetting the angiographic revascularization endpoint to perfect revascularization (rTICI 2c or 3 grades), a target that neurointerventionalists should strive to achieve.

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Need for refining successful revascularization in endovascular treatment of acute ischemic stroke: Data from real-world

Cited by 15 publications

References 18 publications

Futile complete recanalization: patients characteristics and its time course

Futile complete recanalization: patients characteristics and its time course

Predictive factors of functional independence after optimal reperfusion in anterior circulation ischaemic stroke with indication for intravenous thrombolysis plus mechanical thrombectomy

Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

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