Time to redefine success? TICI 3 versus TICI 2b recanalization in middle cerebral artery occlusion treated with thrombectomy

Kleine, Justus F.; Wunderlich, Silke; Zimmer, Claus; Kaesmacher, Johannes

doi:10.1136/neurintsurg-2015-012218

Cited by 164 publications

(135 citation statements)

References 23 publications

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“…Our results among low NIHSS stroke patients are in accordance with the recently described strong links between successful reperfusion and favourable functional outcome in AIS patients with moderate-to-severe stroke enrolled in recent RCT [24,25,26]. …”

Section: Discussionsupporting

confidence: 79%

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

et al. 2017

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Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.

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Section: Discussionsupporting

confidence: 79%

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

et al. 2017

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“…TICI 2b implies residual perfusion deficits which are, albeit confined to relatively small territories, relevant for the infarct severity in this area, and consequently for subsequent HTs [9,10]. This observation once more underlines the notion that potentially more aggressive approaches to achieve TICI 3 may be of benefit [26]. …”

Section: Discussionmentioning

confidence: 95%

“…Scores were assessed by an experienced vascular neurologist. NIHSS score <5 was defined as good neurologic outcome [26], while substantial neurologic improvement was defined as a compound criterion of either NIHSS at discharge of ≤1 or difference between baseline NIHSS and NIHSS at discharge of ≥8. Patients who died during their stay at the hospital were assigned to a score of 42 [27].…”

Section: Methodsmentioning

confidence: 99%

Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance

Kaesmacher

Kaesmacher²,

Maegerlein³

et al. 2017

Cerebrovasc Dis

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128

106

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Background: Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke, potentially associated with clinical deterioration. We attempted to identify risk factors and evaluated clinical relevance of minor and major HTs following endovascular thrombectomy (ET) in isolated middle cerebral artery (MCA) occlusions. Methods: This is a retrospective single-center analysis of 409 patients with isolated MCA occlusion treated with ET. Patients' and procedural characteristics, severity of HT according to the European Cooperative Acute Stroke Study criteria, and clinical outcomes were analyzed. Multivariate logistic regression models with standard retention criteria (p < 0.1) were used to determine risk factors and clinical relevance of HT. Results are shown as adjusted OR (aOR) and respective 95% CIs. Good neurologic short-term outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score <5 at the day of discharge. Results: Of 299 patients included, hemorrhagic infarction (HI) was detected in 87 patients, while 13 patients developed parenchymal hematoma (PH). Higher age (aOR 0.970, 95% CI 0.947-0.993, p = 0.012), eligibility for intravenous recombinant tissue plasminogen activator (IV rtPA; aOR 0.512, 95% CI 0.267-0.982, p = 0.044), and complete recanalization (TICI 3, aOR 0.408, 95% CI 0.210-0.789, p = 0.008) were associated with a lower risk of HI. Risk factors for HI included higher admission NIHSS score (aOR 1.080, 95% CI 1.010-1.153, p = 0.024) and higher admission glucose levels (aOR 1.493, 95% CI 1.170-1.904, p = 0.001). Further, female sex tended to be associated with a lower risk of HI (aOR 0.601, 95% CI 0.316-1.143, p = 0.121), while a statistical trend was observable for proximal MCA occlusion (aOR 1.856, 95% CI 0.945-3.646, p = 0.073) and a history of hypertension (aOR 2.176, 95% CI 0.932-5.080, p = 0.072) to increase risk of HI. Longer intervals from symptom onset to first digital subtraction angiography runs (aOR 1.013, 95% CI 1.003-1.022, p = 0.009), lower preinterventional Alberta Stroke Program Early CT score (aOR 0.536, 95% CI 0.307-0.936, p = 0.028) and wake-up stroke (aOR 18.540, 95% CI 1.352-254.276, p = 0.029) were associated with PH. Both, PH and HI were independently associated with lower rates of good neurologic outcome (aOR 0.086, 95% CI 0.008-0.902, p = 0.041 and aOR 0.282, 95% CI 0.131-0.606, p = 0.001). Conclusion: Risk of HI following MCA occlusion and subsequent ET is mainly determined by factors influencing infarct severity. Good recanalization results seem to be protective against subsequent HI. Our results support the notion that occurrence of PH after ET is time dependent and risk increases with more extensive early ischemic damage. Both, HI and PH do not seem to be facilitated by bridging therapy with IV rtPA or the use of oral anticoagulants, but were independently associated with more severe neurologic disability. These results support the notion that HI is not a “benign” imaging sign.

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“…For instance, Kleine et al reported that compared with almost complete reperfusion (TICI 2b), complete reperfusion (TICI 3) was associated with significantly greater neurologic recovery and better neurologic outcomes (37% versus 68%). 11 Although not significant, Yoo et al likewise observed a higher rate of good functional outcomes (mRS of 0-2 at $90 days) in patients with a TICI 3 grade compared with patients with a TICI 2b grade (62% vs. 46%). 12 The present results are in agreement with the results of these prior studies.…”

Section: Discussionmentioning

confidence: 99%

“…Of the 69 included patients, 35 (50.7%) had atrial fibrillation, 36 (52.2%) had hypertension, and 15 (21.7%) had diabetes mellitus. The patients' mean DWI-ASPECTS was 7.5 (range, [3][4][5][6][7][8][9][10][11]. Among the 69 patients, the occluded vessel was the ICA in 24 patients (34.8%), the MCA M1 portion in 41 patients (59.4%), and the MCA M2 portion in 4 patients (5.8%).…”

Section: Baseline Characteristics Of the Patientsmentioning

confidence: 99%

Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

Tajima

Hayasaka

Ebihara

et al. 2017

J Clin Interv Radiol ISVIR

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Successful revascularization is one of the main predictors of a favorable clinical outcome after mechanical thrombectomy. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome. This study aimed to investigate the clinical, imaging, and procedural factors that are predictive of poor clinical outcomes despite successful revascularization after mechanical thrombectomy in patients with acute anterior circulation stroke. The authors evaluated 69 consecutive patients (mean age, 74.6 years, 29 women) who presented with acute ischemic stroke due to internal cerebral artery or middle cerebral artery occlusions and who were successfully treated with mechanical thrombectomy between July 2014 and November 2016. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months after treatment. The associations between the clinical, imaging, and procedural factors and poor outcome were evaluated using logistic regression analyses. Using multivariate analyses, the authors found that the preoperative National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR], 1.152; 95% confidence interval [CI], 1.004–1.325; p = 0.028), the diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) (OR, 0.604; 95% CI, 0.412–0.882; p = 0.003), and a Thrombolysis in Cerebral Infarction (TICI) 2b classification (OR, 4.521; 95% CI, 1.140–17.885; p = 0.026) were independent predictors of poor outcome. Complete revascularization to reduce the infarct volume should be performed, especially in patients with a high DWI-ASPECTS, to increase the likelihood of a good outcome.

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Time to redefine success? TICI 3 versus TICI 2b recanalization in middle cerebral artery occlusion treated with thrombectomy

Cited by 164 publications

References 23 publications

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance

Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

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