2C or not 2C: defining an improved revascularization grading scale and the need for standardization of angiography outcomes in stroke trials

Goyal, Mayank; Fargen, Kyle M; Turk, Aquilla S; Mocco, J; Liebeskind, David S; Frei, Donald; Demchuk, Andrew M.

doi:10.1136/neurintsurg-2013-010665

Cited by 234 publications

(195 citation statements)

References 28 publications

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“…Ideally, angiographic success should entail restoring both the patency of the target occlusion (full recanalization) and blood flow in the downstream vascular territory (complete reperfusion) [7][8][9] . The scoring systems used to measure the success of recanalization are the Arterial proposed TICI 2c score are different in their baseline characteristics and outcomes from the TICI 2a, 2b or 3.…”

Section: Introductionmentioning

confidence: 99%

Not All “Successful” Angiographic Reperfusion Patients Are an Equal Validation of a Modified TICI Scoring System

et al. 2014

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Rapid reperfusion of the entire territory distal to vascular occlusions is the aim of stroke interventions. Recent studies defined successful reperfusion as establishing some perfusion with distal branch filling of <50% of territory visualized (Thrombolysis In Cerebral Infarction “TICI” 2a) or more. We investigate the importance of the quality of final reperfusion and whether a revision of the successful reperfusion definition is warranted. We retrospectively evaluated a prospective database of anterior circulation strokes treated using stentrievers to assess the quality of final reperfusion using two scores: the traditional TICI score and a modified TICI score. The modified TICI score includes an additional category (TICI 2c): near complete perfusion except for slow flow or distal emboli in a few distal cortical vessels. We compared different cut-off definitions of reperfusion (TICI 2a–3 vs. TICI-2b–3 vs. TICI 2c–3) using the area under the curve to identify their correlation with a favorable 90-day outcome (mRS≤2). In our cohort of 110 patients, 90% achieved TICI 2a-3 reperfusion with 80% achieving TICI 2b-3 and 55.5% achieving TICI 2c-3. The proportion of patients with a favorable 90-day outcome was higher in the TICI 2c (62.5%) compared to TICI 2b (44.4%) or TICI 2a (45.5%) but similar to the TICI 3 group (75.9%). A TICI 2c-3 reperfusion had a better predictive value than TICI 2b-3 for 90-day mRS 0–1. Defining successful reperfusion as TICI 2c/3 has merits. In this cohort, there was evidence toward faster recovery and better outcomes in patients with the TICI 2c vs. the traditional TICI 2b grade.

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Section: Introductionmentioning

confidence: 99%

Not All “Successful” Angiographic Reperfusion Patients Are an Equal Validation of a Modified TICI Scoring System

et al. 2014

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“…Another grade, namely TICI 2c, exists and is defined as "nearcomplete perfusion except for slow flow in a few distal cortical vessels, or presence of small distal cortical emboli." 19 Furthermore, Almekhlafi et al reported that a combined criterion subsuming TICI 2c/3 as "successful" revascularization might be a more accurate predictor of a favorable clinical outcome than the widely applied TICI 2b/3 criterion. 20 Further prospective studies using the TICI 2c category will be required to determine which grade best predicts patients' outcomes.…”

Section: Discussionmentioning

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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“…Recently, a revised TICI scale that includes a 2c designation has been advocated for better end-point assessment. 24 The reperfusion rates in the recent trials (TICI or modified TICI) were 72.4%, 58.7%, 86.2%, 88%, and 65.7% in ESCAPE, MR CLEAN, SWIFT-PRIME, EXTEND-IA, and RE-VASCAT, respectively. [1][2][3][4][5] The reasons for this variability are currently not clear and may be related to lack of standardized methodology for scoring and patient selection.…”

Section: Neurointervention: Assessing the Neuroangiographic Outcomementioning

confidence: 99%

Imaging, Intervention, and Workflow in Acute Ischemic Stroke: The Calgary Approach

Zerna

Assis

d’Esterre

et al. 2015

AJNR Am J Neuroradiol

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SUMMARY:Five recently published clinical trials showed dramatically higher rates of favorable functional outcome and a satisfying safety profile of endovascular treatment compared with the previous standard of care in acute ischemic stroke with proximal anterior circulation artery occlusion. Eligibility criteria within these trials varied by age, stroke severity, imaging, treatment-time window, and endovascular treatment devices. This focused review provides an overview of the trial results and explores the heterogeneity in imaging techniques, workflow, and endovascular techniques used in these trials and the consequent impact on practice. Using evidence from these trials and following a case from start to finish, this review recommends strategies that will help the appropriate patient undergo a fast, focused clinical evaluation, imaging, and intervention. ABBREVIATIONS: MR CLEAN ϭ Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands; EMS ϭ Emergency

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2C or not 2C: defining an improved revascularization grading scale and the need for standardization of angiography outcomes in stroke trials

Cited by 234 publications

References 28 publications

Not All “Successful” Angiographic Reperfusion Patients Are an Equal Validation of a Modified TICI Scoring System

Not All “Successful” Angiographic Reperfusion Patients Are an Equal Validation of a Modified TICI Scoring System

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

Imaging, Intervention, and Workflow in Acute Ischemic Stroke: The Calgary Approach

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