Impact of Time on Thrombolysis in Cerebral Infarction Score Results

Behme, Daniel; Gera, Roland Gerard; Tsogkas, Ioannis; Colla, Ruben; Liman, Jan; Maier, Ilko; Liebeskind, David S; Psychogios, Marios

doi:10.1007/s00062-019-00786-0

Cited by 12 publications

(6 citation statements)

References 18 publications

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“…[1][2][3] Although the chances for a clinical benefit are optimal if complete reperfusion is attained after the first pass, 4 5 there is a growing body of evidence suggesting that an effect of improved reperfusion is still tangible after multiple attempts and prolonged procedure time. [6][7][8] Despite recent technical advances, failed reperfusion (Thrombolysis in Cerebral Infarction (TICI) 0/1) is the final result of MT in every 10th patient, [9][10][11] and most patients treated successfully do not reach complete reperfusion (TICI 3). 12 13 Treatment options in these scenarios are distal MT of thrombus fragments, 7 14 bailout stenting 15 or administration of intra-arterial (IA) fibrinolytics.…”

Section: Introductionmentioning

confidence: 99%

Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data

Kaesmacher

Meinel

Kurmann

et al. 2021

J NeuroIntervent Surg

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BackgroundAchieving the best possible reperfusion is a key determinant of clinical outcome after mechanical thrombectomy (MT). However, data on the safety and efficacy of intra-arterial (IA) fibrinolytics as an adjunct to MT with the intention to improve reperfusion are sparse.MethodsWe performed a PROSPERO-registered (CRD42020149124) systematic review and meta-analysis accessing MEDLINE, PubMed, and Embase from January 1, 2000 to January 1, 2020. A random-effect estimate (Mantel-Haenszel) was computed and summary OR with 95% CI were used as a measure of added IA fibrinolytics versus control on the risk of symptomatic intracranial hemorrhage (sICH) and secondary endpoints (modified Rankin Scale ≤2, mortality at 90 days).ResultsThe search identified six observational cohort studies and three observational datasets of MT randomized-controlled trial data reporting on IA fibrinolytics with MT as compared with MT alone, including 2797 patients (405 with additional IA fibrinolytics (100 urokinase (uPA), 305 tissue plasminogen activator (tPA)) and 2392 patients without IA fibrinolytics). Of 405 MT patients treated with additional IA fibrinolytics, 209 (51.6%) received prior intravenous tPA. We did not observe an increased risk of sICH after administration of IA fibrinolytics as adjunct to MT (OR 1.06, 95% CI 0.64 to 1.76), nor excess mortality (0.81, 95% CI 0.60 to 1.08). Although the mode of reporting was heterogeneous, some studies observed improved reperfusion after IA fibrinolytics.ConclusionThe quality of evidence regarding peri-interventional administration of IA fibrinolytics in MT is low and limited to observational data. In highly selected patients, no increase in sICH was observed, but there is large uncertainty.

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Section: Introductionmentioning

confidence: 99%

Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data

Kaesmacher

Meinel

Kurmann

et al. 2021

J NeuroIntervent Surg

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“…Successful reperfusion in endovascular therapy (EVT) for acute ischemic stroke is commonly defined as modified thrombolysis in cerebral infarction (mTICI) scores of 2b or 3 [1][2][3] . It has been shown that outcomes of patients with complete reperfusion (mTICI-3) are superior to those with incomplete reperfusion (mTICI-2b) [4][5][6][7][8][9][10][11][12][13][14][15][16] , and the importance of achieving mTICI-3 reperfusion is remarked. However, whether the superiority of mTICI-3 is retained in any patient subgroups has not been fully investigated.…”

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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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“…High‐volume hospitals might have more focus on preoperative protocols with detailed specification of care processes, including collaboration between different professionals, like neurologists, radiologists, anesthesiologists, intensive care unit staff, and nursing staff, for rapid imaging and shorter procedural duration. 26 , 27 Therefore, when it comes to improving the quality of stroke care, the eTICI score is more actionable for hospitals because it is more sensitive to, for example, logistical improvements that reduce, for example, periprocedural or procedural times to treatment. 27 Further research is needed to understand what processes or other factors underlie the variation in this outcome as this information would be of great importance to providers and patients.…”

Section: Discussionmentioning

confidence: 99%

“… 26 , 27 Therefore, when it comes to improving the quality of stroke care, the eTICI score is more actionable for hospitals because it is more sensitive to, for example, logistical improvements that reduce, for example, periprocedural or procedural times to treatment. 27 Further research is needed to understand what processes or other factors underlie the variation in this outcome as this information would be of great importance to providers and patients.…”

Section: Discussionmentioning

confidence: 99%

Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care

Amini

Eijkenaar

Lingsma

et al. 2023

JAHA

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Background Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). Methods and Results We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between‐hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between‐hospital variation in outcomes was assessed using the variance of random hospital effects (tau 2 ). In addition, we estimated the correlation between hospitals' EVT‐patient volume and (case‐mix–adjusted) outcomes. Both early outcomes and case‐mix characteristics varied significantly across hospitals. Between‐hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case‐mix adjustment (tau 2 =0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case‐mix adjustment led to a decrease in variation between hospitals (tau 2 decreases from 0.19 to 0.17). Hospitals' EVT‐patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores ( r =0.48) and weakly with lower NIHSS score at 24 to 48 hours ( r =0.15). Conclusions Between‐hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case‐mix but not by patient volume. In contrast, between‐hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT‐patient volume but not by case‐mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case‐mix is applied for NIHSS score.

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Impact of Time on Thrombolysis in Cerebral Infarction Score Results

Cited by 12 publications

References 18 publications

Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data

Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data

Futile complete recanalization: patients characteristics and its time course

Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care

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