Reliability of the Modified TICI Score among Endovascular Neurosurgeons

Heiferman, Daniel M.; Pecoraro, Nathan C.; Wozniak, Amy; Ebersole, Koji; Jimenez, Lincoln; Reynolds, Matthew R.; Ringer, Andrew J.; Serrone, Joseph C.

doi:10.3174/ajnr.a6696

Cited by 17 publications

(16 citation statements)

References 26 publications

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“…Focusing on M1 occlusions, the DL system achieved an agreement of network-predicted and expertassigned mTICI scores in the range of published expert-based TICI scoring variability measures [15][16][17][18][19] for 2 independent DSA datasets from different centers. In addition, the dichotomous distinction between open (mTICI score ≥2b) and remaining states (mTICI score ≤2a) was highly reliable.…”

Section: Discussionmentioning

confidence: 98%

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Deep Learning–Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study

Nielsen

Waldmann

Frölich

et al. 2021

Stroke

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Background and Purpose: Mechanical thrombectomy is an established procedure for treatment of acute ischemic stroke. Mechanical thrombectomy success is commonly assessed by the Thrombolysis in Cerebral Infarction (TICI) score, assigned by visual inspection of X-ray digital subtraction angiography data. However, expert-based TICI scoring is highly observer-dependent. This represents a major obstacle for mechanical thrombectomy outcome comparison in, for instance, multicentric clinical studies. Focusing on occlusions of the M1 segment of the middle cerebral artery, the present study aimed to develop a deep learning (DL) solution to automated and, therefore, objective TICI scoring, to evaluate the agreement of DL- and expert-based scoring, and to compare corresponding numbers to published scoring variability of clinical experts. Methods: The study comprises 2 independent datasets. For DL system training and initial evaluation, an in-house dataset of 491 digital subtraction angiography series and modified TICI scores of 236 patients with M1 occlusions was collected. To test the model generalization capability, an independent external dataset with 95 digital subtraction angiography series was analyzed. Characteristics of the DL system were modeling TICI scoring as ordinal regression, explicit consideration of the temporal image information, integration of physiological knowledge, and modeling of inherent TICI scoring uncertainties. Results: For the in-house dataset, the DL system yields Cohen’s kappa, overall accuracy, and specific agreement values of 0.61, 71%, and 63% to 84%, respectively, compared with the gold standard: the expert rating. Values slightly drop to 0.52/64%/43% to 87% when the model is, without changes, applied to the external dataset. After model updating, they increase to 0.65/74%/60% to 90%. Literature Cohen’s kappa values for expert-based TICI scoring agreement are in the order of 0.6. Conclusions: The agreement of DL- and expert-based modified TICI scores in the range of published interobserver variability of clinical experts highlights the potential of the proposed DL solution to automated TICI scoring.

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Section: Discussionmentioning

confidence: 98%

“…12,13 Despite its common use and the coarse distribution of the categories of the original TICI scale and suggested modifications (modified TICI [mTICI)], 14 expanded TICI 13 ), the inter- and intraobserver variability of TICI scoring is surprisingly high, with corresponding numbers varying from study to study (Table 1). 13,15–19…”

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confidence: 99%

Deep Learning–Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study

Nielsen

Waldmann

Frölich

et al. 2021

Stroke

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“…Furthermore, core laboratories use a limited number of experienced panelists, whereas site reads can be carried out by a wider array of interventionalists/readers with different degrees of expertise 6. It has been shown previously that the reliability of scoring and the degree of inter-rater agreement increase substantially with experience 25…”

Section: Discussionmentioning

confidence: 99%

Operator assessment versus core laboratory adjudication of recanalization following endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

Ibrahim

Shehata

Ghozy

et al. 2022

J NeuroIntervent Surg

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BackgroundSuccessful recanalization after endovascular thrombectomy serves as the primary endpoint in clinical trials and is a crucial predictor of long-term outcomes. Radiographic outcomes for various interventions have been shown to vary based on the type of interpreter, including the site interventionalist compared with an independent reader.ObjectiveTo compare angiographic outcomes in stroke thrombectomy procedures based on the type of reader.MethodsA systematic literature search was conducted in Medline, EMBASE, Scopus, and Web-of-Science through February 2022. We included primary studies that reported core laboratory-read and operator angiographic outcomes after mechanical thrombectomy for ischemic stroke. Furthermore, study-defined successful recanalization data were collected.ResultsEight studies were included with 4797 patients, 51.2% of whom were male. Four thousand, four hundred and thirty-one patients had core readings, and 4211 had operator readings. Study-defined successful recanalization was significantly higher for operator (84%, 3543/4211) examinations than for core laboratory-read (78.4%, 3476/4431) examinations (p<0.001; OR=1.462, 95% CI 1.175 to 1.819). The modified Thrombolysis in Cerebral Infarction (mTICI) scale score of ≥2 b was higher for operator (85%, 3341/3929) examinations than for core laboratory-read (78.6%, 3107/3952) examinations (p<0.001; OR=1.349, 95% CI 1.071 to 1.701). mTICI 3 was significantly higher for operator (54.6%, 1000/1832) examinations than for core laboratory-read (39.9%, 731/1832) examinations (p<0.001; OR=1.823, 95% CI 1.598 to 2.081).ConclusionOperator angiographic reads are statistically significantly higher than core laboratory-read readings following stroke thrombectomy, especially for complete recanalization. These differences should be considered when interpreting reports of angiographic outcomes after thrombectomy.

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“…Functional outcome at 90 days was assessed by board-certified vascular neurologists during a routinely scheduled clinical visit or by a study nurse certified in administering the mRS during a standardized telephone interview if the patient was unable to attend a clinic visit. Imaging variables, including mTICI score,20 were adjudicated by one interventionalist for each center.…”

Section: Methodsmentioning

confidence: 99%

Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion

Havenon

Elhorany

Boulouis

et al. 2022

J NeuroIntervent Surg

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BackgroundThe number of mechanical thrombectomy (MT) passes is strongly associated with angiographic reperfusion as well as clinical outcomes in patients with anterior circulation ischemic stroke. However, these associations have not been analyzed in patients with basilar artery occlusion (BAO). We investigated the influence of the number of MT passes on the degree of reperfusion and clinical outcomes, and compared outcome after ≤3 passes versus >3 passes.MethodsWe used data from the prospective multicentric Endovascular Treatment in Ischemic Stroke (ETIS) Registry at 18 sites in France. Patients with BAO treated with MT were included. The primary outcome was a favorable outcome, defined as a modified Rankin Scale score of 0–3 at 90 days. We fit mixed multiple regression models, with center as a random effect.ResultsWe included 275 patients. Successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3) was achieved in 88.4%, and 41.8% had a favorable outcome. The odds ratio for favorable outcome with each pass above 1 was 0.41 (95% CI 0.23 to 0.73) and for recanalization (mTICI 2b-3) it was 0.70 (95% CI 0.57 to 0.87). In patients with ≤3 passes, the rate of favorable outcome in recanalized versus non-recanalized patients was 50.5% versus 10.0% (p=0.001), while in those with >3 passes it was 16.7% versus 15.2% (p=0.901).ConclusionsWe found that BAO patients had a significant relationship between the number of MT passes and both recanalization and favorable functional outcome. We further found that the benefit of recanalization in BAO patients was significant only when recanalization was achieved within three passes, encouraging at least three passes before stopping the procedure.

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Reliability of the Modified TICI Score among Endovascular Neurosurgeons

Cited by 17 publications

References 26 publications

Deep Learning–Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study

Deep Learning–Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study

Operator assessment versus core laboratory adjudication of recanalization following endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion

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