Rethinking Thrombolysis in Cerebral Infarction 2b

Tung, Eric L.; McTaggart, Ryan; Baird, Grayson L.; Yaghi, Shadi; Hemendinger, Morgan; DiBiasio, Eleanor L.; Hidlay, Douglas T; Tung, Glenn A.; Jayaraman, Mahesh

doi:10.1161/strokeaha.117.017182

Cited by 90 publications

(62 citation statements)

References 15 publications

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“…A recent observational study failed to prove the existence of significant outcome differences among TICI3 and TICI2b patients when applying the oTICI or mTICI scale, although a clear trend was recognisable. 15 However, significant differences between TICI2c/3 and TICI2b were noted if the eTICI scale was applied. The study was excluded from quantitative analyses because no dichotomised mRS values were provided.…”

Section: Resultsmentioning

confidence: 99%

“…If available, TICI2c was pooled together with TICI3, as preliminary evidence has suggested that both are associated with a comparable clinical course. 15–17 In a sensitivity analysis, comparisons of TICI2c/3 and TICI2b were excluded leading to a comparison confined to mTICI2b versus mTICI3 in order to rule out the possibility that potential differences are only discernible when applying the more detailed eTICI scale. Studies that did not meet the eligibility criteria but appraised the topic of outcome differences between TICI2b and TICI3 reperfusions were included into further semiquantitative or qualitative analyses.…”

Section: Methodsmentioning

confidence: 99%

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Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited

Kaesmacher

Dobrocky

Heldner

et al. 2018

J Neurol Neurosurg Psychiatry

108

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ObjectiveA reperfusion quality of thrombolysis in cerebral infarction (TICI)≥2b has been set as the therapeutic angiography target for interventions in patients with acute ischaemic stroke. This study addresses whether the distinction between TICI2b and TICI3 reperfusions shows a clinically relevant difference on functional outcome.MethodsA systematic literature review and meta-analysis was carried out and presented in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to test the primary hypothesis that TICI2b and TICI3 reperfusions are associated with different rates of modified Rankin Scale (mRS) ≤2 at day 90. Secondary endpoints included rates of haemorrhagic transformations, mortality and excellent functional outcome (mRS ≤1). Summary estimates of ORs (sOR) with 95% CI were calculated using the inverse variance heterogeneity model accounting for multiple true effect sizes.ResultsFourteen studies on 2379 successfully reperfused patients were included (1131 TICI3, 1248 TICI2b). TICI3 reperfusions were associated with higher rates of functional independence (1.74, 95% CI 1.44 to 2.10) and excellent functional outcomes (2.01, 95% CI 1.60 to 2.53), also after including adjusted estimates. The safety profile of patients with TICI3 was superior, as demonstrated by lower rates of mortality (sOR 0.59, 95% CI 0.37 to 0.92) and symptomatic intracranial haemorrhages (sOR 0.42, 95% CI 0.25 to 0.71).ConclusionTICI3 reperfusions are associated with superior outcome and better safety profiles than TICI2b reperfusions. This effect seems to be independent of time and collaterals. As reperfusion quality is the most important modifiable predictor of patients’ outcome, a more conservative definition of successful therapy and further evaluation of treatment approaches geared towards achieving TICI3 reperfusions are desirable.

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited

Kaesmacher

Dobrocky

Heldner

et al. 2018

J Neurol Neurosurg Psychiatry

108

View full text Add to dashboard Cite

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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%

“…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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“…Our study results seem in line with those findings. Another recent study suggested that the outcome of patients with eTICI 2C is not clearly worse than patients with eTICI 3, whilst outcomes of both groups are significantly better than with eTICI 2B [32]. …”

Section: Discussionmentioning

confidence: 99%

Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke

et al. 2018

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Background: Reperfusion status after intra-arterial thrombectomy (IAT) is a critical predictor of functional outcome after acute ischemic stroke. However, most prognostic models have not included a detailed assessment of reperfusion status after IAT. Objective: The aim of this work was to assess the association between successful reperfusion and clinical outcome. Methods: Clinical, radiological, and procedural variables of patients treated with IAT were extracted from our prospective stroke registry. The association with functional outcome using the modified Rankin Scale (mRS) after 3 months was assessed using multivariable logistic regression. An extension of the modified TICI score, eTICI, was used to classify reperfusion status. The prognostic value of reperfusion status after IAT in addition to age, stroke severity, imaging characteristics, treatment with intravenous thrombolysis, and time from symptom onset to the end of IAT was assessed with logistic regression and summarized with receiver operating characteristic curves. Results: In total, 119 patients were included (mean age 66 years). In multivariable analysis, age >80 years (OR 6.8, 95% CI 1.2–39.8), NIHSS at presentation >15 (OR 7.3, 95% CI 2.3–23.5), and incomplete reperfusion status (eTICI score <2C; OR 10.3, 95% CI 3.5–30.6) were the strongest predictors of a poor outcome (mRS 3–6). Adding reperfusion status to the model improved the prognostic accuracy (AUC 0.88, 95% CI 0.91–0.94). Our results indicate a large difference between using an eTICI cutoff of ≥2C versus ≥2B: a cutoff ≥2C improved the predictive value for a good clinical outcome (2C: positive predictive value, PPV, 0.78; 2B: PPV 0.32). Conclusion: Our results promote using reperfusion status for assessing prognosis in ischemic stroke patients treated with IAT. A model using eTICI ≥2C had greater PPV than eTICI ≥2B and could improve prognostic accuracy.

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Rethinking Thrombolysis in Cerebral Infarction 2b

Abstract: Using a TICI grading system that includes an additional category beyond TICI 2b allows for refined prediction of early neurological improvement and functional independence.

Cited by 90 publications

References 15 publications

Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited

Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited

Futile complete recanalization: patients characteristics and its time course

Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke

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