Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

Abstract

Background: A 2013 consensus statement recommended the use of the modified Treatment In Cerebral Ischemia (mTICI) scale to evaluate angiographic revascularization after endovascular treatment (EVT) of acute ischemic stroke due to its higher inter-rater agreement and capacity of clinical outcome prediction. The current definition of successful revascularization includes the achievement of grades mTICI 2b or 3. However, mTICI 2b grade encompasses a large heterogeneity of revascularization states, and prior studies suggested that the magnitude of benefit derived from mTICI 2b and mTICI 3 does not seem to be equivalent. In a way to restrain the referred heterogeneity, Goyal et al. [J Neurointerv Surg 2014; 6: 83–86] proposed a revised mTICI scale that includes a 2c grade (rTICI). Methods: Retrospective analysis of prospectively collected data from consecutive cases of EVT for anterior circulation large-vessel occlusion, performed between January 2015 and July 2017. Patients with mTICI 2b or 3 grades were reclassified according to the rTICI scale, and the outcomes between the 3 revascularization grades (rTICI 2b, 2c, 3) compared. Results: Our study population of 226 patients (64 rTICI 2b, 30 rTICI 2c, 132 rTICI 3) has a mean age of 71 years, 48.2% males, median baseline NIHSS of 16 (13–19) and ASPECTS of 8 (7–9). The 3 revascularization grades are represented by homogeneous populations. Logistic regression analysis showed statistically significant higher rates of functional independence at 3 months (65.9 vs. 50.0%; adjusted OR 0.39, 95% CI 0.18–0.86), with lower rates of mortality (8.3 vs. 15.6%; adjusted OR 3.54, 95% CI 1.14–10.97) and intracranial hemorrhage (ICH) in rTICI 3 than 2b groups. When comparing rTICI 3 with 2c groups, there were only statistically significant differences in the total ICH rate (8.3 vs. 26.7%; adjusted OR 7.08, 95% CI 1.80–27.82) but not in symptomatic ICH. Conclusions: These results corroborate the scarce prior findings suggesting that patients with rTICI 2c grade should be reported separately, since they have similar outcomes to rTICI 3, and better than rTICI 2b patients. Therefore, we suggest resetting the angiographic revascularization endpoint to perfect revascularization (rTICI 2c or 3 grades), a target that neurointerventionalists should strive to achieve.

First-line contact aspiration vs stent-retriever thrombectomy in acute ischemic stroke patients with large-artery occlusion in the anterior circulation: Systematic review and meta-analysis

“…In this meta-analysis of acute stroke patients with anterior circulation large-artery occlusion, although the final successful reperfusion rate at the end of all endovascular procedures was significantly higher after first-line contact aspiration than after stent-retriever thrombectomy, the rate of final complete reperfusion and of functional independence did not differ between the two strategies. There is increasing evidence that complete reperfusion (mTICI ¼ 3) may more accurately predict good clinical outcome than the combined criteria of successful reperfusion (mTICI of 2b or 3), [46][47][48][49] and this may partly explain the findings.…”

Futile complete recanalization: patients characteristics and its time course

“…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.…”

Radiomics-based intracranial thrombus features on preoperative noncontrast CT predicts successful recanalization of mechanical thrombectomy in acute ischemic stroke

“…Inclusion criteria: (I) AIS with internal carotid artery/M1 middle cerebral artery segment thrombus; (II) received MTB treatment using the SR technique, followed by additional devices (e.g., ADAPT technique) at the operator’s discretion if failed; (III) all patients underwent CT imaging, including noncontrast CT (NCCT), CT angiography (CTA), and/or CT perfusion. Successful recanalization was defined as a Thrombolysis In Cerebral Infarction score 2b or 3 on the final digital subtracted angiography during MTB, as it represents a powerful predictor of treatment success and clinical outcome ( 19 ). Patients with unsatisfactory image quality, such as motion or metal artifacts, and incomplete clinical information were excluded.…”