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Improving mTICI2b reperfusion to mTICI2c/3 reperfusions: A retrospective observational study assessing technical feasibility, safety and clinical efficacy

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Abstract

Background

Recent studies suggested that modified Thrombolysis in Cerebral Infarction grade (mTICI) 3 reperfusions are associated with superior outcome to mTICI2b reperfusions, questioning if neurointerventionalists should generally strive to achieve mTICI3.

Methods

Retrospective analysis of successfully reperfused MCA occlusions (n=246) with available angiography runs between every manoeuvre was performed. Final reperfusion success and those between all single manoeuvres were evaluated applying the modified version of the TICI score (including TICI2c). Final TICI2c/3 reperfusions were dichotomized as ‘direct’ (reperfusion before final manoeuvre ≤mTICI2a) or ‘secondary improved’ (mTICI2b was achieved).

Results

Patients with mTICI2c reperfusion had similar outcome to patients with mTICI3 rather than mTICI2b reperfusions. Compared with mTICI2c/3-patients, mTICI2b-patients had lower rates of neurological improvement (33.3% vs. 61.2%, p<0.001) and good functional outcome (28.7% vs. 46.5%, p=0.008). In 28 patients, mTICI2b reperfusion was improved to mTICI2c/3 without complications. Outcome of patients with ‘direct’ or ‘secondary improved’ mTICI2c/3 did not differ (p>0.5).

Conclusion

Improving mTICI2b reperfusions to mTICI2c/3 reperfusions is sometimes technically feasible and safe, and associated with clinical benefit comparable to ‘direct’ mTICI2c/3 reperfusions. If confirmed, a more aggressive treatment approach in cases of already achieved mTICI2b may be justified, although proper patient selection is needed.

Key Points

• Patients with mTICI2c or 3 reperfusions have a comparable clinical course.

• mTICI2c/3 are associated with a larger therapeutic benefit than are mTICI2b reperfusions.

• Improving reperfusion from mTICI2b to mTICI2c/3 is sometimes feasible and reasonably safe.

• Outcome of patients with ‘secondary improved’ and ‘direct’ mTICI2c/3 is not different.

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Abbreviations

ACA:

Anterior cerebral artery

ASPECTS:

Alberta Stroke Program Early CT score

DSA:

Digital subtraction angiography

IA:

Intra-arterial

IQR:

Interquartile range

IV:

Intravenous

MCA:

Middle cerebral artery

NIHSS:

National Institute of Health Stroke Scale

mRS:

Modified Rankin Scale

MT:

Mechanical thrombectomy

mTICI:

Modified Thrombolysis In Cerebral Infarction

RCT:

Randomized controlled trial

rtPA:

Recombinant tissue plasminogen activator

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Acknowledgements

We gratefully acknowledge the contribution from all colleagues from the Department of Neurology (Stroke Unit) for collegial cooperation and excellent clinical care for the stroke patients treated in our institution.

Author information

Authors and Affiliations

  1. Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, München, Germany

    Johannes Kaesmacher, Christian Maegerlein, Claus Zimmer & Benjamin Friedrich

  2. Department of Diagnostic and Interventional Neuroradiology, Inselspital Bern, Bern, Switzerland

    Felix Zibold

  3. Department of Neurology, Klinikum rechts der Isar, Technical University Munich, München, Germany

    Silke Wunderlich

Authors
  1. Johannes Kaesmacher
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  2. Christian Maegerlein
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  3. Felix Zibold
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  4. Silke Wunderlich
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  5. Claus Zimmer
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  6. Benjamin Friedrich
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Corresponding author

Correspondence to Johannes Kaesmacher.

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Guarantor

The scientific guarantor of this publication is Benjamin Friedrich.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Funding

This study has received funding by the KKF (‘Fakultätsinterne Förderung’) scholarship of the Technical University Munich (grant number: ‘KKF E-07’).

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Some study subjects or cohorts have been partly previously reported in:

– Lenticulostriate infarctions after successful mechanical thrombectomy in middle cerebral artery occlusion, JNIS, 2017

– Time to redefine success? TICI 3 versus TICI 2b recanalization in middle cerebral artery occlusion treated with thrombectomy, JNIS, 2017

– Bridging Therapy with i.v. rtPA in MCA occlusion prior to endovascular thrombectomy: a double-edged sword? Clinical Neuroradiology, 2017

– Aspiration thrombectomy in clinical routine interventional stroke treatment. Clinical Neuroradiology 2017

– Blood leukocytes as prognostic parameter in stroke thrombectomy. Cerebrovascular Diseases, 2016

– Risk of Thrombus Fragmentation during Endovascular Stroke Treatment. AJNR, 2017

– Intraprocedural Thrombus Fragmentation During Interventional Stroke Treatment: A Comparison of Direct Thrombus Aspiration and Stent Retriever Thrombectomy. Cardiovascular and Interventional Radiology, 2017

– Thrombus Migration in the Middle Cerebral Artery: Incidence, Imaging Signs, and Impact on Success of Endovascular Thrombectomy. JAHA, 2017

– Clinical Outcome Predicted by Collaterals Depends on Technical Success of Mechanical Thrombectomy in Middle Cerebral Artery Occlusion. Stroke and Cerberovascular Diseases, 2016

– Distance to Thrombus in acute middle cerebral artery stroke predicts basal ganglia infarction after mechanical thrombectomy. Oncotarget 2016

– Thrombus Histology Suggests Cardioembolic Cause in Cryptogenic Stroke. Stroke. 2017

Methodology

• retrospective

• observational

• performed at one institution

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Kaesmacher, J., Maegerlein, C., Zibold, F. et al. Improving mTICI2b reperfusion to mTICI2c/3 reperfusions: A retrospective observational study assessing technical feasibility, safety and clinical efficacy. Eur Radiol 28, 274–282 (2018). https://doi.org/10.1007/s00330-017-4928-3

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  • DOI: https://doi.org/10.1007/s00330-017-4928-3

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