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No-reflow phenomenon in acute ischemic stroke: an angiographic evaluation

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Abstract

Background

Futile recanalization (FR) is de fined as a poor 90-day outcome or lack of neurological improvement at 24 h despite successful recanalization in acute ischemic stroke (AIS) with large vessel occlusion (LVO) treated by mechanical throbectomy (MT).

The No-reflow phenomenon (NRP) could be a possible cause of FR, but its evidence in AIS patients is scarce.

Methods

We retrospectively analyzed 185 digital subtraction angiographies (DSA) of AIS patients with anterior circulation LVO after endovascular treatment. To better define NRP, we designed a score called the modified capillary index score (mCIS). The score is obtained by dividing the middle cerebral artery territory in three segments. For each segment, we gave 2 points if the capillary blush was present without any delay, 1 if delayed, and 0 if absent. The primary endpoint was to use mCIS to identify NRP on post-interventional DSA and to test whether this marker may predict FR and failure of early neurological improvement (fENI). The secondary endpoint was to search for a correlation between NRP, lesion volume, and hemorrhagic transformation. We used the ROC curve to define mCIS ≤ 3 as the cut-off and marker of NRP.

Results

NRP was present in 35.1% of patients. NRP predicted fENI at 24 h (aOR 2.825, 95% CI 1.265–6.308, P = 0.011) and at 7 days (aOR 2.191, 95% CI 1.008–4.762, P = 0.048), but not 90-day FR. Moreover, NRP predicted hemorrhagic transformation (aOR 2.444, 95% CI 1.266–4.717, P = 0.008).

Conclusions

The modified capillary index score (mCIS) seems useful in identifying NRP in AIS. In addition, mCIS was able to predict NRP that correlated with early clinical outcome and hemorrhagic transformation of the ischemic lesion. An external validation of the score is warranted.

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Data availability

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Abbreviations

AIS:

Acute ischemic stroke

AP:

Antero-posterior

ASPECTS:

Alberta Stroke Program Early CT Score

CIS:

Capillary index score

DSA:

Digital subtraction angiography

ECASS:

European Cooperative Acute Stroke Study

ENI:

Early neurological improvement

EVF:

Early venous filling

ET-1:

Endothelin-1

EVT:

Endovascular treatment

fENI:

Failure of early neurological improvement

FIV:

Final infarct volume

FR:

Futile recanalization

ICA:

Internal carotid artery

ICH:

Intracerebral hemorrhage

LVO:

Large vessel occlusion

MCA:

Middle cerebral artery

mCIS:

Modified capillary index score

mRS:

Modified Rankin scale\

NIHSS:

National Institute of Health stroke scale

NRP:

No-reflow phenomenon

RCT:

Randomized controlled trial

sICH:

Symptomatic intracerebral hemorrhage

TICI:

Thrombolysis in Cerebral Infarction

TIMI:

Thrombolysis in Myocardial Infarction

TOAST:

Trial of Org 10,172 in Acute Stroke Treatment

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Author notes

  1. Ettore Nicolini and Marta Iacobucci contributed equally to this work.

Authors and Affiliations

  1. Department of Human Neurosciences, Sapienza University of Rome, Viale Dell’Università 30, 00185, Rome, Italy

    Ettore Nicolini, Svetlana Lorenzano & Danilo Toni

  2. Interventional Neuroradiology Unit, Department of Diagnostic Medicine and Radiology, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy

    Marta Iacobucci, Carlo Cirelli & Francesco Biraschi

  3. Emergency Department, Stroke Unit, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy

    Manuela De Michele, Antonio Ciacciarelli, Irene Berto, Luca Petraglia & Anne Falcou

  4. Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA

    Italo Linfante

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  1. Ettore Nicolini
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Correspondence to Ettore Nicolini.

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The ethics committee of Policlinico Umberto I University Hospital approved this study (ID: 6647)

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Nicolini, E., Iacobucci, M., De Michele, M. et al. No-reflow phenomenon in acute ischemic stroke: an angiographic evaluation. Neurol Sci 44, 3939–3948 (2023). https://doi.org/10.1007/s10072-023-06879-6

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