Early TICI 2b or Late TICI 3-Is Perfect the Enemy of Good?

F Flottmann, N van Horn, M E Maros, R McDonough, M Deb-Chatterji, A Alegiani, G Thomalla, U Hanning, J Fiehler, C Brekenfeld, GSR investigators, F Flottmann, N van Horn, M E Maros, R McDonough, M Deb-Chatterji, A Alegiani, G Thomalla, U Hanning, J Fiehler, C Brekenfeld, GSR investigators

Abstract

Background and purpose: A Thrombolysis in Cerebral Infarction (TICI) score of 3 has been established as therapeutic goal in endovascular therapy (EVT) for acute ischemic stroke; however, in the case of early TICI2b reperfusion, the question remains whether to stop the procedure or to continue in the pursuit of perfection (i.e., TICI 2c/3).

Methods: A total of 6635 patients were screened from the German Stroke Registry. Patients who underwent EVT for occlusion of the middle cerebral artery (M1 segment), with final TICI score of 2b/3 were included. Multivariable logistic regression was performed with functional independence (modified Rankin Scale, mRS at day 90 of 0-2) as the dependent variable.

Results: Of 1497 patients, 586 (39.1%) met inclusion criteria with a final TICI score of 2b and 911 (60.9%) with a TICI score of 3. Patients who achieved first-pass TICI3 showed highest odds of functional independence (Odds ratio [OR] 1.71, 95% confidence interval [95% CI] 1.18-2.47). Patients who achieved TICI2b with the second pass (OR 0.53, 95% CI 0.31-0.89) or with three or more passes (OR 0.44, 95% CI 0.27-0.70) had significantly worse clinical outcomes compared to first-pass TICI2b. TICI3 at the second pass was by trend better than first-pass TICI2b (OR 1.55, 95% CI 0.98-2.45), but TICI3 after 3 or more passes (OR 0.93, 95% CI 0.57-1.50) was not significantly different from first-pass TICI2b.

Conclusion: First-pass TICI2b was superior to TICI2b after ≥ 2 retrievals and comparable to TICI3 at ≥ 3 retrievals. The potential benefit in outcome after achieving TICI3 following further retrieval attempts after first-pass TICI2b need to be weighed against the risks.

Keywords: Endovascular therapy; Ischemic stroke; Prognostic factors; Retrievals; Thrombectomy.

Conflict of interest statement

G. Thomalla: unrelated consultancy for Acandis, Stryker; payment for lectures including service on “speakers bureaus”: Bayer, Bristol Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo. J. Fiehler: unrelated consultancy for Acandis, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD-Clinicals, Medtronic, Medina, MicroVention, Penumbra, Route 92 Medical, Stryker, Transverse Medical; grants/grants pending: MicroVention, Medtronic, Stryker, Cerenovus. M.E. Maros: funding from the German Federal Ministry for Economic Affairs and Energy within the scope of Zentrales Innovationsprogramm Mittelstand (ZF 4514602TS8). Unrelated consultancy for Smart Reporting and Siemens Healthineers. F. Flottmann, N. van Horn, R. McDonough, M. Deb-Chatterji, A. Alegiani, U. Hanning and C. Brekenfeld declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Patient selection flowchart. LVO Large Vessel Occlusion, MT Mechanical Thrombectomy, M1 first middle cerebral artery segement, TICI Thrombolysis in Cerebral Infarction score, NIHSS National Institutes of Health Stroke Scale, rtPA recombinant tissue Plasminogen Activator, ASPECTS Alberta Stroke Programme Early CT Score, mRS90 modified Rankin scale at 90 days
Fig. 2
Fig. 2
Rate of good clinical outcome (defined as mRS of 0–2 at day 90) by final TICI score and number of retrieval attempts. mRS 90 modified Rankin scale at day 90, TICI thrombolysis in cerebral iInfarction
Fig. 3
Fig. 3
Odds ratio of good clinical outcome (defined as mRS of 0–2 at day 90) by final TICI score and number of retrieval attempts, adjusted for age, NIHSS score on admission, location of occlusion (proximal vs. distal segment of the MCA), ASPECTS on admission and iv-thrombolysis. mRS modified Rankin scale, TICI thrombolysis in cerebral infarction, MCA middle cerebral artery, ASPECTS Alberta stroke programme early CT score

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