Benchmarking the Extent and Speed of Reperfusion: First Pass TICI 2c-3 Is a Preferred Endovascular Reperfusion Endpoint

Albert J Yoo; Jazba Soomro; Tommy Andersson; Jeffrey L Saver; Marc Ribo; Hormozd Bozorgchami; Guilherme Dabus; David S Liebeskind; Ashutosh Jadhav; Heinrich Mattle; Osama O Zaidat

doi:10.3389/fneur.2021.669934

Benchmarking the Extent and Speed of Reperfusion: First Pass TICI 2c-3 Is a Preferred Endovascular Reperfusion Endpoint

Front Neurol. 2021 May 11:12:669934. doi: 10.3389/fneur.2021.669934. eCollection 2021.

Authors

Albert J Yoo¹, Jazba Soomro¹, Tommy Andersson^{2

3}, Jeffrey L Saver⁴, Marc Ribo⁵, Hormozd Bozorgchami⁶, Guilherme Dabus⁷, David S Liebeskind⁸, Ashutosh Jadhav⁹, Heinrich Mattle¹⁰, Osama O Zaidat¹¹

Affiliations

¹ Department of Neurointervention, Texas Stroke Institute, Fort Worth, TX, United States.
² Neuroradiology, Karolinska University Hospital, Clinical Neuroscience Karolinska Institutet, Stockholm, Sweden.
³ Medical Imaging, Allgemeine Ziekenhuis Groeninge, Kortrijk, Belgium.
⁴ Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States.
⁵ Stroke Unit, Department of Neurology, Vall D'Hebron University Hospital, Barcelona, Spain.
⁶ Department of Neurology, Oregon Health and Science University Hospital, Portland, OR, United States.
⁷ Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, FL, United States.
⁸ Department of Neurology, Neurovascular Imaging Research Core and Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States.
⁹ Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
¹⁰ Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.
¹¹ Mercy St. Vincent Medical Center, Toledo, OH, United States.

Abstract

Background and Purpose: End-of-procedure substantial reperfusion [modified Treatment in Cerebral Ischemia (mTICI) 2b-3], the leading endpoint for thrombectomy studies, has several limitations including a ceiling effect, with recent achieved rates of ~90%. We aimed to identify a more optimal definition of angiographic success along two dimensions: (1) the extent of tissue reperfusion, and (2) the speed of revascularization. Methods: Core-lab adjudicated TICI scores for the first three passes of EmboTrap and the final all-procedures result were analyzed in the ARISE II multicenter study. The clinical impact of extent of reperfusion and speed of reperfusion (first-pass vs. later-pass) were evaluated. Clinical outcomes included 90-day functional independence [modified Rankin Scale (mRS) 0-2], 90-day freedom-from-disability (mRS 0-1), and dramatic early improvement [24-h National Institutes of Health Stroke Scale (NIHSS) improvement ≥ 8 points]. Results: Among 161 ARISE II subjects with ICA or MCA M1 occlusions, reperfusion results at procedure end showed substantial reperfusion in 149 (92.5%), excellent reperfusion in 121 (75.2%), and complete reperfusion in 79 (49.1%). Reperfusion rates on first pass were substantial in 81 (50.3%), excellent reperfusion in 62 (38.5%), and complete reperfusion in 44 (27.3%). First-pass excellent reperfusion (first-pass TICI 2c-3) had the greatest nominal predictive value for 90-day mRS 0-2 (sensitivity 58.5%, specificity 68.6%). There was a progressive worsening of outcomes with each additional pass required to achieve TICI 2c-3. Conclusions: First-pass excellent reperfusion (TICI 2c-3), reflecting rapid achievement of extensive reperfusion, is the technical revascularization endpoint that best predicted functional independence in this international multicenter trial and is an attractive candidate for a lead angiographic endpoint for future trials. Clinical Trial Registration: http://www.clinicaltrials.gov, identifier NCT02488915.

Keywords: brain ischaemia; cerebral infacrction; intra-arterial therapy; mechanical thrombectomy; reperfusion; reperfusion grading; stent retriever.

Associated data

ClinicalTrials.gov/NCT02488915