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The time has come to throw the flag on the Thrombolysis in Cerebral Infarction (TICI) scale. Conceived in surrogacy from our cardiology brethren and sistren’s Thrombolysis in Myocardial Infarction (TIMI) score,1 TICI’s birth was anything but smooth. However, even though plagued by internal inconsistencies,2 confusing nomenclature,3 unclear pronunciation (are you a ‘tissy’ or ‘tiki’ person?), and modifications and more modifications, TICI emerged from a small cohort of recanalization scales (does anyone remember AOL?4) to become the coin of the realm in research and clinical practice. But, heck, we don’t even use thrombolysis anymore, having entered the era of embolectomy years ago.
Before turning to how we might fix this situation, we must acknowledge that TICI—and mTICI and oTICI—have served their purpose. TICI started out as a six-point scale that gradually collapsed to a dichotomous scale (2b or better) that was a simple and useful, yet surrogate, outcome for clinical and device-related trials. But our community can—and must—do better. The three of us are not the first to lament the limitations of TICI. In 2012, a working group led by Dr Zaidat concluded, ‘Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme … A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.’5 That future is now.6
Let us explain
More is better
Multiple recent studies have shown strong correlation between ≥TICI 2b subcategories and outcome.7 Surprise, TICI 3 is better than …
Contributors All authors contributed to the conception, drafting, revisions and approval of this commentary. DFK is the guarantor of this work.
Competing interests DFK: Consulting for Medtronic (all funds to the institution), ownership stake in Marblehead Medical, and has received research support from Medtronic, MicroVention, NeuroSigma, Shape Memory Therapeutics, IndumedX, Sequent Medical, Neurogami, and NeuroSave. AAR: Received funding from DJO Global. MJG: Has been consultant on a fee-per-hour basis for Codman Neurovascular, InNeuroCo, Medtronic Neurovascular, and Stryker Neurovascular; holds stock in InNeuroCo; and has received research support from the National Institutes of Health (NIH), Anaconda, Codman Neurovascular, Gentuity, InNeuroCo, Microvention, Medtronic Neurovascular, MIVI Neurosciences, Neuravi, Philips Healthcare, InNeuroCo, Rapid Medical, R92M, Stryker Neurovascular, The Stroke Project, and the Wyss Institute.
Provenance and peer review Not commissioned; externally peer reviewed.