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The efficacy of stroke thrombectomy is largely determined by patient selection. If clinical trial criteria are used, a strikingly low number-needed-to-treat (NNT) of 2.6 can be achieved as published by the HERMES meta-analysis in 2015.1 In routine clinical practice, however, most physicians would accept a higher NNT if that means more patients benefit and hence, trend toward more liberal patient selection criteria. But just how liberal should we be?
Futile recanalization occurs when the thrombectomy is a technical success but there is no meaningful improvement in disability. This occurs at a higher rate if patient selection criteria are too liberal. Futile recanalization is more common than we think. Van Horn et al evaluated 123 consecutive patients at a single German center from 2015 to 2019 who had complete TICI 3 reperfusion and still found 54.5% to have poor clinical outcomes at 90 days.2
Anyone who has been in practice for some time knows that thrombectomy patient selection is nuanced and gets particularly challenging with older patients where futile recanalization is the rule, not the exception. A patient’s age invariably figures prominently in the decision process. However, age, perhaps similar to how elapsed time is used, is actually a low-value variable. Much like how collateral grade can recalibrate elapsed time thresholds, many difficult to define comorbidities and cognitive changes can similarly recalibrate preconceived age thresholds (>80 years or >90 years). Understanding that futile recanalization in the elderly is a common, complicated, and a costly issue …
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.