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Original research
Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy
  1. Daniel A Tonetti1,2,
  2. Shashvat M Desai2,
  3. Stephanie Casillo1,
  4. Jeremy Stone1,2,
  5. Merritt Brown3,
  6. Brian Jankowitz4,
  7. Tudor G Jovin4,5,
  8. Bradley A Gross1,2,
  9. Ashutosh Jadhav2,6
  1. 1 Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  2. 2 UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  3. 3 Department of Neurology and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  4. 4 Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
  5. 5 Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
  6. 6 Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Daniel A Tonetti, Neurosurgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; tonettida{at}


Introduction For patients undergoing mechanical thrombectomy, numerous (>3) thrombectomy passes may be harmful. However, non-recanalization leads to poor outcomes. For patients requiring multiple thrombectomy passes to achieve reperfusion, it remains unclear if the risk/benefit ratio favors recanalization.

Objective To test the hypothesis that the benefits afforded by successful reperfusion outweigh the risk conveyed by the numerous passes required.

Methods We retrospectively reviewed prospectively collected data for patients presenting to a comprehensive stroke center with anterior circulation large vessel occlusion (ACLVO) and undergoing thrombectomy requiring more than one pass over 24 months. We stratified patients into three groups: group 1 (successful reperfusion in 2–3 passes), group 2 (successful reperfusion in ≥4 passes), and group 3 (unsuccessful reperfusion).

Results 250 patients with ACLVO constituted the study cohort. Despite similar demographics, group 2 patients had better clinical outcomes than those in group 3 at 24 hours (National Institutes of Health Stroke Scale (NIHSS) score 13.5 vs 19.1, p<0.001) and at 90 days (modified Rankin Scale score 0–2 rates of 31.1% vs 0.0%, p=0.006) On multivariate logistic regression analysis, age (p=0.034), Alberta Stroke Program Early CT Score (p<0.01), NIHSS score (p=0.02), and parenchymal hematoma type 2 (p=0.015) were significant predictors of functional independence among those who achieved successful reperfusion, but the number of passes required did not predict outcome for these patients (p=0.74).

Conclusion Patients who achieve successful reperfusion after many passes have better clinical outcomes than those who do not, despite the number of passes and procedural time required. The number of passes required to achieve successful reperfusion beyond the first pass is not a predictor of functional independence.

  • acute ischemic stroke
  • large vessel occlusion
  • mechanical thrombectomy
  • passes
  • reperfusion

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  • Contributors Study design: DAT, AJ; drafting the article: DAT; acquisition of data/data analysis: DAT/SMD; reviewed and revised article before submission: all authors. Study supervision: AJ.

  • 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 BTJ: consultant: Medtronic. MB: investor: Penumbra, Inc. BAG: consultant: Microvention. TGJ: consultant: Stryker Neurovascular (PI DAWN-unpaid); ownership Interest: Anaconda; advisory board/investor: FreeOx Biotech, Route92, Corindus, Viz. ai, Blockade Medical; honoraria: Cerenovus.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.