Article Text

Original research
Is a picture-perfect thrombectomy necessary in acute ischemic stroke?
  1. Ching-Jen Chen1,
  2. Reda Chalhoub2,
  3. Dale Ding3,
  4. Jeyan S Kumar1,
  5. Natasha Ironside1,
  6. Ryan T Kellogg1,
  7. Bradford B Worrall4,
  8. Andrew M Southerland4,
  9. Pascal Jabbour5,
  10. Stacey Q Wolfe6,
  11. Adam S Arthur7,
  12. Nitin Goyal7,8,
  13. Isabel Fragata9,
  14. Ilko Maier10,
  15. Charles Matouk11,
  16. Jonathan A Grossberg12,
  17. Peter Kan13,
  18. Clemens M Schirmer14,
  19. R Webster Crowley15,
  20. William J Ares16,
  21. Christopher S Ogilvy17,
  22. Ansaar T Rai18,
  23. Michael R Levitt19,
  24. Maxim Mokin20,
  25. Waldo R Guerrero20,
  26. Justin R Mascitelli21,
  27. Albert J Yoo22,
  28. Richard Williamson23,
  29. Andrew Walker Grande24,
  30. Roberto Javier Crosa25,
  31. Sharon Webb26,
  32. Marios N Psychogios27,
  33. Robert M Starke28,
  34. Alejandro M Spiotta2,
  35. Min S Park1
  36. on behalf of the STAR collaborators
    1. 1 Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
    2. 2 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
    3. 3 Neurosurgery, University of Louisville, Louisville, Kentucky, USA
    4. 4 Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
    5. 5 Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    6. 6 Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
    7. 7 Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    8. 8 Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    9. 9 Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
    10. 10 Neurology, University Medicine Goettingen, Goettingen, NS, Germany
    11. 11 Neurosurgery, Yale University, New Haven, Connecticut, USA
    12. 12 Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
    13. 13 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
    14. 14 Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
    15. 15 Neurosurgery, Rush University, Chicago, Illinois, USA
    16. 16 Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
    17. 17 Neurosurgery, BIDMC, Boston, Massachusetts, USA
    18. 18 Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
    19. 19 Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
    20. 20 Neurosurgery, University of South Florida, Tampa, Florida, USA
    21. 21 Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
    22. 22 Neurointerventional Radiology, Texas Stroke Institute, Plano, Texas, USA
    23. 23 Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
    24. 24 Neurosurgery, Radiology and Neurology, University of Minnesota, Mendota Heights, Minnesota, USA
    25. 25 Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
    26. 26 Neurosurgery, Bon Secours, Greenville, South Carolina, USA
    27. 27 Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
    28. 28 Neurological Surgery, University of Miami, Miami, Florida, USA
    1. Correspondence to Dr Ching-Jen Chen, Neurosurgery, University of Virginia Health System, Charlottesville, VA 22908-0816, USA; chenjared{at}


    Background The benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.

    Methods This is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.

    Results The unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).

    Conclusions Complete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

    • stroke
    • thrombectomy

    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the principal investigator upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the principal investigator upon reasonable request.

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    • Twitter @ChalhoubReda, @PascalJabbourMD, @AdamArthurMD, @brainvesseldoc, @DrMichaelLevitt, @WaldoGuerrero82, @Starke_neurosurgery

    • Collaborators on behalf of the STAR collaborators Dileep R Yavagal, Eric C Peterson, Daniel Raper, Patrick A Brown, M Reid Gooch, Nabeel Herial, Ajith Thomas, Justin Moore, Felipe Albuquerque, Louis J Kim, Melanie Walker, Michael Chen, Stephan Munich, Daniel Alan Hoit, Violiza Inoa-Acosta, Christopher Nickele Lucas, Elijovich Fernanda, Rodriguez-Erazú, Jan Liman, Michael Cawley, Gustavo Pradilla, Brian Howard, Brian Walcott, Zeguang Ren, Ryan Hebert, João Reis, Jaime Pamplona, Rui Carvalho, Mariana Baptista, Ana Nunes, Russell Cerejo, Ashis Tayal, Parita Bhuva, Paul Hansen, Norman Ajiboye, Alex Brehm, Sami Al Kasab, Jonathan Lena, Kimberly Kicielinski.

    • Contributors Design and conception: C-JC, MSP. Data collection: All authors. Statistical analysis: RC, C-JC. Interpretation of results: All authors. Drafting of manuscript: All authors. Revision of manuscript: All Authors. Approval of final manuscript: All authors. Study supervision: MSP, AMS.

    • 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 MRL: Grants from the NIH (R01NS105692, R01NS088072, U24NS100654, UL1TR002319, R25NS079200) and the American Heart Association (18CDA34110295). Unrestricted educational grants from Medtronic, Stryker and Philips Volcano. Consultant for Medtronic. Minor equity/ownership interest in Proprio, Cerebrotech, Synchron. Adviser to Metis Innovative. JAG: Grants from the Georgia Research Alliance. Consultant for Cognition Medical. AJY: Grants from Medtronic, Cerenovus, Penumbra, and Stryker. Consultant for Penumbra and Cerenovus. Equity interest in Insera Therapeutics. RWC: Proctor for Medtronic and Cerenovus. AMS: Research support from Penumbra, Stryker, Medtronic, and Siemens. Consultant for Penumbra, Stryker, Terumo, and Arsenal. MM: Consultant for Medtronic and Cerenovus. Stock ownership in Serenity Medical, Synchron, and Endostream. RMS: Grants from the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, the NIH (R01NS111119-01A1, UL1TR002736, KL2TR002737), the National Center for Advancing Translational Sciences, the National Institute on Minority Health and Health Disparities, and Medtronic. Consultant for Penumbra, Abbott, Medtronic, InNeuroCo and Cerenovus. Others: None.

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

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