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Original research
Effect of incomplete reperfusion patterns on clinical outcome: insights from the ESCAPE-NA1 trial
  1. Petra Cimflova1,2,3,
  2. Nishita Singh2,4,
  3. Manon Kappelhof5,
  4. Johanna M Ospel1,2,6,
  5. Arshia Sehgal2,
  6. Nima Kashani7,
  7. Mohammed A Almekhlafi1,2,8,9,
  8. Andrew M Demchuk1,2,8,
  9. Joerg Berrouschot10,
  10. Franziska Dorn11,
  11. Michael E Kelly12,
  12. Brian H Buck13,
  13. Thalia S Field14,
  14. Dariush Dowlatshahi15,
  15. Michael Tymianski16,
  16. Michael D Hill1,2,8,9,
  17. Mayank Goyal1,2,8
  1. 1 Department of Radiology, University of Calgary, Calgary, Alberta, Canada
  2. 2 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  3. 3 Department of Medical Imaging and Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia
  4. 4 Department of Internal Medicine - Neurology division, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
  5. 5 Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
  6. 6 Clinic of Radiology and Nuclear Medicine, Universitatsspital Basel, Basel, Switzerland
  7. 7 University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
  8. 8 Hotchkis Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
  9. 9 Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
  10. 10 Klinik für Neurologie und Neurologische Intensivmedizin, Klinikum Altenburger Land GmbH, Altenburg, Germany
  11. 11 Klinik für Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
  12. 12 Department of Neurosurgery, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
  13. 13 Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
  14. 14 Division of Neurology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
  15. 15 Division of Neurology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
  16. 16 NoNO Inc, Toronto, Ontario, Canada
  1. Correspondence to Dr Mayank Goyal; mgoyal2412{at}gmail.com

Abstract

Background Incomplete reperfusion (IR) after mechanical thrombectomy (MT) can be a consequence of residual occlusion, no-reflow phenomenon, or collateral counterpressure. Data on the impact of these phenomena on clinical outcome are limited.

Methods Patients from the ESCAPE-NA1 trial with IR (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b) were compared with those with complete or near-complete reperfusion (eTICI 2c-3) on the final angiography run. Final runs were assessed for (a) an MT-accessible occlusion, or (b) a non-MT-accessible occlusion pattern. The primary clinical outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Our imaging outcome was infarction in IR territory on follow-up imaging. Unadjusted and adjusted incidence rate ratios (aIRR) with 95% confidence intervals (95% CI) were obtained.

Results Of 1105 patients, 443 (40.1%) with IR and 506 (46.1%) with complete or near-complete reperfusion were included. An MT-accessible occlusion was identified in 147/443 patients (33.2%) and a non-MT-accessible occlusion in 296/443 (66.8%). As compared with patients with near-complete/complete reperfusion, patients with IR had significantly lower chances of achieving mRS 0–2 at 90 days (aIRR 0.82, 95% CI 0.74 to 0.91). Rates of mRS 0–2 were lower in the MT-accessible occlusion group as compared with the non-MT-accessible occlusion pattern group (aIRR 0.71, 95% CI 0.60 to 0.83, and aIRR 0.89, 95% CI 0.81 to 0.98, respectively). More patients with MT-accessible occlusion patterns developed infarcts in the non-reperfused territory as compared with patients with non-MT occlusion patterns (68.7% vs 46.3%).

Conclusion IR was associated with worse clinical outcomes than near-complete/complete reperfusion. Two-thirds of our patients with IR had non-MT-accessible occlusion patterns which were associated with better clinical and imaging outcomes compared with those with MT-accessible occlusion patterns.

  • Thrombectomy
  • Stroke
  • Angiography

Data availability statement

Data are available upon reasonable request. Data used in the current study are available from the author upon reasonable request.

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Data availability statement

Data are available upon reasonable request. Data used in the current study are available from the author upon reasonable request.

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Footnotes

  • X @nishita_singh3, @johanna_ospel, @nimakashani, @AlmekhlafiMa, @mihill68

  • Contributors PC, NS, MK, JO, AS, NK, and MG contributed to the study conception and design. Material preparation, data collection, and analysis were performed by PC, NS, MK, AS, JO, and NK. The first draft of the manuscript was written by PC, NS, MK, and JO. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. MG is the study guarantor.

  • Funding The ESCAPE-NA1 trial was funded by the Canadian Institutes for Health Research, Alberta Innovates, and NoNO Inc. (Grant number: 389143).

  • Competing interests PC reports honoraria from A-care Medical, outside the submitted work. JO reports consultancy fee from NicoLab. ADM received grants from NoNO; honoraria from Medtronic; patent Circle NVI. MT is CEO of NoNO; patents owned by NoNO. MDH received grants from Canadian Institutes for Health Research, Alberta Innovates, NoNO, Heart & Stroke Foundation of Canada, National Institutes of Neurological Disorders and Stroke, Covidien, Boehringer-Ingleheim, Stryker, and Medtronic; fees from Merck; patent for systems of acute stroke diagnosis; a patent issued and licensed to US Patent office Number: 62/086,077; stock in Calgary Scientific. MG reports consultancy for Medtronic, Stryker, Microvention, GE Healthcare, Mentice, outside the submitted work. All other authors have nothing to disclose.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.