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2C or not 2C: defining an improved revascularization grading scale and the need for standardization of angiography outcomes in stroke trials
  1. Mayank Goyal1,
  2. Kyle M Fargen2,
  3. Aquilla S Turk3,
  4. J Mocco4,
  5. David S Liebeskind5,
  6. Donald Frei6,
  7. Andrew M Demchuk7
  1. 1Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
  2. 2Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  3. 3Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
  5. 5Department of Neurosurgery, UCLA Stroke Center, Los Angeles, California, USA
  6. 6Radiology Imaging Associates, Swedish Medical Center, Colorado Neurological Institute, Denver, Colorado, USA
  7. 7Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Mayank Goyal, Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, 1403, 29th St NW, Calgary, AB, Canada T2N2T9; mgoyal{at}

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Although improvements in thrombectomy devices, stroke management and patient selection in clinical trials over the last two decades have occurred in concert with increasingly greater angiographic recanalization rates, clinical outcomes have remained largely unchanged.1 For example, recently completed prospective trials using Stentriever technology have reported successful recanalization or reperfusion in upwards of 90% of enrolled patients, yet the percentage of patients with a good outcome at 90 days remains at only 35–55%.2–4 The association between adequate recanalization and good functional outcome has been well-documented in a number of studies.5–12 Furthermore, those making a dramatic recovery, defined as a decrease in the NIH Stroke Scale (NIHSS) score to ≤3 within 24 h, are more likely to have had early or more complete recanalization.13

However, the definition of ‘successful’ or adequate recanalization/reperfusion as an angiographic endpoint for treatment effect in such trials has become increasingly varied and confusing. The different grading scales and non-standardized definitions of successful thrombectomy reported in published stroke trials have made direct comparison of results difficult. In fact, some authors have called for increasing standardization of reporting among the stroke community using angiographic reperfusion to enhance generalizability.14 ,15 In this paper we review the current grading systems for recanalization/reperfusion, discuss the current controversies in grading systems and the need for standardization of recanalization and reperfusion in trial reporting. Finally, we offer a revised grading system that accounts for less than perfect but clearly excellent reperfusion within its scale.

Current revascularization scales

There are a number of proposed scales for documenting the degree of revascularization after acute stroke intervention. These include the Thrombolysis In Myocardial Infarction scale (TIMI)16 recanalization, TIMI reperfusion, Thrombolysis In Cerebral Infarction scale (TICI),17 the modified TICI scale,18 the Mori reperfusion scale19 and the Qureshi score,20 among others. These scales …

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  • Contributors All authors contributed to the composition and/or critical review of the manuscript.

  • Competing interests MG is a consultant for Covidien/ev3 and serves as a co-principal investigator for SWIFT-PRIME and ESCAPE trials. AST has research grants or consulting agreements with Stryker, Microvention, Penumbra and Codman. JM serves as a consultant for Lazarus Effect and Nfocus and has investor interests in Blockade Medical. DSL serves as a consultant for Stryker and Covidien. AMD has received honoraria from Covidien. All other authors have no disclosures to report.

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