Article Text

other Versions

Download PDFPDF
Original research
eTICI reperfusion: defining success in endovascular stroke therapy
  1. David S Liebeskind1,2,
  2. Serge Bracard3,
  3. Francis Guillemin4,
  4. Reza Jahan2,
  5. Tudor G Jovin5,
  6. Charles BLM Majoie6,
  7. Peter J Mitchell7,
  8. Aad van der Lugt8,
  9. Bijoy K Menon9,
  10. Luis San Román10,
  11. Bruce CV Campbell11,
  12. Keith W Muir12,
  13. Michael D Hill9,
  14. Diederik WJ Dippel13,
  15. Jeffrey L Saver2,
  16. Andrew M Demchuk9,
  17. Antoni Dávalos14,
  18. Philip White15,
  19. Scott Brown16,
  20. Mayank Goyal9,17
  21. for the HERMES Collaborators
  1. 1Neurovascular Imaging Research Core, UCLA, Los Angeles, California, USA
  2. 2UCLA Stroke Center, Los Angeles, California, USA
  3. 3Department of Diagnostic and Interventional Neuroradiology, INSERM U 947, University of Lorraine and University Hospital of Nancy, Nancy, France
  4. 4INSERM, CHRU Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
  5. 5Stroke Institute, Department of Neurology, University of Pittsburgh Medical Centerx, Pittsburgh, Pennsylvania, USA
  6. 6Departments of Radiology and Nuclear Medicine, Academic Medical Centre, Amsterdam, The Netherlands
  7. 7Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  8. 8Departments of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
  9. 9Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
  10. 10Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Catalunya, Cataluña, Spain
  11. 11Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  12. 12Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
  13. 13Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
  14. 14Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
  15. 15Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
  16. 16Altair Biostatistics, Mooresville, North Carolina, USA
  17. 17Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Canada
  1. Correspondence to Dr David S Liebeskind, Neurovascular Imaging Research Core, Los Angeles, CA 90095, USA; davidliebeskind{at}


Background Revascularization after endovascular therapy for acute ischemic stroke is measured by the Thrombolysis In Cerebral Infarction (TICI) scale, yet variability exists in scale definitions. We examined the degree of reperfusion with the expanded TICI (eTICI) scale and association with outcomes in the HERMES collaboration of recent endovascular trials.

Methods The HERMES Imaging Core, blind to all other data, evaluated angiography after endovascular therapy in HERMES. A battery of TICI scores (mTICI, TICI, TICI2C) was used to define reperfusion of the initial target occlusion defined by non-invasive imaging and conventional angiography.

Results Angiography of 801 subjects was available, including 797 defined by non-invasive imaging (154 internal carotid artery (ICA), 583 M1, 60 M2) and 748 by conventional angiography (195 ICA, 459 M1, 94 M2). Among 729 subjects in whom the reperfusion grade could be established, using eTICI (3=100%, 2C=90–99%, 2b67=67–89%, 2b50=50–66%) of the conventional angiography target occlusion, there were 63 eTICI 3 (9%), 166 eTICI 2c (23%), 218 eTICI 2b67 (30%), 103 eTICI 2b50 (14%), 100 eTICI 2a (14%), 19 eTICI 1 (3%), and 60 eTICI 0 (8%). Modified Rankin Scale shift analyses from baseline to 90 days showed that increasing TICI grades were linked with better outcomes, with significant distinctions between TICI 0/1 versus 2a (p=0.028), 2a versus 2b50 (p=0.017), and 2b50 versus 2b67 (p=0.014).

Conclusions The benefit of endovascular therapy in HERMES was strongly associated with increasing degrees of reperfusion defined by eTICI. The eTICI metric identified meaningful distinctions in clinical outcomes and may be used in future studies and routine practice.

  • stroke
  • angiography

Statistics from


  • Contributors DSL prepared the first draft of the report based on an analysis plan agreed by the HERMES Executive who also contributed to study interpretation. SB performed the statistical analyses. DSL coordinated the central imaging repository. All authors participated in patient enrollment, data collection, critically reviewed the report and approved the final version.

  • 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 DSL reports having received grant funding from NINDS and consulting fees as an imaging core laboratory from Stryker and Medtronic. RJ reports consulting with Medtronic. CBLMM reports having received grant funding from the Dutch Heart Foundation and European Commission and an unrestricted grant from Stryker. AvdL reports consulting fees from Stryker and grant funding from the Dutch Heart Foundation, AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Top Medical/Concentric, and Stryker, received by the Erasmus University Medical Center. LSR proctors for Stryker and Medtronic. PW discloses institutional research grant support within the last 2 years from Microvention Terumo. He declares the following relevant professional relationships: Chair of the European Society of Minimally Invasive Neurotherapeutics Guidelines Committee, sits on the Policy Working Group for Thrombectomy of NHS England and represents the Royal College of Radiologists on the UK Intercollegiate Stroke Working party (none of these are associated with financial reimbursement). He reports the following modest consultancy work: member of Stryker’s Global Hemorrhagic Stroke Advisory Board and educational consultancy work for Microvention Terumo. He has no other interests to declare. MG reports being the principal investigator of an unrestricted research grant to the University of Calgary for the HERMES collaboration by Medtronic. He also reports consulting services with Medtronic, Stryker, Microvention, Cerenovus and a licensing agreement with GE Healthcare re systems of acute stroke diagnosis.

  • Patient consent Not required.

  • Ethics approval Ethics approval was obtained from the local institutional review board and written informed consent was obtained from patients.

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

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.