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Ischemic stroke
Original research
Whether mTICI 3 or mTICI 2b is better in patients with vertebrobasilar artery occlusion undergoing endovascular treatment depends on pc-ASPECTS
  1. Pan Zhang1,
  2. Ping Chen2,
  3. Yingjie Xu1,
  4. Miaomiao Hu3,
  5. Ruyue Wang3,
  6. Zhanglin Li1,
  7. Andrea M Alexandre4,
  8. Alessandro Pedicelli4,
  9. Aldobrando Broccolini5,6,
  10. Luca Scarcia7,
  11. Xinfeng Liu1,
  12. Wen Sun1
    1. 1Department of Neurology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
    2. 2Department of Neurology, The First Hospital of Putian City, Putian, Fujian, China
    3. 3Department of Neurology, Bengbu Medical College, Bengbu, Anhui, China
    4. 4UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
    5. 5Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
    6. 6Catholic University School of Medicine, Rome, Italy
    7. 7Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
    1. Correspondence to Dr Wen Sun; sunwen_medneuro{at}163.com; Professor Xinfeng Liu; xfliu2{at}ustc.edu.cn

    Abstract

    Background The clinical relevance of differentiating between mTICI (modified Thrombolysis In Cerebral Infarction) 2b and mTICI 3 in patients with vertebrobasilar artery occlusion (VBAO) remains unclear. This study aimed to investigate whether mTICI 3 improves functional outcomes compared with mTICI 2b in patients with VBAO and whether this improvement differs according to extent of ischemic damage.

    Methods This retrospective study enrolled patients with VBAO within 24 hours of the estimated occlusion time at 65 stroke centers in a nationwide registration in China. The primary outcome was favorable functional outcome (modified Rankin scale score 0–3) at 90 days. Patients were matched by final mTICI grade using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Logistic regression and ordinal regression models were used to assess the impact of mTICI 2b versus mTICI 3 grading on prognosis, based on different extent of ischemia damage (posterior circulation Alberta Stroke Program Early CT Score—pc-ASPECTS of 9–10, 7–8, and 3–6) and treatment strategies (bridging therapy and direct endovascular therapy (EVT)).

    Results A total of 2075 patients with VBAO and successful reperfusion were included, 652 patients (31.4%) achieved mTICI 2b and 1423 patients (68.6%) achieved mTICI 3. After adjustment for confounders, achieving mTICI 3 following EVT in patients with VBAO and pc-ASPECTS 9–10 (OR 1.54, 95% CI 1.16 to 2.03) and pc-ASPECTS 7–8 (OR 1.80, 95% CI (1.26 to 2.56) were associated with favorable functional outcome compared with mTICI 2b, especially in those receiving direct EVT. However, in patients with pc-ASPECTS≤6, functional outcomes at 90 days did not differ between mTICI 3 and mTICI 2b (OR 1.12, 95% CI 0.67 to 1.88), irrespective of using bridging therapy or direct EVT.

    Conclusion In patients with VBAO undergoing EVT with pc-ASPECTS>6, achieving mTICI 3 favors better outcomes compared with mTICI 2b, especially in those receiving direct EVT. However, in patients with pc-ASPECTS≤6, mTICI 3 did not improve functional outcomes compared with mTICI 2b. Interventionalists should carefully assess the risk-benefit of additional maneuvers once mTICI 2b reperfusion is restored in EVT for patients with VBAO and pc-ASPECTS≤6. Further studies are needed to guide treatment decisions in these cases.

    • Thrombectomy
    • Stroke
    • Intervention
    • Artery

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/jnis-2024-022020

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • PZ and PC contributed equally.

      • Contributors The study was conceived by WS, PZ, PC, and YX. PC and PZ prepared the initial draft of the manuscript. PC, YX, and PZ carried out the statistical analysis. WS, XL, and YX revised the manuscript. WS is responsible for the overall content as a guarantor. All authors participated in the data collection, analysis, and interpretation. The final version of the manuscript was reviewed and approved by all authors.

      • Funding The study was supported by grants from Medical Artificial Intelligence Joint Fund No MIA2022Q018, and Research Funds of Centre for Leading Medicine and Advanced Technologies of IHM No 2023IHM01054.

      • Competing interests None declared.

      • 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.