TICI-RANKIN mismatch: Poor clinical outcome despite complete endovascular reperfusion in the ETIS Registry - 10/03/23

Doi : 10.1016/j.neurol.2022.10.003

A. Dong ^a,^b, B. Maier ^c, B. Guillon ^d, C. Preterre ^d, S. De Gaalon ^d, B. Gory ^e,^f,^g,^h, S. Richard ^e,^f,^g,^h, A.-L. Kaminsky ^e,^f,^g,^h, C. Tracol ⁱ, F. Eugene ^j, I. Sibon ^k, T. Tourdias ^l, S. Smajda ^c, G. Marnat ^l, R. Bourcier ^m, N. Gaillard ⁿ, A. Consoli ^o, M. Kyheng ^p, J. Labreuche ^p, B. Lapergue ^q, F. Pico ^b,^⁎
on behalf of the Endovascular Treatment in Ischemic Stroke (ETIS) Investigators^¹
A complete list of the ETIS Investigators can be found in the Appendix at the end of the manuscript.
^a Faculté de médecine, Sorbonne université, 91-105, boulevard de l’Hôpital, 75013 Paris, France
^b Department of Neurology and Stroke Center, centre hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay-Rocquencourt, France
^c Interventional Neuroradiology Department, Fondation Rothschild, 25-29 rue Manin, 75019 Paris, France
^d Neurology Department and Stroke Center, hôpital Guillaume et René Laennec, centre hospitalo-universitaire de Nantes, boulevard Jacques Monod, 44093 Saint-Herblain, France
^e Université de Lorraine, CHRU-Nancy, Department of Neurology, Stroke Unit, 29, avenue. du Maréchal de Lattre de Tassigny, 54000 Nancy, France
^f CIC 1433 Plurithematic, Nancy University Hospital, université de Lorraine, Nancy, France
^g Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, 54000 Nancy, France
^h Université de Lorraine, IADI, Inserm U1254, 54000 Nancy, France
ⁱ Neurology Department and Stroke Center, Centre Hospitalo-Universitaire de Pontchaillou, 2, rue Henri le Guilloux, 35000 Rennes, France
^j Diagnostic and Interventional Neuroradiology Department, centre hospitalo-universitaire de Pontchaillou, 2, rue Henri le Guilloux, 35000 Rennes, France
^k Neurology Department and Stroke Center, centre hospitalo-universitaire de Bordeaux, Pl. Amélie Raba Léon, 33000 Bordeaux, France
^l Diagnostic and Therapeutic Neuroradiology Department, centre hospitalo-universitaire de Bordeaux, Pl. Amélie Raba Léon, 33000 Bordeaux, France
^m Diagnostic and Interventional Neuroradiology Department, hôpital Guillaume et René Laennec, centre hospitalo-universitaire de Nantes, boulevard Jacques Monod, 44093 Saint-Herblain, France
ⁿ Neurology Department and Stroke Center, centre hospitalo-universitaire de Montpellier, 191, avenue du Doyen Gaston Giraud, 34295 Montpellier, France
^o Diagnostic and Interventional Neuroradiology Department, hôpital Foch, 40, rue Worth, 92150 Suresnes, France
^p Department of Public Health, Epidemiology and Standard of Care, EA 2964, centre hospitalo-universitaire de Lille, 2, avenue Oscar Lambret 59000 Lille, France
^q Neurology Department and Stroke center, hôpital Foch, 40, rue Worth, 92150 Suresnes, France

^⁎Corresponding author.

Highlights

•	Half of stroke patients treated by endovascular therapy have poor clinical outcome.
•	Poor clinical outcome is associated with older age, higher admission NIHSS.
•	Poor clinical outcome is associated with absence of intravenous thrombolysis.
•	T24h NIHSS change could predict longer term functional prognosis.
•	These high risk patients could be a target population for neurorepair strategies.

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Abstract

Introduction

Endovascular treatment (EVT) is a well-established technic for acute ischemic stroke, but despite a high recanalization rate of near 80%, at 3 months roughly 50% of patients have a poor functional outcome with a modified Rankin score (mRS) ≥3. The aim of this study was to determine predictive factors of poor functional outcomes in patients with complete recanalization after EVT, defined as modified thrombolysis in cerebral infarction (mTICI) 3.

Patients and methods

This retrospective analysis based on the prospective multicenter ETIS registry (endovascular treatment in ischemic stroke) in France included 795 patients from January 2015 and November 2019 with acute ischemic stroke due to anterior circulation occlusion and prestroke mRS 0-1, treated with EVT and who achieved complete recanalization. Univariate and multivariate logistic regression models were used to identify predictive factors of poor functional outcome.

Results

365 patients (46%) showed a poor functional outcome (mRS>2). In backward-stepwise logistic regression analysis, poor functional outcome was independently associated with older age (OR per 10-year increase, 1.51; 95%CI, 1.30 to 1.75), higher admission NIHSS (OR per 1 point increase, 1.28; 95%CI, 1.21 to 1.34), absence of prior intravenous thrombolysis (OR, 0.59; 95%CI, 0.39 to 0.90), and an unfavorable 24-hour NIHSS change (24h-baseline) (OR, 0.82; 95%CI, 0.79 to 0.87). We calculated that patients whose 24h NIHSS decreased by less than 5 points are more at risk of a poor outcome, with a sensitivity and a specificity of 65.0%.

Conclusion

Despite complete reperfusion after EVT, half of patients had a poor clinical outcome. These patients, who were mainly older with a high initial NIHSS and an unfavorable post-EVT 24h NIHSS change, could represent a target population for early neurorepair and neurorestorative strategies.

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Keywords : Endovascular treatment, Poor outcome, Prognosis, Predictors

Abbreviations : ETIS, EVT, mRS, NIHSS, mTICI, ASPECTS, BP, CAD, ICA, IQR, CI, OR, MCA, rt-PA, SD, TIA