Biomarkers of Technical Success After Embolectomy for Acute Stroke
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Abstract
Purpose of the Review Stent retrievers and large-bore aspiration catheters have doubled substantial reperfusion rates compared to first-generation devices. This has been accompanied by a 3-fold reduction in procedural time to revascularization. To measure future thrombectomy improvements, new benchmarks for technical efficacy are needed. This review summarizes the recent literature concerning biomarkers of procedural success and harm and highlights future directions.
Recent Findings Expanded Treatment in Cerebral Ischemia (eTICI), which incorporates scores for greater levels of reperfusion, improves outcome prediction. Core laboratory–adjudicated studies show that outcomes following eTICI 2c (90%–99% reperfusion) are superior to eTICI 2b50 and nearly equivalent to eTICI 3. Moreover, eTICI 2c improves scale reliability. Studies also confirm the importance of rapid revascularization, whether measured as first pass effect or procedural duration under 30 minutes. Distal embolization is a complication that impedes the extent and speed of revascularization, but few studies have reported its per-pass occurrence. Distal embolization and emboli to new territory should be measured after each thrombectomy maneuver. Collaterals have been shown to be an important modifier of thrombectomy benefit. A drawback of the currently accepted collateral grading scale is that it does not discriminate among the broad spectrum of partial collateralization. Important questions that require investigation include reasons for failed revascularization, the utility of a global Treatment in Cerebral Ischemia scale, and the optimal grading system for vertebrobasilar occlusions.
Summary Emerging data support a lead technical efficacy endpoint that combines the extent and speed of reperfusion. Efforts are needed to better characterize angiographic measures of treatment harm and of collateralization.
Glossary
- ACA=
- anterior cerebral artery;
- ASITN=
- American Society of Interventional and Therapeutic Neuroradiology;
- eASITN=
- expanded American Society of Interventional and Therapeutic Neuroradiology;
- ENT=
- emboli to new territory;
- eTICI=
- expanded Treatment in Cerebral Ischemia scale;
- FPE=
- first-pass effect;
- IAT=
- intraarterial stroke therapy;
- ICA=
- internal carotid artery;
- IMS=
- Interventional Management of Stroke;
- INT=
- infarct in new territory;
- MCA=
- middle cerebral artery;
- mRS=
- modified Rankin Scale;
- mTICI=
- modified Treatment in Cerebral Ischemia;
- OR=
- odds ratio;
- oTICI=
- original Treatment in Cerebral Ischemia;
- PT=
- procedure time;
- SIR=
- Society of Interventional Radiology;
- TICI=
- Treatment in Cerebral Ischemia;
- TIMI=
- Thrombolysis in Myocardial Ischemia
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received June 28, 2020.
- Accepted in final form September 25, 2020.
- © 2021 American Academy of Neurology
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