Effect of incomplete reperfusion patterns on clinical outcome: insights from the ESCAPE-NA1 trial

Petra Cimflova; Nishita Singh; Manon Kappelhof; Johanna M Ospel; Arshia Sehgal; Nima Kashani; Mohammed A Almekhlafi; Andrew M Demchuk; Joerg Berrouschot; Franziska Dorn; Michael E Kelly; Brian H Buck; Thalia S Field; Dariush Dowlatshahi; Michael Tymianski; Michael D Hill; Mayank Goyal

doi:10.1136/jnis-2023-020553

Effect of incomplete reperfusion patterns on clinical outcome: insights from the ESCAPE-NA1 trial

J Neurointerv Surg. 2023 Jul 25:jnis-2023-020553. doi: 10.1136/jnis-2023-020553. Online ahead of print.

Authors

Petra Cimflova^{1

2

3}, Nishita Singh^{2

4}, Manon Kappelhof⁵, Johanna M Ospel^{1

2

6}, Arshia Sehgal², Nima Kashani⁷, Mohammed A Almekhlafi^{1

2

8

9}, Andrew M Demchuk^{1

2

8}, Joerg Berrouschot¹⁰, Franziska Dorn¹¹, Michael E Kelly¹², Brian H Buck¹³, Thalia S Field¹⁴, Dariush Dowlatshahi¹⁵, Michael Tymianski¹⁶, Michael D Hill^{1

2

8

9}, Mayank Goyal^{17

2

8}

Affiliations

¹ Department of Radiology, University of Calgary, Calgary, Alberta, Canada.
² Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
³ Department of Medical Imaging and Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia.
⁴ Department of Internal Medicine - Neurology division, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada.
⁵ Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.
⁶ Clinic of Radiology and Nuclear Medicine, Universitatsspital Basel, Basel, Switzerland.
⁷ University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada.
⁸ Hotchkis Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
⁹ Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
¹⁰ Klinik für Neurologie und Neurologische Intensivmedizin, Klinikum Altenburger Land GmbH, Altenburg, Germany.
¹¹ Klinik für Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany.
¹² Department of Neurosurgery, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada.
¹³ Division of Neurology, University of Alberta, Edmonton, Alberta, Canada.
¹⁴ Division of Neurology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada.
¹⁵ Division of Neurology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada.
¹⁶ NoNO Inc, Toronto, Ontario, Canada.
¹⁷ Department of Radiology, University of Calgary, Calgary, Alberta, Canada mgoyal2412@gmail.com.

PMID: 37491383
DOI: 10.1136/jnis-2023-020553

Abstract

Background: Incomplete reperfusion (IR) after mechanical thrombectomy (MT) can be a consequence of residual occlusion, no-reflow phenomenon, or collateral counterpressure. Data on the impact of these phenomena on clinical outcome are limited.

Methods: Patients from the ESCAPE-NA1 trial with IR (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b) were compared with those with complete or near-complete reperfusion (eTICI 2c-3) on the final angiography run. Final runs were assessed for (a) an MT-accessible occlusion, or (b) a non-MT-accessible occlusion pattern. The primary clinical outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Our imaging outcome was infarction in IR territory on follow-up imaging. Unadjusted and adjusted incidence rate ratios (aIRR) with 95% confidence intervals (95% CI) were obtained.

Results: Of 1105 patients, 443 (40.1%) with IR and 506 (46.1%) with complete or near-complete reperfusion were included. An MT-accessible occlusion was identified in 147/443 patients (33.2%) and a non-MT-accessible occlusion in 296/443 (66.8%). As compared with patients with near-complete/complete reperfusion, patients with IR had significantly lower chances of achieving mRS 0-2 at 90 days (aIRR 0.82, 95% CI 0.74 to 0.91). Rates of mRS 0-2 were lower in the MT-accessible occlusion group as compared with the non-MT-accessible occlusion pattern group (aIRR 0.71, 95% CI 0.60 to 0.83, and aIRR 0.89, 95% CI 0.81 to 0.98, respectively). More patients with MT-accessible occlusion patterns developed infarcts in the non-reperfused territory as compared with patients with non-MT occlusion patterns (68.7% vs 46.3%).

Conclusion: IR was associated with worse clinical outcomes than near-complete/complete reperfusion. Two-thirds of our patients with IR had non-MT-accessible occlusion patterns which were associated with better clinical and imaging outcomes compared with those with MT-accessible occlusion patterns.

Keywords: Angiography; Stroke; Thrombectomy.