Journal article
Thrombolysis in Cerebral Infarction 2b Reperfusions
- Kaesmacher, Johannes ORCID University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
- Ospel, Johanna M. Department of Clinical Neuroscience, University of Calgary, Canada (J.M.O., M.G.).
- Meinel, Thomas R. Department of Neurology (T.R.M., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
- Boulouis, Grégoire Department of Neuroradiology, Paris Descartes University, INSERM U1266, DHU Neurovasculaire, Sainte-Anne Hospital (G.B.).
- Goyal, Mayank ORCID Department of Clinical Neuroscience, University of Calgary, Canada (J.M.O., M.G.).
- Campbell, Bruce C.V. ORCID Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.).
- Fiehler, Jens Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.).
- Gralla, Jan University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
- Fischer, Urs Department of Neurology (T.R.M., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
Published in:
- Stroke. - Ovid Technologies (Wolters Kluwer Health). - 2020, vol. 51, no. 11, p. 3461-3471
English
In patients undergoing mechanical thrombectomy, achieving complete (Thrombolysis in Cerebral Infarction 3) rather than incomplete successful reperfusion (Thrombolysis in Cerebral Infarction 2b) is associated with better functional outcome. Despite technical improvements, incomplete reperfusion remains the final angiographic result in 40% of patients according to recent trials. As most incomplete reperfusions are caused by distal vessel occlusions, they are potentially amenable to rescue strategies. While observational data suggest a net benefit of up to 20% in functional independence of incomplete versus complete reperfusions, the net benefit of secondary improvement from Thrombolysis in Cerebral Infarction 2b to 3 reperfusion might differ due to lengthier procedures and delayed reperfusion. Current strategies to tackle distal vessel occlusions consist of distal (microcatheter) aspiration, small adjustable stent retrievers, and administration of intra-arterial thrombolytics. While there are promising reports evaluating those techniques, all available studies show relevant limitations in terms of selection bias, single-center design, or nonconsecutive patient inclusion. Besides an assessment of risks associated with rescue maneuvers, we advocate that the decision-making process should also include a consideration of potential outcomes if complete reperfusion would successfully be achieved. These include (1) a futile angiographic improvement (hypoperfused territory is already infarcted), (2) an unnecessary angiographic improvement (the patient would not have developed infarction if no rescue maneuver was performed), and (3) a successful rescue maneuver with clinical benefit. Currently there is paucity of data on how these scenarios can be predicted and the decision whether to treat or to stop in a patient with incomplete reperfusion involves many unknowns. To advance the status quo, we outline current knowledge gaps and avenues of potential research regarding this clinically important question.
- Language
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- English
- Open access status
- closed
- Identifiers
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- DOI 10.1161/strokeaha.120.030157
- ISSN 0039-2499
- Persistent URL
- https://sonar.ch/global/documents/239
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