Predictors and Outcomes of Excellent Recanalization Versus Successful Recanalization After Thrombectomy in Proximal and Distal Medium Vessel Occlusion Strokes: A Multinational Study
Authors: Yedavalli Vivek , Salim Hamza Adel , Musmar Basel , Adeeb Nimer , Naamani Kareem El , Henninger Nils , Sundararajan Sri Hari , Kühn Anna Luisa , Khalife Jane , Ghozy Sherief , Scarcia Luca , Tan Benjamin Y. Q. , Heit Jeremy J. , Regenhardt Robert W. , Cancelliere Nicole M. , Bernstock Joshua D. , Rouchaud Aymeric , Fiehler Jens , Sheth Sunil , Essibayi Muhammed Amir , Puri Ajit S. , Dyzmann Christian , Colasurdo Marco , Barreau Xavier , Renieri Leonardo , Filipe João Pedro , Harker Pablo , Radu Răzvan Alexandru , Abdalkader Mohamad , Klein Piers , Marotta Thomas R. , Spears Julian , Ota Takahiro , Mowla Ashkan , Jabbour Pascal , Biswas Arundhati , Clarençon Frédéric , Siegler James E. , Nguyen Thanh N. , Varela Ricardo , Baker Amanda , Altschul David , Gonzalez Nestor R. , Möhlenbruch Markus A. , Costalat Vincent , Gory Benjamin , Stracke Christian Paul , Aziz‐Sultan Mohammad Ali , Hecker Constantin , Shaikh Hamza , Liebeskind David S. , Pedicelli Alessandro , Alexandre Andrea M. , Tancredi Illario , Faizy Tobias D. , Kalsoum Erwah , Lubicz Boris , Patel Aman B. , Pereira Vitor Mendes , Guenego Adrien , Dmytriw Adam A. ,   the MAD MT Investigators
Published: October 2024

Background
Acute ischemic stroke arising from medium vessel occlusions (MeVO) poses substantial challenges in treatment and management. This study aims to elucidate the outcomes and factors contributing to achieving excellent recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] 2c–3) versus successful recanalization (mTICI 2b) in patients with MeVO stroke undergoing mechanical thrombectomy (MT).

Methods
We conducted a multinational study analyzing data from the MAD‐MT (Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy) registry, encompassing 37 centers across North America, Asia, and Europe, collected between September 2017 and July 2023. The study included acute ischemic stroke patients with MeVO treated with MT, with or without intravenous thrombolysis, who achieved mTICI 2b–3 post‐MT.

Results

Among 1463 patients with successful recanalization (mTICI 2b–3), 523 achieved mTICI 2b recanalization, and 940 achieved mTICI 2c–3. Distal occlusions exhibited higher odds of excellent recanalization compared with proximal MeVO vessel occlusions (odds ratio, 1.58; 95% CI, 1.17–2.15;
P
= 0.003). Cardioembolic stroke pathogenesis was associated with a higher likelihood of excellent recanalization (1.67; 95% CI, 1.07–2.59;
P
= 0.018). Patients achieving mTICI 2c–3 recanalization demonstrated lower initial National Institutes of Health Stroke Scale scores, significant improvements in postprocedural National Institutes of Health Stroke Scale shift, and a higher percentage of favorable 90‐day outcomes compared with those with mTICI 2b. However, no significant difference in 90‐day mortality rates was observed.

Conclusion
This study underscores that among patients with MeVO stroke with successful recanalization (mTICI 2b–3) there is higher likelihood of achieving excellent recanalization (mTICI 2c–3) in distal occlusions and cardioembolic pathogenesis. mTICI 2c–3 scores post‐MT correlate with improved clinical outcomes compared with mTICI 2b, affirming the superiority of excellent recanalization over successful recanalization in patients with MeVO stroke. Further prospective studies and randomized controlled trials are warranted for validation.