Heterogeneity of the Relative Benefits of TICI 2c/3 over TICI 2b50/2b67: Are there Patients who are less Likely to Benefit?

PURPOSE: Incomplete reperfusion after mechanical thrombectomy (MT) is associated with a poor outcome. Rescue therapy would potentially benefit some patients with an expanded treatment in cerebral ischemia score (eTICI) 2b50/2b67 reperfusion but also harbors increased risks. The relative benefits of eTICI 2c/3 over eTICI 2b50/67 in clinically important subpopulations were analyzed. METHODS: Retrospective analysis of our institutional database for all patients with occlusion of the intracranial internal carotid artery (ICA) or the M1/M2 segment undergoing MT and final reperfusion of ≥eTICI 2b50 (903 patients). The heterogeneity in subgroups of different time metrics, age, National Institutes of Health Stroke Scale (NIHSS), number of retrieval attempts, Alberta Stroke Programme Early CT Score (ASPECTS) and site of occlusion using interaction terms (p(i)) was analyzed. RESULTS: The presence of eTICI 2c/3 was associated with better outcomes in most subgroups. Time metrics showed no interaction of eTICI 2c/3 over eTICI 2b50/2b67 and clinical outcomes (onset to reperfusion p(i) = 0.77, puncture to reperfusion p(i) = 0.65, onset to puncture p(i) = 0.63). An eTICI 2c/3 had less consistent association with mRS ≤2 in older patients (>82 years, p(i) = 0.038) and patients with either lower NIHSS (≤9) or very high NIHSS (>19, p(i) = 0.01). Regarding occlusion sites, the beneficial effect of eTICI 2c/3 was absent for occlusions in the M2 segments (aOR 0.73, 95% confidence interval [CI] 0.33–1.59, p(i) = 0.018). CONCLUSION: Beneficial effect of eTICI 2c/3 over eTICI 2b50/2b67 only decreased in older patients, M2-occlusions and patients with either low or very high NIHSS. Improving eTICI 2b50/2b67 to eTICI 2c/3 in those subgroups may be more often futile. SUPPLEMENTARY INFORMATION: The online version of this article (10.1007/s00062-021-01131-0) contains supplementary material, which is available to authorized users.