Systemic biomarker associated with poor outcome after futile reperfusion.

BACKGROUND: Successful recanalization does not lead to complete tissue reperfusion in a considerable percentage of ischemic stroke patients. This study aimed to identify biomarkers associated with futile recanalization. Leukoaraiosis predicts poor outcomes of this phenomenon. Soluble tumour necrosis factor-like weak inducer of apoptosis (sTWEAK), which is associated with leukoaraiosis degrees, could be a potential biomarker. METHODS: This study includes two cohorts of ischemic stroke patients in a multicentre retrospective observational study. Effective reperfusion, defined as a reduction of ≥8 points in the National Institutes of Health Stroke Scale (NIHSS) within the first 24 h, was used as a clinical marker of effective reperfusion. RESULTS: In the first cohort study, female sex, age, and high NIHSS at admission (44.7% vs. 81.1%, 71.3 ± 13.7 vs. 81.1 ± 6.7; 16 [13, 21] vs. 23 [17, 28] respectively; p < .0001) were confirmed as predictors of futile recanalization. ROC curve analysis showed that leukocyte levels (sensitivity of 99%, specificity of 55%) and sTWEAK level (sensitivity of 92%, specificity of 88%) can discriminate between poor and good outcomes. Both biomarkers simultaneously are higher associated with outcome after effective reperfusion (OR: 2.17; CI 95% 1.63-4.19; p < .0001) than individually (leukocytes OR: 1.38; CI 95% 1.00-1.64, p = .042; sTWEAK OR: 1.00; C I95% 1.00-1.01, p = .019). These results were validated using a second cohort, where leukocytes and sTWEAK showed a sensitivity of 100% and specificity of 66.7% and 75% respectively. CONCLUSIONS: Leukocyte and sTWEAK could be biomarkers of reperfusion failure and subsequent poor outcomes. Further studies will be necessary to explore its role in reperfusion processes.

Predictors of futile recanalization after endovascular treatment of acute ischemic stroke.

OBJECTIVE: Endovascular therapy (EVT) is the most successful treatment for patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation. However, futile recanalization (FR) seriously affects the prognosis of these patients. The aim of this study was to investigate predictors of FR after EVT in patients with AIS. METHOD: Patients diagnosed with AIS due to anterior circulation LVO and receiving EVT between June 2020 and October 2022 were prospectively enrolled. FR after EVT was defined as a poor 90-day prognosis (modified Rankin Scale [mRS] score ≥ 3) despite achieving successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] classification of 2b-3). All included patients were categorized into control group (mRS score < 3) and FR group (mRS score ≥ 3). Demographic characteristics, comorbidities (hypertension, diabetes, atrial fibrillation, smoking, etc.), stroke-specific data (NIHSS score, ASPECT score and site of occlusion), procedure data (treatment type [direct thrombectomy vs. bridging thrombectomy], degree of vascular recanalization [mTICI], procedure duration time and onset-recanalization time), laboratory indicators (lymphocytes count, neutrophils count, monocytes count, C-reactive protein, neutrophil-to-lymphocyte ratio [NLR], monocyte-to-high-density lipoprotein ratio [MHR], lymphocyte-to-monocyte ratio [LMR], lymphocyte-to-C-reactive protein ratio [LCR], lymphocyte-to-high-density lipoprotein ratio[LHR], total cholesterol and triglycerides.) were compared between the two groups. Multivariate logistic regression analysis was performed to explore independent predictors of FR after EVT. RESULTS: A total of 196 patients were included in this study, among which 57 patients were included in the control group and 139 patients were included in the FR group. Age, proportion of patients with hypertension and diabetes mellitus, median NIHSS score, CRP level, procedure duration time, neutrophil count and NLR were higher in the FR group than in the control group. Lymphocyte count, LMR, and LCR were lower in the FR group than in the control group. There were no significant differences in platelet count, monocytes count, total cholesterol, triglycerides, HDL, LDL, gender, smoking, atrial fibrillation, percentage of occluded sites, onset-recanalization time, ASPECT score and type of treatment between the two groups. Multivariate logistic regression analysis demonstrated that NLR was independently associated with FR after EVT (OR = 1.37, 95%CI = 1.005-1.86, P = 0.046). CONCLUSION: This study demonstrated that high NLR was associated with a risk of FR in patients with AIS due to anterior circulation LVO. These findings may help clinicians determine which patients with AIS are at higher risk of FR after EVT. Our study can provide a theoretical basis for interventions in the aforementioned population.

Non-contrast CT radiomics-clinical machine learning model for futile recanalization after endovascular treatment in anterior circulation acute ischemic stroke.

OBJECTIVE: To establish a machine learning model based on radiomics and clinical features derived from non-contrast CT to predict futile recanalization (FR) in patients with anterior circulation acute ischemic stroke (AIS) undergoing endovascular treatment. METHODS: A retrospective analysis was conducted on 174 patients who underwent endovascular treatment for acute anterior circulation ischemic stroke between January 2020 and December 2023. FR was defined as successful recanalization but poor prognosis at 90 days (modified Rankin Scale, mRS 4-6). Radiomic features were extracted from non-contrast CT and selected using the least absolute shrinkage and selection operator (LASSO) regression method. Logistic regression (LR) model was used to build models based on radiomic and clinical features. A radiomics-clinical nomogram model was developed, and the predictive performance of the models was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS: A total of 174 patients were included. 2016 radiomic features were extracted from non-contrast CT, and 9 features were selected to build the radiomics model. Univariate and stepwise multivariate analyses identified admission NIHSS score, hemorrhagic transformation, NLR, and admission blood glucose as independent factors for building the clinical model. The AUC of the radiomics-clinical nomogram model in the training and testing cohorts were 0.860 (95%CI 0.801-0.919) and 0.775 (95%CI 0.605-0.945), respectively. CONCLUSION: The radiomics-clinical nomogram model based on non-contrast CT demonstrated satisfactory performance in predicting futile recanalization in patients with anterior circulation acute ischemic stroke.

Systemic Immune-Inflammation Response is Associated with Futile Recanalization After Endovascular Treatment.

BACKGROUND: Frequent incidence of futile recanalization decreases the benefit of endovascular treatment (EVT) in acute ischemic stroke. We hypothesized that the inflammation and immune response after ischemic are associated with futile recanalization. We aimed to investigate the correlation of admission systemic immune-inflammation index (SII) with futile recanalization post EVT. METHODS: Patients with successful recanalization (modified Thrombolysis in Cerebral Ischemia angiographic score 2b-3) and maintained artery recanalized after 24 h of EVT were chosen from a prospective nationwide registry study. Futile recanalization was defined as a poor functional outcome (modified Rankin Scale score 3-6) at 90 days, irrespective of a successful recanalization. At admission, SII was calculated as (platelet count × neutrophil count)/lymphocyte count/100. Logistic regression analysis helped to test the relationship of SII with futile recanalization. RESULTS: Among the 1,002 patients included, futile recanalization occurred in 508 (50.70%). No matter whether tested as quartiles or continuous variables, SII was significantly associated with futile recanalization (P < 0.05), and for every one standard deviation increase of SII, the risk of futile recanalization elevated by 22.3% (odds ratio 1.223, 95% confidence interval 1.053-1.444, P = 0.0093). Moreover, no significant interactions could be observed between SII or SII quartiles and age, baseline National Institutes of Health Stroke Scale scores, onset-to-recanalization time, and modified Thrombolysis in Cerebral Ischemia angiographic scores (all P for interaction > 0.05). CONCLUSIONS: Early SII elevation was associated with an increased risk of futile recanalization among patients with EVT. Our results indicated that therapeutic drug targeting hyperreactive immune-inflammation response might be helpful for reducing the incidence of futile recanalization.

Ensemble Machine Learning to Predict Futile Recanalization After Mechanical Thrombectomy based on Non-Contrast CT Imaging.

OBJECTIVES: Despite successful recanalization after Mechanical Thrombectomy (MT), approximately 25% of patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) show unfavorable clinical outcomes, namely Futile Recanalization (FR). We aimed to use a Machine Learning (ML) Non-Contrast brain CT (NCCT) imaging predictive model to identify FR in patients undergoing MT. MATERIALS & METHODS: Between July 2022 and December 2022, 70 consecutive patients with LVO undergoing a complete recanalization (eTICI 3) with MT within 8 hours from onset at our Centre were analyzed. Two NCCT images per patient of middle cerebral artery vascular territory and patients' clinical characteristics were classified by the presence of ischemic features on 24h NCCT after MT. Each slice was segmented with "Mazda" software ver.4.6 by placing a Region Of Interest (ROI) on the whole brain by two radiologists in consensus. A total of 381 features were extracted for each slice. The dataset was split into train and test set with a 70:30 ratio. RESULTS: Eleven classification models were trained. An Ensemble Machine Learning (EML) model was obtained by averaging the predictions of models with accuracy on a test set >70%, with and without patients' clinical characteristics. The EML model combined with clinical data showed an accuracy of 0.76, a sensitivity of 0.88, a specificity of 0.69 with a NPV of 0.90, a PPV of 0.64, with AUC of 0.84. CONCLUSION: NCCT and ML analysis shows promise in predicting FR after complete recanalization following MT in AIS patients. Larger studies are required to confirm these preliminary results.

Influencing factors of futile recanalization after endovascular therapy for cerebral infarction with posterior circulation occlusion of large vessels: a retrospective study.

BACKGROUND: The optimal treatment for cerebral infarction caused by posterior circulation occlusion of large vessels has not yet been determined. Intravascular interventional therapy is an important treatment for cerebral infarction with posterior circulation occlusion of large vessels. However, endovascular therapy (EVT) of some posterior circulation cerebrovascular is ineffective and eventually become futile recanalization. Therefore, we performed a retrospective study to explore the factors influencing futile recanalization after EVT in patients with posterior circulation large-vessel occlusion. METHODS: Eighty-six patients with acute cerebral infarction and posterior circulation large vessel occlusion after intravascular intervention were divided into two groups according to their modified Rankin scale (mRS) scores after 3 months: group 1, mRS scores less than or equal to 3 (the effective recanalization group); group 2, mRS scores greater than 3 (the ineffective recanalization group). The basic clinical data, imaging index scores, time from onset to recanalization, and operation time between the two groups were compared and analyzed. Logistic regression was used to analyze the factors influencing indicators of good prognosis, and the ROC curve and Youden index were used to determine the best cutoff value. RESULTS: Between the two groups, there were significant differences in the posterior circulation CT angiography (pc-CTA) scores, GCS scores, pontine midbrain index scores, time from discovery to recanalization, operation time, NIHSS score and incidence of gastrointestinal bleeding. The logistic regression revealed that the NIHSS score and time from discovery to recanalization were associated with good prognoses. CONCLUSION: NIHSS score and recanalization time were independent influencing factors of ineffective recanalization of cerebral infarctions caused by posterior circulation occlusion. EVT is relatively effective for cerebral infarction caused by posterior circulation occlusion when the NIHSS score is less than or equal to 16 and the time from onset to recanalization is less than or equal to 570 min.

Postoperative blood glucose increase is associated with futile recanalization in patients with successful thrombectomy: a retrospective study.

BACKGROUND: Timely recognition of futile recanalization might enable a prompt response and an improved outcome in post-thrombectomy patients. This study aims to evaluate whether postoperative blood glucose increase (BGI) could act as an indicator of futile recanalization in patients receiving a successful thrombectomy. METHODS: This is a single-center, retrospective analysis of patients with anterior circulation large-vessel occlusion and successful thrombectomy between February 2019 and June 2022. BGI was defined as a higher level of blood glucose at the first postoperative morning than at admission. Futile recanalization was defined as patients with a modified Rankin Scale score of 3-6 at 90 days after onset. Multivariable binary logistic regression was used to assess the association of BGI with futile recanalization. RESULTS: A total of 276 patients were enrolled, amongst which 120 patients (43.5%) had BGI. Futile recanalization was more prevalent among patients with BGI compared to those without (70.0 vs. 49.4%, P = 0.001). After adjusting for potential confounders, BGI was associated with a higher likelihood of futile recanalization (adjusted OR: 2.97, 95%CI: 1.50-5.86, P = 0.002). This association was consistently observed regardless of diabetes history, occlusion site, time from symptom onset to groin puncture, or reperfusion status. CONCLUSION: Our findings support BGI serving as an indicator of futile recanalization in patients with anterior circulation large-vessel occlusion and successful thrombectomy.

Does stress hyperglycemia in diabetic and non-diabetic acute ischemic stroke patients predict unfavorable outcomes following endovascular treatment?

BACKGROUND: Hyperglycemia in hospitalized patients is related to increased morbidity and mortality, we determine if stress hyperglycemia, as assessed by the stress hyperglycemia ratio (SHR) index, increases the risk of adverse events in diabetic and non-diabetic AIS (acute ischemic stroke) patients following EVT (endovascular treatment). METHODS: We retrospectively analyzed data of 209 patients who achieved complete recanalization. SHR was defined as [FPG (mmol/L)/HbA1c (%)]. This study comprised 130 non-diabetic AIS patients and 79 people with diabetes, and they were categorized into three different groups based on SHR (Q1-Q3) tertiles. The primary outcome was futile recanalization, characterized as a 3-month modified Rankin scale score (mRS) of 3-6. Multivariable logistic regression analyses were utilized to calculate the relationship between stress hyperglycemia and poor outcomes. RESULTS: Non-diabetic patients showed statistically significant differences in the proportion of 3-month all-cause mortality (14.6% for Q1, 63.0% for Q2, 74.4% for Q3, p<0.001) and futile recanalization (2.4% for Q1, 19.6% for Q2, 37.2% for Q3, p<0.001) between the three groups. After adjusting for potential confounders, we found that the highest SHR tertile remained an independent risk factor of futile recanalization (OR 18.13, 95% CI 3.38-97.38, p = 0.001) and 3-month all-cause mortality (OR 15.9, 95% CI 1.46-173.26, p = 0.023) among non-diabetic patients. As demonstrated by restricted cubic splines, the SHR reference was 1.12. CONCLUSIONS: Severe stress hyperglycemia independently increased the odds of futile recanalization and 3-month all-cause mortality in AIS patients receiving EVT but without diabetes.

No-reflow phenomenon in acute ischemic stroke: an angiographic evaluation.

BACKGROUND: Futile recanalization (FR) is de fined as a poor 90-day outcome or lack of neurological improvement at 24 h despite successful recanalization in acute ischemic stroke (AIS) with large vessel occlusion (LVO) treated by mechanical throbectomy (MT). The No-reflow phenomenon (NRP) could be a possible cause of FR, but its evidence in AIS patients is scarce. METHODS: We retrospectively analyzed 185 digital subtraction angiographies (DSA) of AIS patients with anterior circulation LVO after endovascular treatment. To better define NRP, we designed a score called the modified capillary index score (mCIS). The score is obtained by dividing the middle cerebral artery territory in three segments. For each segment, we gave 2 points if the capillary blush was present without any delay, 1 if delayed, and 0 if absent. The primary endpoint was to use mCIS to identify NRP on post-interventional DSA and to test whether this marker may predict FR and failure of early neurological improvement (fENI). The secondary endpoint was to search for a correlation between NRP, lesion volume, and hemorrhagic transformation. We used the ROC curve to define mCIS ≤ 3 as the cut-off and marker of NRP. RESULTS: NRP was present in 35.1% of patients. NRP predicted fENI at 24 h (aOR 2.825, 95% CI 1.265-6.308, P = 0.011) and at 7 days (aOR 2.191, 95% CI 1.008-4.762, P = 0.048), but not 90-day FR. Moreover, NRP predicted hemorrhagic transformation (aOR 2.444, 95% CI 1.266-4.717, P = 0.008). CONCLUSIONS: The modified capillary index score (mCIS) seems useful in identifying NRP in AIS. In addition, mCIS was able to predict NRP that correlated with early clinical outcome and hemorrhagic transformation of the ischemic lesion. An external validation of the score is warranted.

Red Cell Distribution Width and Futile Recanalization in Individuals with Acute Ischemic Stroke following Endovascular Treatment.

BACKGROUND: Previous studies reported that red cell distribution width (RDW) was related to acute ischemic stroke (AIS). Endovascular treatment (EVT) still faces a huge challenge: futile recanalization. The goal of our study was to investigate the relationship between futile recanalization and RDW in AIS patients receiving EVT. METHODS: We retrospectively identified 188 AIS individuals with anterior circulation occlusion throughout EVT and obtained complete or near-total recanalization. The subjects were classified into futile recanalization group by their 3-month modified Rankin scale (mRS) score ≥3. The predictive value of RDW was calculated using receiver operating characteristic (ROC) curves, area under the curve (AUC) values, and logistic regression approaches. RESULTS: One hundred and eleven (59.0%) patients were defined as futile recanalization. The RDW was observed as an novel factor of futile recanalization in the multivariate regression model ([OR, odd-ratio] = 5.233, 95% [CI, confidence interval] = 2.656-10.307; p < 0.001). According to the ROC, the model integrating RDW with other risk factors had a relatively higher AUC compared than the RDW alone model (0.944 vs 0.798; p < 0.001) via DeLong's test. CONCLUSIONS: Higher RDW is associated with poor functional outcome in anterior circulation AIS patients undergoing EVT at 3 months.

Clinical Relevance of Computed Tomography Perfusion-Estimated Infarct Volume in Acute Ischemic Stroke Patients within the 6-h Therapeutic Time Window.

INTRODUCTION: Although the estimated infarct volume on baseline computed tomography perfusion (CTP) can identify patients who are likely to benefit from endovascular thrombectomy (EVT) in late time window strokes, the role of CTP imaging in early time windows has not been established. We assessed the clinical impact of CTP-estimated infarct volume on long-term prognosis after EVT, particularly in patients with early time window stroke. METHODS: We retrospectively reviewed patients who underwent pretreatment CTP and EVT for large vessel occlusion in the anterior circulation within 6 h after symptom onset between March 2014 and February 2019. The infarct volume at baseline CTP was estimated using commercially available software (RAPID, iSchemaView, Menlo Park, CA, USA) with a cerebral blood flow threshold <30% of the normal brain. Risk factors for poor outcome after EVT were evaluated, and a receiver operating characteristic (ROC) curve analysis was used to identify CTP-estimated infarct volumes that optimally predicted the development of symptomatic intracranial hemorrhage (sICH) and poor outcomes (modified Rankin Scale [mRS] 3-6) at 90 days. RESULTS: Of 120 patients, successful recanalization was achieved in 89 (74.2%) patients, while 61 (50.8%) showed poor outcomes at 90 days. Among 89 patients with successful recanalization after EVT, age, diabetes, clinical stroke severity, CTP-estimated infarct volume, and sICH development were independently associated with 90-day clinical outcomes. ROC analysis identified infarct volumes of ≥88.5 mL and ≥74 mL as the optimal thresholds for predicting poor outcome and development of sICH, respectively. Patients with large infarct volumes showed poorer outcomes (odds ratio [OR], 7.704; 95% confidence interval [CI], 1.528-38.839) and higher rates of sICH development (OR, 10.857; 95% CI, 1.835-64.235). Among patients with large infarction volumes (≥88.5 mL), the 90-day mRS demonstrated a shift toward better outcomes in patients with successful recanalization. CONCLUSION: Larger initial infarct volumes are significantly associated with worse clinical outcomes in patients who underwent EVT because of early time window stroke. Furthermore, our study of 6-h data demonstrated that an initial infarction of more than a certain volume might be an independent risk factor for sICH development and poor outcomes even in patients with successful recanalization. However, we still observed benefits of EVT in patients with large ischemic cores. The CTP-estimated infarct volume might be an important prognostic factor after EVT rather than a biomarker predicting treatment effectiveness.

Biomarkers of Unfavorable Outcome in Acute Ischemic Stroke Patients with Successful Recanalization by Endovascular Thrombectomy.

BACKGROUND: We aimed to identify plasma markers of unfavorable outcomes for patients with acute ischemic stroke (AIS) after recanalization by endovascular thrombectomy (EVT). METHODS: From November 2017 to May 2019, we prospectively collected 61 AIS patients due to anterior large vessel occlusion who achieved recanalization by EVT. Plasma samples were obtained between 18 and 24 h after recanalization. Unfavorable outcomes included futile recanalization at 90 days and overall early complications within 7 days after EVT. RESULTS: After adjustment for age and initial National Institute of Health Stroke Scale (NIHSS), matrix metalloproteinase-9 (MMP-9), tenascin-C, thioredoxin, ADAMTS13, and gelsolin were independently associated with both futile recanalization and overall early complications significantly (all p < 0.05), while C-reactive protein (CRP) was independently associated with overall early complications (p = 0.031) but at the limit of significance for futile recanalization (p = 0.051). The baseline clinical model (BCM) (including age and initial NIHSS) demonstrated discriminating ability to indicate futile recanalization (area under the curve [AUC] 0.807, 95% confidence interval [CI] 0.693-0.921) and overall early complications (AUC 0.749, 95% CI 0.611-0.887). BCM+MMP-9+thioredoxin enhanced discrimination (AUC 0.908, 95% CI 0.839-0.978, p = 0.043) and reclassification (net reclassification improvement [NRI] 67.2%, p < 0.001) to indicate futile recanalization. With respect to overall early complications, BCM+MMP-9+tenascin-C, BCM+MMP-9+CRP, BCM+MMP-9+ADAMTS13, BCM+tenascin-C+ADAMTS13, and BCM+CRP+ADAMTS13, all improved discrimination (AUC [95% CI]: 0.868 [0.766-0.970], 0.882 [0.773-0.990], 0.886 [0.788-0.984], 0.880 [0.783-0.977], and 0.863 [0.764-0.962], respectively, all p < 0.05 by the DeLong method) and reclassification (NRI 59.1%, 71.8%, 51.1%, 67.4%, and 38.3%, respectively, all p < 0.05). CONCLUSIONS: The increased levels of MMP-9, tenascin-C, CRP, thioredoxin, and decreased levels of ADAMTS13 and gelsolin were independent predictors of futile recanalization in AIS patients after recanalization by EVT.

Predictors of Futile Recanalization After Endovascular Treatment in Patients with Acute Ischemic Stroke in a Multicenter Registry Study.

BACKGROUND: Futile recanalization, defined as the early recanalization of an occluded artery failing to improve neurological outcome, remains a persistent concern in the endovascular treatment of acute ischemic stroke. We investigated the occurrence and predictors of futile recanalization after endovascular treatment in a nationwide multicenter stroke registry study. METHODS: The subjects consisted of eligible patients from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment registry study (2015-2017). Subjects with acute anterior large vessel occlusion who achieved successful angiographic recanalization (defined as modified Thrombolysis in Cerebral Infarction grades 2b or 3) by endovascular treatment were dichotomized into the futile-recanalization group (with a modified Rankin Scale score of 3-6) and the favorable-recanalization group (with a modified Rankin Scale score of 0-2) according to 90-day functional independence. Logistic regression analysis was performed to investigate predictors of futile recanalization. RESULTS: Futile recanalization was observed in 200 (49.6%) out of 403 patients. On multivariate analysis, older age (>74 vs. ≤74; odds ratio (OR), 2.41; 95% confidence interval (CI), 1.31-4.44; P=0.005), high baseline National Institutes of Health Stroke Scale score (>21 vs. ≤13; OR, 2.52; 95% CI, 1.21-5.28; P=0.014), delayed puncture to recanalization time (>80 vs. ≤80 min; OR, 2.75; 95% CI, 1.67-4.51; P=0.000), and the use of general anesthesia (OR, 1.90; 95% CI, 1.15-3.14; P=0.012) were positively associated with futile recanalization after mechanical thrombectomy. CONCLUSIONS: The incidence of futile recanalization is common following endovascular treatment among Asian patients with anterior circulation occlusion. Advanced age, higher baseline National Institutes of Health Stroke Scale score, delayed puncture to reperfusion, and the use of general anesthesia are associated with lower functional independence 90 days post-treatment despite successful recanalization.

Rates and predictors of futile recanalization in patients undergoing endovascular treatment in a multicenter clinical trial.

PURPOSE: The phenomenon of futile recanalization, defined as lack of clinical benefit despite angiographic recanalization, is an important limitation of endovascular treatment for acute ischemic stroke. We aim to characterize the occurrence and predictors of futile recanalization in the endovascular arm of the Interventional Management of Stroke (IMS) III trial. METHODS: Patients with near complete or complete recanalization (TICI grades 2b and 3) were divided according to functional outcome at 3 months into "meaningful recanalization," defined as mRS score 0-2, and "futile recanalization," mRS score 3-6. Multivariate analysis was performed to identify predictors of futile recanalization. RESULTS: Futile recanalization was observed in 61 (47%) of 130. Compared to meaningful recanalization group, the futile recanalization group had higher proportion of women (62.3 vs. 43.5%; p = 0.032), higher incidence of diabetes mellitus (29.5 vs. 8.7%; p = 0.004) and coronary artery disease (27.9 vs. 13%; p = 0.05), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (median [range] 19 [11-31] vs. 15 [8-26], p < 0.001), higher baseline serum glucose (7.6 ± 2.6 vs. 6.7 ± 1.7 mmol/L; p = 0.039), and longer onset-to-start of endovascular treatment time (265.8 ± 48.3 vs. 239.2 ± 47.7 min; p = 0.007). In multivariate analysis, NIHSS (OR 1.3; 95% CI 1.1-1.4), female gender (OR 3.0; 95% CI 1.1-8.2), and onset-to-start of endovascular treatment time (OR 1.2; 95% CI 1.1-1.3) were independent predictors of futile recanalization. CONCLUSION: In IMS III, futile recanalization was common. Delay in endovascular treatment is the only modifiable risk factor. Additional strategies for non-modifiable risk factors-female gender and high NIHSS-need to be identified.

A novel nomogram to predict futile recanalization in patients with acute ischemic stroke undergoing mechanical thrombectomy.

Background and objective: Futile recanalization (FR) is defined as patients with acute ischemic stroke (AIS) due to large vessel occlusion who still exhibits functional dependence although undergoing successful mechanical thrombectomy (MT). We aimed to develop and validate a simple nomogram for predicting the probability of FR after MT treatment in AIS patients. Methods: Clinical data of AIS patients in the Jrecan clinical trial in China from March 2018 to June 2019 were collected as the derivation set (n = 162). Meanwhile, clinical data of AIS patients who underwent MT in Baotou Central Hospital and Ningbo No.2 Hospital from 2019 to 2021 were collected as the validation set (n = 170). Multivariate logistic regression analysis was performed for all variables that had p < 0.2 in the univariate analysis in the derivation set. The independent risk factors of FR were further screened out and a nomogram was constructed. The performance of the nomogram was analyzed in the derivation and validation set using C-index, calibration plots, and decision curves. Results: No significant difference in FR rate was detected between the derivation set and the validation set [88/162 (54.32%) and 82/170 (48.23%), p = 0.267]. Multivariate logistic regression analysis showed that age ≥ 65 years old (OR = 2.096, 95%CI 1.024-4.289, p = 0.043), systolic blood pressure (SBP) ≥ 180 mmHg (OR = 5.624, 95%CI 1.141-27.717, p = 0.034), onset to recanalization time (OTR) ≥ 453 min (OR = 2.759, 95%CI 1.323-5.754, p = 0.007), 24 h intracerebral hemorrhage (ICH; OR = 4.029, 95%CI 1.844 ~ 8.803, p < 0.001) were independent risk factors for FR. The C-index of the nomogram of the derivation set and the verification set were 0.739 (95%CI 0.662~0.816) and 0.703 (95%CI 0.621~0.785), respectively. Conclusion: The nomogram composed of age, SBP, OTR, and 24 h ICH can effectively predict the probability of FR after MT in AIS patients.

Long term for patients with futile endovascular reperfusion after stroke.

AIMS: With the progress of thrombectomy technology, the vascular recanalization rate of patients with stroke has been continuously improved, but the proportion of futile recanalization (FR) is still quite a few. The long-term prognosis and survival of patients with FR and its influencing factors remain unclear. METHODS: Consecutive patients who received endovascular treatment (EVT) for ischemic stroke were enrolled between 2013 and 2021 from a single-center prospectively registry study. We evaluated the long-term outcome of these patients by Kaplan-Meier survival analysis, and the multivariable logistic regression curve was performed to analyze influencing factors. RESULTS: Among 458 patients with FR, 56.4% of patients survived at 1 year, and 50.4% at 2 years. In the multivariate regression analysis, age, premorbid modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), posterior circulation infarct, general anesthesia, symptomatic intracerebral hemorrhage (sICH), and decompressive craniectomy were found to be related to unfavorable outcomes in long-term. Age, premorbid mRS, NIHSS, general anesthesia, and sICH were predictors of long-term mortality. CONCLUSIONS: Futile recanalization accounts for a large proportion of stroke patients after thrombectomy. This study on the long-term prognosis of such patients is beneficial to the formulation of treatment plans and the prediction of therapeutic effects.

Predictors of futile recanalization in nonagenarians treated with mechanical thrombectomy: a multi-center observational study.

BACKGROUND: There is a lack of data regarding patients aged 90 years or older undergoing mechanical thrombectomy and their predictors of futile recanalization. AIMS: We sought to evaluate the predictors of futile recanalization in patients ≥ 90 years with large vessel occlusion undergoing mechanical thrombectomy. METHODS: This multi-center observational retrospective study included patients ≥ 90 years consecutively treated with mechanical thrombectomy in four thrombectomy capable centers between January 1st, 2016 and 30th March 2023. Futile recanalization was defined as large vessel occlusion patients experiencing a 90-day poor outcome (mRS 3-6) despite successful recanalization (mTICI ≥ 2b) after mechanical thrombectomy. RESULTS: Our cohort included 139 patients ≥ 90 years with acute ischemic stroke due to anterior circulation large vessel occlusion treated with mechanical thrombectomy. One hundred seventeen of one hundred thirty-nine patients ≥ 90 years who achieved successful recanalization were included in the analysis (seventy-six female (64.9%)), of whom thirty-one (26.49%) experienced effective recanalization and eighty-six (73.51%) experienced futile recanalization. Patients with futile recanalization had higher NIHSS on admission (p < 0.001); they were less frequently treated with intravenous thrombolysis (p = 0.048), had more often general anesthesia (p = 0.011), and longer door to groin puncture delay (p = 0.002). Univariable regression analysis showed that use of intravenous thrombolysis (0.29, 95% CI 0.02-0.79, p = 0.034) and site of occlusion distal vs proximal (0.34, 95% CI 0.11-0.97, p = 0.044) were associated with reduced probability of futile recanalization while NIHSS on admission (1.29, 95% CI 1.16-1.45, p < 0.001), NIHSS at 24 h (1.15, 95% CI 1.07-1.25, p = 0.002), type of anesthesia used (4.18, 95% CI 1.57-11.08, p = 0.004), and door to groin puncture time (1.02, 95% CI 1.00-1.05, p = 0.005) were associated with increased probability of futile recanalization. Multivariable regression analysis showed that use of intravenous thrombolysis (0.44, 95% CI 0.09-0.88, p = 0.039) was associated with reduced probability of futile recanalization. CONCLUSION: Our study seems to suggest that mechanical thrombectomy with intravenous thrombolysis is associated with reduced probability of futile recanalization in a multi-center cohort of patients aged 90 years or older.

Introducing the Futile Recanalization Prediction Score (FRPS): A Novel Approach to Predict and Mitigate Ineffective Recanalization after Endovascular Treatment of Acute Ischemic Stroke.

Objective: This study aims to develop and validate the Futile Recanalization Prediction Score (FRPS), a novel tool designed to predict the severity risk of FR and aid in pre- and post-EVT risk assessments. Methods: The FRPS was developed using a rigorous process involving the selection of predictor variables based on clinical relevance and potential impact. Initial equations were derived from previous meta-analyses and refined using various statistical techniques. We employed machine learning algorithms, specifically random forest regression, to capture nonlinear relationships and enhance model performance. Cross-validation with five folds was used to assess generalizability and model fit. Results: The final FRPS model included variables such as age, sex, atrial fibrillation (AF), hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, cognitive impairment, pre-stroke modified Rankin Scale (mRS), systolic blood pressure (SBP), onset-to-puncture time, sICH, and NIHSS score. The random forest model achieved a mean R-squared value of approximately 0.992. Severity ranges for FRPS scores were defined as mild (FRPS < 66), moderate (FRPS 66-80), and severe (FRPS > 80). Conclusions: The FRPS provides valuable insights for treatment planning and patient management by predicting the severity risk of FR. This tool may improve the identification of candidates most likely to benefit from EVT and enhance prognostic accuracy post-EVT. Further clinical validation in diverse settings is warranted to assess its effectiveness and reliability.

Predicting Futile Recanalization in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: The Role of White Blood Cell Count to Mean Platelet Volume Ratio.

BACKGROUND: Approximately half of AIS patients have an unfavorable outcome even after complete reperfusion. White blood cell (WBC) count to mean platelet volume (MPV) ratio (WMR) may be a promising predictive factor for futile recanalization. This study aimed to determine the predictive value of WMR in identifying individuals at higher risk of futile recanalization. METHODS: In this retrospective cohort study, 296 patients who achieved complete reperfusion after endovascular treatment (EVT) were included in the analysis. WBC count and MPV were collected at admission. Multivariable logistic regression was used to examine the independent association of the WMR with functional outcomes at three months. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses were used to compare the accuracy of WMR for predicting futile recanalization. RESULTS: The adjusted odds ratios for the fourth quartile of WMR were 3.142 (95% CI 1.405- 7.027, P = 0.005) for unfavorable outcomes at 3 months in comparison with the first quartile. The inclusion of WMR in the traditional model enabled a more accurate prediction of unfavorable outcomes (NRI 0.250, P = 0.031; IDI 0.022, P = 0.017). CONCLUSION: Elevated WMR at admission was independently associated with futile recanalization among AIS patients who received EVT and might be useful in identifying futile recanalization.

CBF Profile in Computed Tomography Perfusion-Based AutoMIStar Software Predicts Futile Recanalization After Basilar Artery Thrombectomy.

Background: Futile recanalization (FR) remains a significant challenge in patients with acute basilar artery occlusion (BAO) following successful endovascular treatment (EVT). This study aimed to investigate the predictive value of computed tomography perfusion (CTP)-based software (AutoMIStar; Apollo) for FR among BAO patients undergoing EVT. Methods: We analyzed a prospectively maintained database to identify consecutive BAO patients who achieved successful recanalization (modified Thrombolysis in Cerebral Infarction grade ≥ 2b) after EVT between January 2020 and September 2022. Clinical characteristics and imaging parameters from non-contrast CT, CT angiography, and CTP-AutoMIStar were collected for analysis. FR was defined as an unfavorable outcome (modified Rankin Scale score > 3) at 90 days despite successful recanalization. Multivariable stepwise logistic regression analysis was performed to identify independent predictors of FR. Results: Of the 54 patients included in this study, 24 (44.4%) experienced FR. In the univariate analysis, admission National Institutes of Health Stroke Scale score, posterior circulation Acute Stroke Prognosis Early CT Score, Basilar Artery on Computed Tomography Angiography (BATMAN) score, hypoperfusion intensity ratio, and perfusion deficit volume in delay time (DT) > 4 s, DT > 6 s, DT > 8 s, and all cerebral blood flow (CBF) thresholds were associated with FR (all P < 0.05). In the multivariate analysis, perfusion deficit volume in CBF < 35% (adjusted odds ratio [aOR] = 1.105, 95% confidence interval [CI]: 1.004-1.215; P = 0.040) and BATMAN score (aOR = 0.662, 95% CI: 0.455-0.964; P = 0.031) remained independent predictors of FR. Conclusion: Perfusion deficit volume in CBF < 35% on CTP-AutoMIStar imaging maps and BATMAN score are independent predictors of FR after EVT in BAO patients. There is a significant positive correlation between perfusion deficit volume in CBF < 35% and the occurrence of FR.