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September 24, 2012

Revascularization grading in endovascular acute ischemic stroke therapy

O.O. Zaidat, MD, MS, M.A. Lazzaro, MD, D.S. Liebeskind, MD, N. Janjua, MD, L. Wechsler, MD, R.G. Nogueira, MD, R.C. Edgell, MD, … Show All … , J.S. Kalia, MD, A. Badruddin, MD, J. English, MD, D. Yavagal, MD, J.F. Kirmani, MD, A.V. Alexandrov, MD, and P. Khatri, MDAuthors Info & Affiliations
September 25, 2012 issue
79 (13_supplement_1) S110-S116
https://doi.org/10.1212/WNL.0b013e3182695916
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Abstract

Background:

Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner.

Method:

Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems.

Results and Conclusion:

The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced “tissy”) and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.

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Information & Authors

Information

Published In

Neurology®
Volume 79 • Number 13_supplement_1 • September 25, 2012
Pages: S110-S116
PubMed: 23008384

Copyright

Copyright © 2012 by AAN Enterprises, Inc.

Publication History

Received: July 10, 2011
Accepted: October 26, 2011
Published online: September 24, 2012
Published in print: September 25, 2012

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Disclosure

Dr. Zaidat serves on the scientific advisory board for Talecris; served on the adjudication committee for Stryker; received speaker honoraria from Stryker; served on the editorial board of Frontiers in Neurology (Endovascular & Interventional Neurology Section); serves as Editor of The Journal of Neurointerventional Surgery; serves as Associate Editor and is a member of the Editorial Board of Journal of Stroke & Cerebrovascular Diseases; served as a consultant for Stryker Neurovascular, Codman Neurovascular, Microvention Inc; and has received research support from Society of Vascular & Interventional Neurology (SVIN) for this educational activity. Dr. Lazzaro reports no disclosures. Dr. Liebeskind served as a consultant for Concentric Medical and CoAxia and receives research support from NIH. Dr. Janjua serves on the scientific advisory board for Lundbeck/DSMB and Neurointerventions; receives research support from NIH/NINDS; and holds stock or stock options or Board of Directors Compensation for Neurointerventions. Dr. Wechsler reports no disclosure. Dr. Nogueira serves as a consultant for Concentric and Coaxia. Dr. Edgell serves as a member of the data safety monitoring board for the Medtronic INPACT SFT clinical trial and Medtronic ACTIVE clinical trial; serves as a member of the Clinical Events Committee, Concentric TREVO-2 clinical trial; and serves as an editorial board member for The Neurohospitalist. Dr. Kalia has received funding for travel or speaker honoraria from Penumbra Inc. for consultation and speaking over the past 2 years; serves as Associate Editor for Frontiers in Endovascular Neurology; served as a consultant to Penumbra Inc, Codman Neurovascular, Micrus Inc, Genentech, and Boston Scientific; received research support from the Florida Biomedical New Investigator Award; and received an intramural grant. Dr. Badruddin received funding for travel and speaker honoraria for the SVIN conference and to attend the SVIN roundtable summit. Dr. English served on the scientific advisory boards for Concentric Medical Inc.; served as a medical advisory board member of Co-Aaxia Inc. and eV 3 Inc.; served as an Associate Editor for Journal of Neuroimaging; was employed by Concentric Medical Inc. in 2008–2009, Co-Aaxia Inc. in 2008, and eV 3 Inc. in 2008; and has acted as an expert witness. Dr. Yavagal received an honorarium from Penumbra Inc. for consultation and speaking; serves as an Associate Editor for Frontiers in Endovascular Neurology; and serves as a consultant to Penumbra Inc., Codman Neurovascular, Micrus Inc., Genentech, and Boston Scientific. Dr. Kirmani served on the advisory board for Otsuka Pharmaceuticals; served as an Associate Editor for Frontiers in Clinical Trials in Neurology; received publishing royalties from Taylor and Francis Group for The Stroke Center Handbook; receives research support from Penumbra, Inc., and Genentech, Inc.; received research support from NIH/NINDS; and has served as expert witness for stroke cases. Dr. Alexandrov serves as an Associate Editor for Frontiers of Interventional Neurology. Dr. Khatri is on the Executive Committee of the IMS III Trial; is the Neurology PI of the Penumbra THERAPY Trial; has received research support from Genentech, Inc., for survey implementation; and served on the editorial boards of Frontiers in Endovascular and Interventional Neurology. Go to Neurology.org for full disclosures.

Authors

Affiliations & Disclosures

O.O. Zaidat, MD, MS
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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M.A. Lazzaro, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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D.S. Liebeskind, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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N. Janjua, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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L. Wechsler, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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R.G. Nogueira, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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R.C. Edgell, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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J.S. Kalia, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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A. Badruddin, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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J. English, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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D. Yavagal, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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J.F. Kirmani, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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A.V. Alexandrov, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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P. Khatri, MD
From the Departments of Neurology (O.O.Z., M.A.L.), Neurosurgery (O.O.Z.), and Radiology (O.O.Z.), Medical College of Wisconsin/Froedtert Hospital, Milwaukee; UCLA Stroke Center (D.S.L.), Los Angeles, CA; Department of Neurology, Asia Pacific Comprehensive Stroke Institute (N.J.), Pahoa, HI; Department of Neurology, University of Pittsburgh Medical Center (L.W.), PA; Emory University (R.G.N.), Atlanta, GA; St. Louis University (R.C.E.), St. Louis, MO; University of Illinois at Chicago/Provena St. Joseph Hospital (A.B. [Daniel M. Soref Clinical Neuroscience Fellow]), Chicago; Department of Neurology, University of California San Francisco (J.E.), San Francisco; University of Miami (D.Y.), Miami, FL; JFK Neuroscience Center (J.F.K.), Edison, NJ; Comprehensive Stroke Center, University of Alabama Hospital (A.V.A.), Birmingham; and University of Cincinnati (P.K.), Cincinnati, OH.
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Notes

Correspondence & reprint requests to Dr. Zaidat: [email protected]

Author Contributions

Dr. Zaidat: drafting/revising the manuscript, study concept or design, study supervision. Dr. Lazzaro: drafting/revising the manuscript, study concept or design, analysis or interpretation of data. Dr. Liebeskind: drafting/revising the manuscript, acquisition of data. Dr. Janjua: drafting/revising the manuscript, study concept or design. Dr. Wechsler: drafting/revising the manuscript, contribution of vital reagents/tools/patients, acquisition of data. Dr. Nogueira: study concept or design, analysis or interpretation of data. Dr. Edgell: drafting/revising the manuscript, analysis or interpretation of data. Dr. Kalia: drafting/revising the manuscript. Dr. Badruddin: drafting/revising the manuscript, contribution of vital reagents/tools/patients. Dr. English: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, contribution of vital reagents/tools/patients, acquisition of data, statistical analysis, study supervision, obtaining funding. Dr. Yavagal: drafting/revising the manuscript. Dr. Kirmani: drafting/revising the manuscript, study concept or design, analysis or interpretation of data. Dr. Alexandrov: drafting/revising the manuscript, acquisition of data. Dr. Khatri: study concept or design, study supervision.

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