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    Area of Science:

    • Neurology
    • Interventional Radiology
    • Medical Imaging

    Background:

    • Successful endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) does not always restore functional independence.
    • No-reflow, characterized by poor perfusion despite large vessel occlusion (LVO) recanalization, is a key factor contributing to this disparity.
    • Current methods for assessing no-reflow lack standardization and face challenges in differentiating it from other hemodynamic issues and accounting for temporal dynamics.

    Purpose of the Study:

    • To explore the impact of time since EVT on the performance of various no-reflow assessment methods.
    • To evaluate the agreement and reliability of different no-reflow detection techniques at different time points post-EVT.

    Main Methods:

    • A cohort of UCLA Health patients with successful LVO recanalization (≥ mTICI 2b) in M1 or ICA segments were analyzed.
    • Patients were divided into early (<24 hours) and follow-up (<48 hours) cohorts post-EVT.
    • Published perfusion imaging methods for no-reflow detection were adapted for semi-automatic application in both cohorts.

    Main Results:

    • No-reflow rates varied widely (4.2%–51.4%) depending on the method, time since EVT, and mTICI score.
    • Follow-up assessments aligned more closely with existing literature compared to early assessments.
    • Inter-method agreement was poor in the early cohort (kappa as low as -0.017) but improved significantly in the follow-up cohort (up to 0.72).
    • No-reflow rates decreased by approximately 50% for mTICI 2c/3 cases compared to mTICI 2b, suggesting mTICI 2b may inflate no-reflow rates.

    Conclusions:

    • No-reflow assessment is highly time-dependent, influencing the performance of all evaluated detection methods.
    • While methods using similar perfusion parameters show good agreement, confounding factors necessitate robust, potentially aggregate, evaluation approaches.
    • The temporal dynamics of no-reflow detection raise critical questions regarding optimal imaging timing post-EVT for timely intervention.