Complete Sudden Recanalization: There Is Hope Beyond the First Pass Effect

In the endovascular treatment of stroke, achieving complete recanalization in a minimum number of attempts is the main procedural objective. We aimed to explore the effect of the per pass recanalization pattern in patients with final complete recanalization.

We analyzed all patients admitted in our center from 2014 to 2022 with a terminal internal carotid artery or M1-middle cerebral artery occlusion who received endovascular treatment and achieved complete recanalization (expanded thrombolysis in cerebral infarction 2c-3) in our center. Complete sudden recanalization (cSR) was considered when expanded thrombolysis in cerebral infarction improved from 0-1 to 2c-3 in a single pass as opposed to complete progressive recanalization when partial recanalization (2a or 2b) was observed after interim passes.

Among the 400 included patients with final complete recanalization, 301 (75%) showed a cSR pattern. There were no differences in baseline demographic characteristics between patients with cSR and complete progressive recanalization, including intravenous tissue plasminogen activator treatment (42.2% versus 44.4%; P=0.69). The rate of terminal carotid artery occlusion (28.6% versus 44.4%; P=0.003), median number of passes (1 [interquartile range 1-2] versus 2 [2-3]; P<0.001), and time from puncture to recanalization (27 [interquartile range 18-43] versus 46 [34-66] minutes; P<0.001) were lower in cSR group. At 90 days cSR was an independent predictor of good functional outcome (57.8% versus 44.4%, adjusted odds ratio 1.72 [CI 95% 1.03-2.88]; P=0.038). The rate of favorable outcome did not decrease with additional passes as long as cSR was observed (cSR after pass 1: 57.6%, after pass 2: 55.6%, after >2 passes: 63.6%; P=0.825).

Among stroke patients with a large vessel occlusion, the cSR pattern predicted favorable outcome independently of the number of thrombectomy passes.