Thrombolysis in Cerebral Infarction Grade 2C or 3 Represents a Better Outcome than 2B for Endovascular Thrombectomy in Acute Ischemic Stroke: A Network Meta-Analysis

World Neurosurg. 2020 Apr;136:e419-e439. doi: 10.1016/j.wneu.2020.01.020. Epub 2020 Jan 10.


Background: Although Thrombolysis in Cerebral Infarction (TICI) grade 2B or 3 is considered successful after endovascular thrombectomy (EVT) for acute ischemic stroke, TICI 2B was found to be associated with poorer outcomes than was 3. Furthermore, the newly proposed TICI 2C grade seems to be clinically equivalent to TICI 3 rather than to 2B. This network meta-analysis aimed to assess the differences in clinical outcomes between TICI grades and redefine successful reperfusion.

Methods: PubMed, Embase, and Cochrane Central Register were queried. A random-effect model with frequentist framework was applied to evaluate outcomes using odds ratios (ORs) and 95% confidence intervals (CIs). Using surface under the cumulative ranking curve (SUCRA), the hierarchy of TICI grades was indicated.

Results: Analysis of 12 studies, with 2084 patients, indicated that TICI 2C (OR, 2.28; 95% CI, 1.65-3.13) and 3 (OR, 2.40; 95% CI, 1.74-3.30) were significantly more associated with favorable 90-day clinical outcomes than were 2B; there was no significant difference between TICI 2C and 3 (OR, 1.05; 95% CI, 0.76-1.46). Based on the SUCRA, TICI 2C and 3 were considered as more effective reperfusion end points than was 2B (TICI 3, 80.8%; 2C, 69.2%; 2B, 0.0%) and showed significant association with lower rates of mortality and symptomatic intracranial hemorrhage.

Conclusions: Patients with TICI 2C grade would be distinguished from those with 2B, because 2C is clinically equivalent to 3 and has a better outcome than 2B. Therefore, achieving 2C or 3 is likely to be closer to the successful aim of endovascular thrombectomy in acute ischemic stroke than achieving 2B.

Keywords: Acute ischemic stroke; Endovascular thrombectomy; Network meta-analysis; Thrombolysis in Cerebral Infarction grade.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Aged
  • Brain Ischemia / mortality
  • Brain Ischemia / therapy*
  • Cerebral Infarction / mortality
  • Cerebral Infarction / therapy*
  • Cerebral Revascularization / methods
  • Cerebral Revascularization / mortality
  • Endovascular Procedures / methods*
  • Endovascular Procedures / mortality
  • Female
  • Humans
  • Male
  • Middle Aged
  • Network Meta-Analysis
  • Stroke / mortality
  • Stroke / therapy*
  • Thrombectomy / methods*
  • Thrombectomy / mortality
  • Thrombolytic Therapy / methods*
  • Treatment Outcome