Predictors of futile recanalization in completely recanalized middle cerebral artery occlusions: multicenter study

 Absolutely useless; provided NO PROTOCOLS that address these futile recanalization problems!  Are your incompetent? mentors and senior researchers  THAT BLITHERINGLY STUPID?

Predictions are invariably useless unless they direct you to EXACT PROTOCOLS that fix the problem!

Predictors of futile recanalization in completely recanalized middle cerebral artery occlusions: multicenter study

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  Zülfikar Memiş 1†

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  Erdem Gürkaş 2†

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  Atilla Özcan Özdemir 3†

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  Bilgehan Atılgan Acar 4† *

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  Muhammed Nur Ögün 5†

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  Emrah Aytaç 6†

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  Çetin Kürşad Akpınar 7†

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  Ayşenur Önalan 2†

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• Ü

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  Talip Asil 24†

• 1. Prof. Dr. Cemil Tascioglu City Hospital, Department of Neurology, Istanbul, Türkiye

• 2. Department of Neurology, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye

Abstract

Background: 

Endovascular thrombectomy (EVT) improves outcomes and reduces mortality in acute ischemic stroke. However, despite achieving successful recanalization in most patients, a subset still experiences poor functional outcomes at 3 months(Well, you idiots are not doing anything to stop 

the neuronal cascade of death in the first week and you don't know about that? The absolute stupidity in stroke is world class!)

. This failure, despite complete vessel reopening, is termed futile recanalization (FR). We investigated clinical and radiological predictors of FR in a multicenter cohort in Türkiye.

Methods: 

We retrospectively analyzed 497 consecutive patients with middle cerebral artery (M1 or M2) occlusion who underwent EVT and achieved modified Thrombolysis in Cerebral Infarction (mTICI) 3 recanalization within 6 h of symptom onset at 19 stroke centers. FR was defined as a modified Rankin Scale (mRS) score ≥4 at 3 months. Clinical and radiological parameters were recorded, and logistic regression was used to identify independent predictors of FR.

Results: 

Among 497 patients, 133 (26.7%) experienced FR despite complete recanalization. Independent predictors included older age (adjusted odds ratio [aOR] 1.07; 95% CI 1.03–1.10; p < 0.001), longer puncture-to-recanalization time (aOR 1.03; 95% CI 1.02–1.05; p < 0.001), higher admission C-reactive protein (aOR 1.01; 95% CI 1.00–1.02; p = 0.03), intracranial hemorrhage on 24-h CT (aOR 0.46; 95% CI 0.23–0.95; p = 0.04), lower collateral score (aOR 42.98; 95% CI 6.15–30.62; p < 0.001), and higher 24-h NIHSS score (aOR 1.34; 95% CI 1.24–1.44; p < 0.001).

Conclusion: 

Even with early and complete recanalization, elderly patients and those with poor collateral circulation remain at risk for futile recanalization. Identifying these predictors can guide patient selection, procedural planning, and post-procedural management to optimize functional outcomes.

1 Introduction

Stroke is a global health problem and a leading cause of mortality and long-term disability worldwide (1). The advent of reperfusion therapy has revolutionized the management of acute ischemic stroke (AIS), providing significant benefits to those affected.

Endovascular thrombectomy (EVT) has been shown to improve outcomes for up to a 24-h time window in selected patients with AIS due to large vessel occlusion, providing significant benefits, including reduced long-term functional disability and mortality (2). However, despite advances such as EVT, functional outcomes remain suboptimal for a significant proportion of patients, even after achieving complete recanalization (3). This phenomenon, referred to as futile recanalization (FR), describes cases where successful vessel reopening does not translate into meaningful clinical recovery. Identifying and understanding the determinants of FR is therefore a critical unmet need in stroke research (4). Although the term FR remains a matter of debate, it is usually used to describe cases with mRS score ≥4 at 3 months, in accordance with prior literature. This threshold was deliberately chosen to exclude patients with mRS 3, who may still maintain ambulatory capacity and acceptable quality of life (5, 6).

FR is a multifactorial and complex process, and currently, the underlying mechanisms and prevention methods are still not clearly known. Investigating the risk factors associated with FR has important clinical implications, as it may improve patient selection, optimize treatment strategies, and prevent unnecessary interventions. Current relevant research results indicate that stroke severity, age, pre-stroke disability, prehospital duration, blood glucose level, comorbidities, gender, National Institutes of Health Stroke Scale (NIHSS) score, and Alberta Stroke Program Early Computed Tomography Score (ASPECTS) are associated factors for ineffective recanalization in patients who achieved satisfactory reperfusion after EVT treatment (6–9).

Nevertheless, heterogeneity in patient selection across studies has contributed to conflicting findings. While outcomes after complete recanalization [thrombolysis in cerebral infarction (TICI) 3] are consistently superior to those after incomplete recanalization (TICI 2b), it remains unclear whether this advantage is uniform across different patient subgroups (10, 11). This knowledge gap underscores the need for further investigation into which patients are most likely to benefit from successful EVT.

The present study therefore focuses specifically on patients with large vessel occlusion of the middle cerebral artery (MCA M1 or M2), aged 18–80 years, treated within 6 h of symptom onset, and achieving complete recanalization (TICI 3). By narrowing the inclusion criteria to this well-defined cohort, we aim to identify precise predictors of FR, thereby providing evidence that may guide clinical decision-making and enhance the effectiveness of EVT in real-world practice.

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