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International Journal of Stroke 19(1)
Figure 2. Prevalence of no-reflow stratified by macrovascular reperfusion score. TICI: thrombolysis in cerebral infarction. When
stratified across the TICI scale, no-reflow prevalence rates were very high in the TICI2b subgroup (55%, 95% CI, 45-66%), being
more than double the rates observed in the TICI2c (21%, 95% CI, 15-27%) and TICI3 subgroups (24%, 95% CI, 0-41%).
reperfusion across time. Most recent studies used the TICI
scale as it has become an accepted convention for grading
macrovascular reperfusion. However, evaluating noreflow
in patients who achieved 50% macrovascular reperfusion
of the target territory (i.e. patients with TICI2b)
might be ineffective, as these patients are expected to
have a substantial perfusion deficit due to incomplete
macrovascular reperfusion.36 In those cases, perfusion
abnormalities observed on the follow-up imaging are true
persistent macrovascular perfusion deficits. They do not
provide evidence of a mismatch between macro- and
microvascular reperfusion (i.e. no evidence of no-reflow),
as there is hypoperfusion on both the macro- and microvascular
level.36 This would explain why higher rates of
no-reflow were observed in patients with lower TICI
scores (e.g. TICI2b vs 2c-3). Even in cases of near-complete
reperfusion (TICI2c), the hypoperfusion observed
on the follow-up perfusion imaging may just correspond
to non-reperfused distal vessel occlusion and, again,
would not be evidence of true no-reflow.36
The optimal approach would be to evaluate no-reflow
only in patients with complete reperfusion (TICI3). Ideally,
TICI grading would be performed by an independent
International Journal of Stroke, 19(1)
core-lab, as treating physicians tend to overestimate the
extent of reperfused tissue in acute care settings.37 A corelab
would be able to evaluate reperfusion success impartially
and, in patients graded as TICI3 by the core-lab, any
findings of microvascular hypoperfusion could not be
explained by the presence of distal occlusions and would
therefore represent true no-reflow. The most frequently
cited causes of bad outcome despite successful macrovascular
reperfusion are large initial infarct core
(ASPECTS < 5) and hemorrhagic transformation after the
intervention.3,4 However, once factors known to be associated
with bad outcome are excluded or accounted for, presence
of no-reflow in TICI3 patients could also inform
reasons for not achieving functional independence despite
complete macrovascular reperfusion.38
Functional independence and no-reflow
We found a strong positive association between the presence
of no-reflow and lower rates of functional independence
after the index event. Point estimates seemed
consistent across all subgroup analyses that reported rates
of tissue hypoperfusion.

WSO - January 2024

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WSO - January 2024 - Cover3
WSO - January 2024 - Cover4
https://europe.nxtbook.com/nxteu/sageuk/wso_202404
https://europe.nxtbook.com/nxteu/sageuk/ukstrokeforum_202402_supp
https://europe.nxtbook.com/nxteu/sageuk/wso_202403
https://europe.nxtbook.com/nxteu/sageuk/wso_202402
https://europe.nxtbook.com/nxteu/sageuk/wso_202401
https://europe.nxtbook.com/nxteu/sageuk/wso_2023123_US_UKOnly
https://europe.nxtbook.com/nxteu/sageuk/wso_2023123_ROW
https://europe.nxtbook.com/nxteu/sageuk/wso_2023101
https://europe.nxtbook.com/nxteu/sageuk/wso_202308
https://europe.nxtbook.com/nxteu/sageuk/wso_202307
https://europe.nxtbook.com/nxteu/sageuk/wso_202306
https://europe.nxtbook.com/nxteu/sageuk/wso_202304
https://europe.nxtbook.com/nxteu/sageuk/wso_202303
https://europe.nxtbook.com/nxteu/sageuk/wso_202302
https://europe.nxtbook.com/nxteu/sageuk/wso_202301
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