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Observational Study
. 2025 Jul 11;272(8):504.
doi: 10.1007/s00415-025-13235-5.

Key to better outcomes in stroke intervention: early versus complete reperfusion in first pass recanalization

Alexander Heitkamp #  1 , Sophie-Maria Hierholzer #  2 , Christian Heitkamp  2 , Laurens Winkelmeier  2 , Lukas Meyer  2 , Matthias Bechstein  2 , Vincent Geest  2 , Gabriel Broocks  3 , Caspar Brekenfeld  2 , Fabian Flottmann  2 , Maximilian Schell  4 , Götz Thomalla  4 , Tobias Faizy  5 , Jens Fiehler  2 , Helge C Kniep #  2 , Susanne Gellißen #  2 ; German Stroke Registry -Endovascular Treatment (GSR-ET)
Affiliations
Observational Study

Key to better outcomes in stroke intervention: early versus complete reperfusion in first pass recanalization

Alexander Heitkamp et al. J Neurol. .

Abstract

Background and purpose: First pass (FP) recanalization, defined as achieving mTICI 2b or higher in a single thrombectomy attempt, has been linked to better functional recovery in acute ischemic stroke patients. This study aimed to investigate whether the benefits of FP are primarily driven by higher rates of complete reperfusion (mTICI 3) or by faster procedure times.

Methods: Data from 3707 patients with middle cerebral artery occlusion and successful recanalization (mTICI 2b or higher) were extracted from the prospectively designed German Stroke Registry (2015-2021). Good functional outcomes were defined as a modified Rankin Scale (mRS) score of ≤ 2 at 90 days. Mediation analysis was used to evaluate the extent to which complete reperfusion (mTICI 3) and shorter groin puncture to recanalization time contributed to improved outcomes.

Results: FP recanalization was associated with significantly better functional outcomes: 46.9% of FP patients achieved an mRS ≤ 2 compared to 37.2% in the multi-pass group. Mediation analysis showed that only 14% of the improved outcomes with FP were explained by higher mTICI 3 rates, while 37% were attributed to faster recanalization times.

Conclusion: The improved outcomes associated with FP recanalization are primarily driven by the speed of reperfusion rather than the degree of complete recanalization. This highlights the importance of minimizing procedure times and the number of thrombectomy attempts. Strategies aimed at optimizing treatment workflows and improving device design to prioritize early and efficient reperfusion after the FP are critical to improving patient outcomes (ClinicalTrials.gov identifier: NCT03356392).

Keywords: First pass; Ischemic stroke; Mechanical thrombectomy; Mediation analysis; mTICI.

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Conflict of interest statement

Declarations. Conflicts of interest: The authors declare that they have no conflict of interest. Ethical approval: This study was performed in line with the principles of the Declaration of Helsinki. Ethical approval was obtained from the ethics committee of the Ludwig Maximilian University in Munich, Germany (689-15), and local ethics committees of each participating center approved the contribution of fully anonymized data to the registry. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Figures

Fig. 1
Fig. 1
Flow chart of patient inclusion and exclusion criteria. Abbreviations: EVT, Endovascular Thrombectomy; NIHSS, National Institutes Health Stroke Scale; ASPECTS, Alberta Stroke Program Early CT Score; mRS, modified Rankin Scale; ACA, Anterior Cerebral Artery; ICA, Internal Carotid Artery; MCA, Middle Cerebral Artery; BA, Basilar Artery; VA, Vertebral Artery; PCA, Posterior Cerebral Artery; M1-occlusion, first segment middle cerebral artery occlusion; M2-occlusion, second segment middle cerebral artery occlusion; mTICI, modified thrombolysis in cerebral infarction. aMultipe selection of patients possible
Fig. 2
Fig. 2
Logistic (a, b) and linear (c) multivariable regression model results. Multivariable regression models of (adjusted) odds ratios and 95% confidence interval in multivariable and linear logistic regression models of relevant predictors for a good functional outcome and b complete recanalization and c time groin puncture to recanalization (min). Abbreviations: NIHSS, National Institutes Health Stroke Scale; ASPECTS, Alberta Stroke Program Early CT Score; pmRS, premorbid modified Rankin Scale; CI, confidence interval; Ate, adverse treatment event
Fig. 3
Fig. 3
Mediation layout Model A (Mediator mTICI 3 vs. 2b) and Model B (Mediator groin puncture to recanalization time). Schematic model overview of the mediaton analysis, a mediator full recanalization, b mediator time groin puncture to recanalization. Abbreviations: NIHSS, National Institutes Health Stroke Scale; ASPECTS, Alberta Stroke Program Early CT Score; mRS, modified Rankin Scale; Iv thrombolysis, intravenous thrombolysis; FP first pass; mTICI modified thrombolysis in cerebral infarction
See this image and copyright information in PMC

References

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