DOI: 10.1161/strokeaha.123.042794 ISSN: 0039-2499

Association Between Recanalization Attempts and Functional Outcome After Thrombectomy for Large Ischemic Stroke

Laurens Winkelmeier, Tobias D. Faizy, Gabriel Broocks, Lukas Meyer, Christian Heitkamp, Caspar Brekenfeld, Christian Thaler, Paul Steffen, Maximilian Schell, Milani Deb-Chatterji, Uta Hanning, Helge Kniep, Máté E. Maros, Götz Thomalla, Jens Fiehler, Fabian Alexander Flottmann, Anna Alegiani, Jörg Berrouschot, Tobias Boeckh-Behrens, Georg Bohner, Jan Borggrefe, Albrecht Bormann, Michael Braun, Franziska Dorn, Bernd Eckert, Ulrike Ernemann, Marielle Ernst, Christian Gerloff, Klaus Gröschel, Gerhard F. Hamann, Jörg Hattingen, Karl-Heinz Henn, Fee Keil, Lars Kellert, Christoffer Kraemer, Ruben Mühl-Benninghaus, Jan Liman, Alexander Ludolph, Christian Nolte, Omid Nikoubashman, Martina Petersen, Gabor Petzold, Sven Poli, Arno Reich, Joachim Röther, Jan Hendrik Schäfer, Peter Schellinger, Eberhard Siebert, Florian Stögbauer, Steffen Tiedt, Christoph Trumm, Timo Uphaus, Silke Wunderlich, Sarah Zweynert
  • Advanced and Specialized Nursing
  • Cardiology and Cardiovascular Medicine
  • Neurology (clinical)


Recently, 3 randomized controlled trials provided high-level evidence that patients with large ischemic stroke achieved better functional outcomes after endovascular therapy than with medical care alone. We aimed to investigate whether the clinical benefit of endovascular therapy is associated with the number of recanalization attempts in extensive baseline infarction.


This retrospective multicenter study enrolled patients from the German Stroke Registry who underwent endovascular therapy for anterior circulation large vessel occlusion between 2015 and 2021. Large ischemic stroke was defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5. The study cohort was divided into patients with unsuccessful reperfusion (Thrombolysis in Cerebral Infarction score, 0–2a) and successful reperfusion (Thrombolysis in Cerebral Infarction score, 2b/3) at attempts 1, 2, 3, or ≥4. The primary outcome was favorable functional outcome defined as modified Rankin Scale score of 0 to 3 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage after 24 hours and death within 90 days. Multivariable logistic regression was used to identify independent determinants of primary and secondary outcomes.


A total of 348 patients met the inclusion criteria. Successful reperfusion was observed in 83.3% and favorable functional outcomes in 36.2%. Successful reperfusion at attempts 1 (adjusted odds ratio, 5.97 [95% CI, 1.71–24.43]; P =0.008) and 2 (adjusted odds ratio, 6.32 [95% CI, 1.73–26.92]; P =0.008) increased the odds of favorable functional outcome, whereas success at attempts 3 or ≥4 did not. Patients with >2 attempts showed higher rates of symptomatic intracranial hemorrhage (12.8% versus 6.5%; P =0.046). Successful reperfusion at any attempt lowered the odds of death compared with unsuccessful reperfusion.


In patients with large vessel occlusion and Alberta Stroke Program Early Computed Tomography Score of 3 to 5, the clinical benefit of endovascular therapy was linked to the number of recanalization attempts required for successful reperfusion. Our findings encourage to perform at least 2 recanalization attempts to seek for successful reperfusion in large ischemic strokes, while >2 attempts should follow a careful risk-benefit assessment in these highly affected patients.


URL: ; Unique identifier: NCT03356392.

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