Parametric color-coding-derived microvascular transit time may predict infarction and reveals microcirculatory benefits of Tenecteplase in acute ischemic stroke.

BACKGROUND

Despite successful macrovascular recanalization a subset of patients with a large vessel occlusion (LVO) have persisting microvascular occlusion, known as the" no-reflow-phenomenon." In this study, we evaluated whether microvascular transit time (mTT), derived from parametric color-coding (PCC) of digital subtraction angiography (DSA) images, can serve as a tool to quantify impaired cerebral microcirculation and to assess its association with infarction. In a second step, we evaluated whether Tenecteplase (TNK), the new primary thrombolytic agent, improves microcirculatory flow compared to Alteplase (rtPA).

METHODS

We retrospectively analyzed 160 (110 received rtPA; 50 received TNK) presenting with anterior circulation LVO who achieved successful macrovascular recanalization (defined as TICI ≥2b). Microvascular flow was quantified using syngo iFLOW software where mTT was defined as the time from peak opacification between cortical regions and the superior sagittal sinus. Patients were stratified based on infarction presence (infarction vs. no infarction) and thrombolytic treatment (TNK vs. rtPA).

RESULTS

Prolonged mTT was significantly associated with infarction compared to non-infarcted regions (3.01 s; IQR: 2.40-3.46) vs. 2.58 s (IQR: 2.13-3.01, p = 0.002). An mTT threshold of >2.857 s was identified as the optimal cutoff for predicting infarction. When stratified by treatment, patients receiving TNK had significantly shorter mean mTT than those treated with rtPA, both in the infarct group (TNK: 2.57 s; IQR 2.10-3.04 vs. rtPA: 3.02 s; IQR: 2.49-3.63, p = 0.034) and the no-infarct group (TNK: 2.22 s; IQR: 1.87-2.74 vs. rtPA: 2.84 s; IQR: 2.4-3.27, p < 0.001).

CONCLUSION

Intra-procedural flow analysis using mTT performed directly in the angio suite may be a predictor of subsequent infarction following EVT. Moreover, Tenecteplase is associated with superior microvascular circulation times compared to Alteplase, supporting its potential benefit as a preferred thrombolytic agent in acute ischemic stroke.