Clinical impact of the first pass effect on clinical outcomes in patients with near or complete recanalization during mechanical thrombectomy for large vessel ischemic stroke

Background and Purpose The first pass effect has been reported as a mechanical thrombectomy (MT) success metric in patients with large vessel occlusive stroke. We aimed to compare the clinical and neuroimagign outcomes of patients who had favorable recanalization (mTICI 2c or mTICI 3) achieved in one pass versus those requiring multiple passes. Methods In this “real‐world” multicenter study, patients with mTICI 2c or 3 recanalization were identified from three prospectively collected stroke databases from January 2016 to December 2019. Clinical outcomes were a favorable functional outcome at 90 days (modified Rankin Scale score 0–2), and the rate of symptomatic intracranial hemorrhage (ICH) any ICH, and 90‐day mortality. Results Favorable recanalization was achieved in 390/664 (59%) of consecutive patients who underwent MT (age 71.2 ± 13.2 years, 188 [48.2%] women). This was achieved after a single thrombectomy pass (n = 290) or multiple thrombectomy passes (n = 100). The rate of favorable clinical outcome was higher (41% vs. 28 %, p = .02) in the first pass group with a continued trend on multivariate analysis that did not reaching statistical significance (OR 1.68 95% confidence interval [CI] 1.0–2.95, p = .07). Similarly, the odds of any ICH were significantly lower (OR 0.56 CI 0.32–0.97, p = .03). A similar trend of favorable clinical outcomes was noticed on subgroup analysis of patients with M1 occlusion (OR 1.81 CI 1.01–3.61, p = .08). Conclusion The first‐pass reperfusion was associated with a trend toward favorable clinical outcome and lower rates of ICH. These data suggest that the first‐pass effect should be the mechanical thrombectomy procedure goal.