Sequential decision-making in endovascular stroke therapy: benefit and harm of the next retrieval attempt after failed reperfusion

@article{meucci2026sequential,
  title = {{Sequential decision-making in endovascular stroke therapy: benefit and harm of the next retrieval attempt after failed reperfusion}},
  author = {Luca Meucci and Lukas Meyer and Gabriel Broocks and Matthias Bechstein and Christian Thaler and Christian Heitkamp and Laurens Winkelmeier and Vincent Geest and Alexander Heitkamp and Gregor Peter and Felix Schlicht and Caspar Brekenfeld and Máté E. Maros and Maximilian Schell and Maxim Bester and Götz Thomalla and Jens Fiehler and Susanne Gellißen and Fabian Flottmann and Helge C. Kniep},
  journal = {Neurological Research and Practice},
  year = {2026},
  month = oct,
  doi = {10.1186/s42466-026-00543-y},
  url = {https://doi.org/10.1186/s42466-026-00543-y},
  note = {CC BY 4.0},
}

TY  - JOUR
TI  - Sequential decision-making in endovascular stroke therapy: benefit and harm of the next retrieval attempt after failed reperfusion
AU  - Luca Meucci
AU  - Lukas Meyer
AU  - Gabriel Broocks
AU  - Matthias Bechstein
AU  - Christian Thaler
AU  - Christian Heitkamp
AU  - Laurens Winkelmeier
AU  - Vincent Geest
AU  - Alexander Heitkamp
AU  - Gregor Peter
AU  - Felix Schlicht
AU  - Caspar Brekenfeld
AU  - Máté E. Maros
AU  - Maximilian Schell
AU  - Maxim Bester
AU  - Götz Thomalla
AU  - Jens Fiehler
AU  - Susanne Gellißen
AU  - Fabian Flottmann
AU  - Helge C. Kniep
PY  - 2026
DA  - 2026/10/26
JO  - Neurological Research and Practice
DO  - 10.1186/s42466-026-00543-y
UR  - https://doi.org/10.1186/s42466-026-00543-y
AB  - Background: After failed reperfusion in endovascular thrombectomy (EVT), interventionalists must outweigh the expected benefit of an additional retrieval attempt with the outcome of the current angiographic result. Framing EVT as an infinite-horizon optimal stopping problem, the present study provides a per-pass evaluation of the expected benefit of EVT continuation versus procedural termination after unsuccessful reperfusion, based on large-scale real-world registry data.  Methods: Patients from the German Stroke Registry – Endovascular Treatment (GSR-ET) between 2015 and 2023 were screened. Inclusion criteria were (1) age ≥ 18 years, (2) anterior circulation LVO, (3) 1–15 retrieval attempts and (4) availability of relevant clinical data. Primary endpoint was the rate of good functional outcome, defined as modified Rankin Scale (mRS) score 0–2 at 90 days. For each retrieval attempt, patients were stratified into successful reperfusion (mTICI 2b–3) and persistent occlusion (mTICI 0–2a). The net expected benefit of EVT continuation, Δ(k), was defined as the difference between the mRS 0–2 rate at pass k + 1, and the mRS 0–2 rate for unsuccessful reperfusion at pass k. A positive Δ(k) indicates that continuation is favored at that decision node k. The pass at which Δ(k) first becomes non-significant identifies the empirical, optimal stopping threshold.  Results: Among 9,495 included patients, successful reperfusion (mTICI 2b–3) was achieved in 8,405 (89%), and 3,428 (36%) achieved good functional outcome at 90 days. Up to six retrieval attempts, Δ(k) was positive and statistically significant (p < 0.05), indicating that continuation of EVT was associated with superior expected outcome at each of these decision points. At pass seven, Δ(k) became negative and lost statistical significance (p = 0.53), identifying this as the empirical optimal stopping threshold.  Conclusion: Continuation of EVT up to six retrieval attempts confers a significant functional benefit over termination after unsuccessful reperfusion. These findings provide a decision-theoretic basis for individualized intraprocedural decision-making and suggest that functional independence can be achieved beyond conventionally assumed pass thresholds.  Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s42466-026-00543-y.
SN  - 2524-3489
ER  -