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The ability of the current grading systems to predict optimal outcomes in stroke patients with favourable collaterals remains unexplored. We evaluated differences in the performance of grading systems between Careggi Collateral Score and ASITN/SIR collateral score to predict clinical and radiological outcomes in stroke patients with favourable collaterals who underwent thrombectomy. We included stroke patients receiving thrombectomy within 360 min after symptom onset with MCA occlusion and favourable collaterals (i.e., without poor collaterals) defined by ASITN/SIR collateral score between 2 and 4. Using ordinal regression, we estimated the association of each CCS and ASITN/SIR grade with mRS shift (0-6) at 3 months, NIHSS score (0-42) and ASPECT score (10-0) at baseline, TICI score (3-0), infarct growth, cerebral bleeding, and cerebral edema grading at 24 h by calculating the odds ratios (ORs) with two-sided 95% confidence intervals after adjustment for predefined variables. Using the best collateral grade (CCS = 4) as reference, ORs of the CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (2.325 for CCS = 3; 5.092 for CCS = 2), in the direction of more severe baseline NIHSS score (5.434 for CCS = 3; 16.041 for CCS = 2), 24-h infarct growth (2.659 for CCS = 3; 8.288 for CCS = 4) and 24-h cerebral edema (1.057 for CCS = 3; 5.374 for CCS = 2) shift. ORs of the ASITN/SIR grades were associated in the direction of more severe baseline NIHSS score (4.332 for ASITN/SIR = 3; 16.960 for ASITN/SIR = 2) and 24-h infarct growth (2.138 for ASITN/SIR = 3; 7.490 for ASITN/SIR = 2) shift. The AUC ROC of CCS and ASITN/SIR for predicting 3-month mRS score 0-1 were 0.681 (95% CI: 0.562-0.799; p = 0.009) and 0.599 (95% CI: 0.466-0.73; p = 0.156), respectively. CCS = 4 and ASITN/SIR ≥ 3 were the optimal cut-offs to predict 3-month mRS score 0-1, respectively. CCS grading system performed better than the ASITN/SIR collateral score predicting 3-month mRS score and 24-h CED grading in stroke patients with favourable collaterals who received thrombectomy for MCA occlusion.

We aimed to examine the association between Careggi Collateral Score (CCS) and radiological outcomes in a large multicenter cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA). We conducted a study on prospectively collected data from 1785 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA). Radiological outcomes at 24 h were the presence and severity of infarct growth defined by the absolute change in ASPECTS from baseline to 24 h; presence and severity of cerebral bleeding defined as no ICH, HI-1, HI-2, PH-1, or PH-2; presence and severity of cerebral edema (CED) defined as no CED, CED-1, CED-2, or CED-3. Using CCS = 0 as reference, ORs of CCS grades were significantly associated in the direction of better radiological outcome on infarct growth (0.517 for CCS = 1, 0.413 for CCS = 2, 0.358 for CCS = 3, 0.236 for CCS = 4), cerebral bleeding grading (0.485 for CCS = 1, 0.445 for CCS = 2, 0.400 for CCS = 3, 0.379 for CCS = 4), and CED grading (0.734 for CCS = 1, 0.301 for CCS = 2, 0.295 for CCS = 3, 0.255 for CSS = 4) shift in ordinal regression analysis after adjustment for pre-defined variables (age, NIHSS score, ASPECTS, occlusion site, onset-to-groin puncture time, procedure time, and TICI score). Using CCS = 4 as reference, ORs of CCS grades were significantly associated in the direction of worse radiological outcome on infarct growth (1.521 for CCS = 3, 1.754 for CCS = 2, 2.193 for CCS = 1, 4.244 for CCS = 0), cerebral bleeding grading (2.498 for CCS = 0), and CED grading (1.365 for CCS = 2, 2.876 for CCS = 1, 3.916 for CCS = 0) shift. The CCS could improve the prognostic estimate of radiological outcomes in patients receiving thrombectomy for stroke with MCA occlusion.