Delayed Neurological Improvement After Full Endovascular Reperfusion in Acute Anterior Circulation Ischemic Stroke

Talavera, Blanca; Gómez‐Vicente, Beatriz; Martínez‐Galdámez, Mario; López‐Cancio, Elena; García-Cabo, Carmen; Roel, Alexia; Meza, H. Tejada; Marta-Moreno, Javier; Pérez-Lázaro, C; Navarro-Pérez, María Pilar; Bravo-Anguiano, Yolanda; Bártulos-Iglesias, Mónica; Tejada-García, J.; Rodrigo-Stevens, Gabriela; Martínez-Zabaleta, Maite; Riva, Patricia de la; Timiraos-Fernández, Juan José; Freijo, María Del Mar; Luna, Alain; García-Sánchez, Juan Manuel; Gil-Alzueta, María Del Carmen; Palacio-Portilla, E.J.; Jiménez-López, Yesica; López-Mesonero, Luis; Redondo-Robles, L.; Mayo-Íscar, Agustín; Arenillas, Juan F.; Investigators, Nordictus

doi:10.1161/strokeaha.120.032066

Cited by 13 publications

(13 citation statements)

References 23 publications

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“…Recent studies suggest that better neurological status at admission, male sex, and intravenous thrombolysis might increase probability of delayed neurological improvement. 11 Our subgroup analysis confirms these results and furthermore underlines the relevance of comorbidities such as diabetes, hypertension, dyslipidemia, and atrial fibrillation. Results suggest that these factors are not fully apparent in the early neurological status and might impact the course of the neurological recovery.…”

Section: Discussionsupporting

confidence: 83%

How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge?

Kniep

Meyer

Bechstein

et al. 2022

Stroke

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Background: Early neurological status has been described as predictor of functional outcome in patients with anterior circulation stroke after mechanical thrombectomy. It remains unclear to what proportion the improvement of functional outcome at day 90 is already apparent at 24 hours and at hospital discharge and how later factors impact outcome. Methods: All patients enrolled in the German Stroke Registry (June 2015–December 2019) with anterior circulation stroke and availability of baseline data and neurological status were included. A mediation analysis was conducted to investigate the effect of successful recanalization (Thrombolysis in Cerebral Infarction scale score ≥2b) on good functional outcome (modified Rankin Scale score ≤2 at day 90) with mediation through neurological status (National Institutes of Health Stroke Scale [NIHSS] at 24 hours and at hospital discharge). Results: Three thousand fifty-seven patients fulfilled the inclusion criteria, thereof 2589 (85%) with successful recanalization and 1180 (39%) with good functional outcome. In a multivariate logistic regression analysis, probability of good outcome was significantly associated with age (odds ratio [95% CI], 0.95 [0.94–0.96]), prestroke modified Rankin Scale (0.48 [0.42–0.55]), admission-NIHSS (0.96 [0.94–0.98]), 24-hour NIHSS (0.83 [0.81–0.84]), diabetes (0.56 [0.43–0.72]), proximal middle cerebral artery occlusions (0.78 [0.62–0.97]), passes (0.88 [0.82–0.95]), Alberta Stroke Program Early CT Score (1.07 [1.00–1.14]), successful recanalization (2.39 [1.68–3.43]), intracerebral hemorrhage (0.51 [0.35–0.73]), and recurrent strokes (0.54 [0.32–0.92]). Mediation analysis showed a 20 percentage points (95% CI‚ 17–24 percentage points) increase of probability of good functional outcome after successful recanalization. Fifty-four percent (95% CI‚ 44%–66%) of the improvement in functional outcome was explained by 24-hour NIHSS and 75% (95% CI‚ 62%–90%) by NIHSS at hospital discharge. Conclusions: Fifty-four percent of the improvement in functional outcome after successful recanalization is apparent in NIHSS at 24 hours, 75% in NIHSS at hospital discharge. Other unknown factors not apparent in NIHSS at the 2 time points investigated account for the remaining effect on long term outcome, suggesting, among others, clinical relevance of delayed neurological improvement and deterioration. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03356392.

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Section: Discussionsupporting

confidence: 83%

How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge?

Kniep

Meyer

Bechstein

et al. 2022

Stroke

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“…Nonetheless, one quarter of these patients still achieves favourable functional outcome at 90 days follow-up [25][26][27]. Recent analyses suggest that better neurological status at admission, male sex and administration of IVT might increase probability of delayed neurological improvement in ACS [25].…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies focusing on ACS observed that approximately one quarter of patients experiences no early clinical improvement after successful recanalization. Nonetheless, one quarter of these patients still achieves favourable functional outcome at 90 days follow‐up [25‐27]. Recent analyses suggest that better neurological status at admission, male sex and administration of IVT might increase probability of delayed neurological improvement in ACS [25].…”

Section: Discussionmentioning

confidence: 99%

Early surrogates of outcome after thrombectomy in posterior circulation stroke

Kniep¹,

Bechstein²,

Broocks³

et al. 2022

Euro J of Neurology

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Background Early surrogates for functional outcome in anterior circulation stroke have been described with the National Institute of Health Stroke Scale (NIHSS) at 24 h being reported as the most accurate metric. We compare discriminatory power of established definitions of early neurological improvement (ENI) and NIHSS scores at admission and 24 h to predict functional outcome at 90 days after thrombectomy in posterior circulation stroke (PCS). Methods All patients enrolled in the German Stroke Registry (June 2015–December 2019) with PCS and at least vertebral or basilar artery occlusions were included. NIHSS admission, 24 h and ENI definitions (improvement of 8/10 NIHSS points or 0/1 NIHSS points at 24 h) were compared for predicting functional outcome at 90 days. Favourable and good outcome were defined as modified Rankin Scale (mRS) 0–2 and 0–3. Multivariable logistic regression analysis was conducted to identify factors impairing predictive power. Results Three hundred and eighty‐seven patients were included. NIHSS 24 h had the highest discriminative power with receiver operator characteristics area under the curve of 0.87 (95% confidence interval: 0.83; 0.90) for good and 0.89 (0.85; 0.92) for favourable outcome; optimal cut‐off values were ≤9 and ≤5. Higher age (odds ratio = 1.10 [1.05; 1.16]), adverse events during treatment (9.46 [1.52; 72.5]) and until discharge (18.34 [2.33; 172]) and high NIHSS scores at 24 h (1.29 [1.10; 1.53]) were independent predictors for turning the outcome prognosis from good (mRS ≤3) to poor (mRS ≥4). Conclusions NIHSS 24 h ≤9 points serves best as surrogate for good functional outcome after thrombectomy in PCS. Advanced age, severe neurological symptoms at admission and adverse events decrease its predictive value.

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“…An increase by 4 or more points of NIHSS score was indicative of END. In patients who underwent rescue EVT, ENI and END were defined as improvement and worsening, respectively, of NIHSS score by more than 4 points after EVT in comparison with scores immediately before EVT [16]. All patients were clinically monitored until day 90 after EVT.…”

Section: Outcome Variablesmentioning

confidence: 99%

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

Ryu

Bae

et al. 2022

Cerebrovasc Dis

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Background and Purpose: Endovascular thrombectomy (EVT) has benefits in selected patients 6–24 h after stroke onset. However, the response to EVT >24 h after stroke onset is still unclear. We compared the early response to EVT in patients with different time windows. Methods: Patients who underwent EVT in an emergency setting were enrolled and categorized according to when EVT was performed: within 6 (early), 6–24 (late), and >24 h (very late) after stroke onset. Early neurological improvement (ENI) and deterioration (END) were defined as improvement and worsening, respectively, of National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points after EVT. The three groups’ clinical characteristics and response to EVT were compared. We also investigated factors associated with ENI and END. Results: During study period, 274 patients underwent EVT (109 early, 104 late, and 61 very late). Patients who underwent EVT very late were younger (p = 0.007), had smaller ischemic cores, and had lower initial NIHSS scores (8 ± 5) than those who underwent EVT early (14 ± 6) and late (13 ± 7; p < 0.001). Stroke mechanisms also differed according to the time window (p < 0.001): cardioembolism was more common after early EVT, whereas large-artery atherosclerosis was more prevalent among patients who underwent EVT very late. ENI was significantly more common after early (60.6%) and late EVT (51.0%) than after very late EVT (29.5%; p = 0.001); however, rates of END did not differ (11.0%, 13.5%, and 4.9%, respectively). ENI was independently associated with male, higher NIHSS score, and early and late EVT. END was associated with failure of recanalization. Conclusions: ENI was more observed and associated with early and late EVT. Highly selected patients receiving very late EVT may not benefit from ENI but may still have a chance to prevent END. The occurrence of END was associated not with time window but with failure of recanalization.

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Delayed Neurological Improvement After Full Endovascular Reperfusion in Acute Anterior Circulation Ischemic Stroke

Cited by 13 publications

References 23 publications

How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge?

How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge?

Early surrogates of outcome after thrombectomy in posterior circulation stroke

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

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