Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke

Abstract

ImportanceOutcome prediction after endovascular treatment (EVT) for ischemic stroke is important to patients, family members, and physicians.ObjectiveTo develop and validate a model based on preprocedural and postprocedural characteristics to predict functional outcome for individual patients after EVT.Design, Setting, and ParticipantsA prediction model was developed using individual patient data from 7 randomized clinical trials, performed between December 2010 and December 2014. The model was developed within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration and external validation in data from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry of patients treated in clinical practice between March 2014 and November 2017. Participants included patients from multiple centers throughout different countries in Europe, North America, East Asia, and Oceania (derivation cohort), and multiple centers in the Netherlands (validation cohort). Included were adult patients with a history of ischemic stroke from an intracranial large vessel occlusion in the anterior circulation who underwent EVT within 12 hours of symptom onset or last seen well. Data were last analyzed in July 2022.Main Outcome(s) and Measure(s)A total of 19 variables were assessed by multivariable ordinal regression to predict functional outcome (modified Rankin Scale [mRS] score) 90 days after EVT. Variables were routinely available 1 day after EVT. Akaike information criterion (AIC) was used to optimize model fit vs model complexity. Probabilities for functional independence (mRS 0-2) and survival (mRS 0-5) were derived from the ordinal model. Model performance was expressed with discrimination (C statistic) and calibration.ResultsA total of 781 patients (median [IQR] age, 67 [57-76] years; 414 men [53%]) constituted the derivation cohort, and 3260 patients (median [IQR] age, 72 [61-80] years; 1684 men [52%]) composed the validation cohort. Nine variables were included in the model: age, baseline National Institutes of Health Stroke Scale (NIHSS) score, prestroke mRS score, history of diabetes, occlusion location, collateral score, reperfusion grade, NIHSS score at 24 hours, and symptomatic intracranial hemorrhage 24 hours after EVT. External validation in the MR CLEAN Registry showed excellent discriminative ability for functional independence (C statistic, 0.91; 95% CI, 0.90-0.92) and survival (0.89; 95% CI, 0.88-0.90). The proportion of functional independence in the MR CLEAN Registry was systematically higher than predicted by the model (41% vs 34%), whereas observed and predicted survival were similar (72% vs 75%). The model was updated and implemented for clinical use.Conclusion and relevanceThe prognostic tool MR PREDICTS@24H can be applied 1 day after EVT to accurately predict functional outcome for individual patients at 90 days and to provide reliable outcome expectations and personalize follow-up and rehabilitation plans. It will need further validation and updating for contemporary patients.

HERMES-24 Score Derivation and Validation for Simple and Robust Outcome Prediction After Large Vessel Occlusion Treatment

“…Using the same HERMES data set, MR PREDICTS@24H developed a comprehensive model in which 24-hour NIHSS plays a key role. 18 As noted in the results, MR PREDICTS@24H was associated with higher c-statistics than this HERMES-24 score. The distinction between the 2 prediction models consists of improved model performance at the cost of greater complexity, which is the typical statistical tradeoff.…”

“…Several post-treatment scores after EVT (Pittsburgh Outcomes After Stroke Thrombectomy [POST], Symptomatic hemorrhage, baseline National Institutes of Health Stroke Scale [NIHSS] score, Age, Reperfusion, and Location of clot [SNARL], and Bronx Endovascular Thrombectomy [10][11][12] ) and prediction tools after EVT or intravenous thrombolysis (IVT) alone [13][14][15][16][17] have been reported. Importantly, MR PREDICTS@24H as developed by Chalos et al 18 represents a comprehensive predictive tool using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set. However, available stroke outcome prediction scales are often complex with many variables and treatment-specific aspects, which affects clinical practicality.…”

Pretreatment and interventional parameters predict excellent recanalization of large vessel occlusion in patients with acute ischemic stroke

“…DM and hyperglycemia are also well researched predictors of poor outcomes in general for AIS-LVO patients. [34][35][36] Additionally, higher stroke severity on admission is well established as a predictor of poorer outcomes. [37][38][39] This study has limitations to acknowledge.…”