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

Abstract

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.

Association of clinical outcome and imaging endpoints in extensive ischemic stroke—comparing measures of cerebral edema

“…Fifth, another limitation is the lack of data on longterm functional outcomes. However, this study focuses on the early post-stroke phase, which is not only of great importance for the planning of post-acute therapy, but also contributes significantly to the long-term outcome [31]. Therefore, we believe that this study leads to reasonable conclusions.…”

Predictors of failure of early neurological improvement in early time window following endovascular thrombectomy: a multi-center study

“…Functional outcome was significantly different between the two groups (Table 2). Patients with ENI were more likely to experience a good outcome at discharge [median mRS 5 (3)(4)(5) in the FENI group vs. 2 (1-3) in the ENI group, p < 0.001] and at the 3 months follow-up (mRS of 0-2 in 22.2% of FENI vs. 80.7% of ENI, and mRS of 6 in 42.1% of FENI vs. 7% of ENI; p < 0.001). Furthermore, mortality was 7.0% (n = 4) in the ENI group in comparison to 42.1% (n = 53) in the FENI group (p < 0.001).…”

“…Treatment of stroke has improved significantly over the past few decades, and endovascular thrombectomy (EVT) has become the gold standard for the treatment of acute ischemic stroke (AIS) ( 2 , 3 ). However, a significant proportion of AIS patients do not benefit from EVT despite successful attempts ( 4 ).…”

Relative versus absolute early neurological improvement after mechanical thrombectomy for large vessel occlusion stroke – hot or not?

“…Only recently, Kniep et al calculated that 54% of the improvement in functional outcome is explained by the NIHSS at 24 hours, while it is even 75% of the improvement by the NIHSS at discharge. This highlights the importance of in-hospital complications following MT, delay of neurological improvements, and post-discharge rehabilitation programs 3. About 16% of patients in studies by Meyer et al and Hendrix et al did not have a favorable outcome despite achieving the 24-hour NIHSS surrogate ≤8.…”

“…Early clinical surrogates for long-term functional outcomes represent valuable clinical adjuncts. Lately, the National Institutes of Health Stroke Scale (NIHSS) score 24 hours after mechanical thrombectomy (MT) for large vessel occlusion (LVO) ischemic stroke has been repeatedly demonstrated to serve as a robust and independent predictor of 90-day functional outcomes 1–5…”