Predictors of Unexplained Early Neurological Deterioration After Endovascular Treatment for Acute Ischemic Stroke

Abstract

Background and Purpose: Although the efficacy of endovascular treatment (EVT) in patients with anterior circulation ischemic stroke (AIS) is well documented, early neurological deterioration after EVT remains a serious issue associated with poor outcome. Besides obvious causes, such as lack of reperfusion, procedural complications, or parenchymal hemorrhage, early neurological deterioration may remain unexplained (UnEND). Our aim was to investigate predictors of UnEND after EVT in patients with AIS. Methods: Patients who underwent EVT for AIS, with an initial National Institutes of Health Stroke Scale score>5, Alberta Stroke Program Early CT Score ≥6, and included in a multicenter prospective observational registry were analyzed. Predictors of UnEND, defined as ≥4-point increase in the National Institutes of Health Stroke Scale score between baseline and day 1 after EVT, were determined via center-adjusted analyses. Results: Among the 1925 included in the analysis, 128 UnEND (6.6%) were recorded. In multivariate analysis, predictors of UnEND were diabetes mellitus (odds ratio [OR], 2.17[95% CI,1.32–3.56]), prestroke modifiedRankinScale score≥2 (OR, 2.22[95% CI,1.09–4.55]), general anesthesia (OR, 2.55[95% CI,1.51–4.30]), admission systolic blood pressure (OR, 1.10[95% CI,1.01–1.20]), age (OR, 1.38[95% CI,1.14–1.67]), number of passes (OR, 1.16[95% CI,1.04–1.28]), direct admission or not to a comprehensive stroke center (OR, 0.49 [95% CI,0.30–0.81]), and initial National Institutes of Health Stroke Scale score (OR, 0.65 [95% CI,0.52–0.81]). Conclusions: Severely impaired AIS patients with nonmodifiable factors are more likely to develop UnEND. Some modifiable predictors of UnEND such as the number of EVT passes could be the object of improvement in AIS management.

Course of Early Neurologic Symptom Severity after Endovascular Treatment of Anterior Circulation Large Vessel Occlusion Stroke: Association with Baseline Multiparametric CT Imaging and Clinical Parameters

“…All the patients were treated with EVT, 131 patients (62.1%) received additional intravenous thrombolysis. The median NIHSS score on admission was 14 in both groups, whereas the median 24-h NIHSS score differed significantly, with 32 (IQR:22-33) in the END group versus 6 (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) in the group without END. Figure 1 illustrates the course of the NIHSS score between the baseline and 24 h of all the patients.…”

“…To date, only a few studies have investigated END after EVT with varying incidence rates and predictors of END due to different definition and inclusion criteria [ 5 , 8 , 10 ]. Girot et al, who focused on unEND, mainly found nonmodifiable factors such as premorbid disability (mRS ≥ 2), age and diabetes mellitus as predictors for neurologic deterioration; however, baseline imaging parameters were not included in the analysis and only cases with favorable reperfusion status and no early complications were considered as END, which limits the comparability with our results [ 5 ]. Kim et al and Zhang et al identified the recanalization status as the most important predictor [ 8 , 10 ].…”

“…Together with multiparametric CT or MRI imaging, it guides therapy decision making toward intravenous thrombolysis (IVT) and endovascular treatment (EVT) [ 4 ]. Early neurological deterioration (END) is commonly defined as increase in ≥4 points of the NIHSS between pretreatment (NIHSS on admission) and day one (24-h NIHSS) [ 5 , 6 , 7 ]. END occurs in 10–40% of patients, depending on different definitional sub-criteria and/or inclusion criteria [ 5 , 6 , 7 , 8 , 9 , 10 ].…”

“…Early neurological deterioration (END) is commonly defined as increase in ≥4 points of the NIHSS between pretreatment (NIHSS on admission) and day one (24-h NIHSS) [ 5 , 6 , 7 ]. END occurs in 10–40% of patients, depending on different definitional sub-criteria and/or inclusion criteria [ 5 , 6 , 7 , 8 , 9 , 10 ]. However, studies have independently shown that the affected patients have a significantly worse functional outcome.…”

“…The reasons for END can be rather obvious, such as infarct expansion, edema, hemorrhagic transformation, therapy-associated complications, or lack of reperfusion—where there is clearly causal crossover between one another — but unclear causes, so-called unexplained END (unEND), are also described [ 12 , 13 ]. A recent study found that mainly non-modifiable factors, such as a premorbid modified Rankin Scale score (mRS), diabetes mellitus and age, predict unEND in patients after EVT; however, baseline imaging parameters were not included in the analysis [ 5 ]. Overall, the 24-h NIHSS has been proven as a good predictor for long-term stroke outcome in a large multicentric study and is, therefore, a promising parameter to determine therapeutic efficacy early.…”