Risk factors of unexplained early neurological deterioration after treatment for ischemic stroke due to large vessel occlusion: a post hoc analysis of the HERMES study

Abstract

BackgroundEarly neurological deterioration (END) after endovascular treatment (EVT) in patients with anterior circulation acute ischemic stroke (AIS) is associated with poor outcome. END may remain unexplained by parenchymal hemorrhage (UnEND). We aim to analyze the risk factors of UnEND in the medical management (MM) and EVT arms of the HERMES study.MethodsWe conducted a post-hoc analysis of anterior AIS patients who underwent EVT for proximal anterior occlusions. Risk factors of UnEND, defined as a worsening of ≥4 points between baseline National Institutes of Health Stroke Scale (NIHSS) and NIHSS at 24 hours without hemorrhage, were compared between both arms using mixed logistic regression models adjusted for baseline characteristics. An interaction analysis between the EVT and MM arms for risk factors of UnEND was conducted.ResultsAmong 1723 patients assessable for UnEND, 160 patients experienced an UnEND (9.3%), including 9.1% (78/854) in the EVT arm and 9.4% (82/869) in the MM arm. There was no significant difference in the incidence of UnEND between the two study arms. In the EVT population, independent risk factors of UnEND were lower baseline NIHSS, higher baseline glucose, and lower collateral grade. In the MM population, the only independent predictor of UnEND was higher baseline glucose. However, we did not demonstrate an interaction between EVT and MM for baseline factors as risk factors of UnEND. UnEND was, similarly in both treatment groups, a significant predictor of unfavorable outcome in both the EVT (p<0.001) and MM (p<0.001) arms.ConclusionsUnEND is not an uncommon event, with a similar rate which ever treatment arm is considered. In the clinical scenario of AIS due to large vessel occlusion, no patient-related factor seems to increase the risk for UnEND when treated by EVT compared with MM.

Early blood pressure changes during systemic thrombolysis and its association with unexplained early neurological deterioration in small subcortical infarct

“…Nevertheless, a sizeable fraction does not recover or even deteriorate within 24 hours, so‐called END strongly associated with poor outcome 18–20 . Currently, extensive research suggests that END is a serious clinical situation with widely different causes 5–11 . Apart from the straightforward causes such as symptomatic intracranial haemorrhage and early stroke recurrence, the cause of END remains unclear in more than a half of cases 9–11,17 .…”

“…[18][19][20] Currently, extensive research suggests that END is a serious clinical situation with widely different causes. [5][6][7][8][9][10][11] Apart from the straightforward causes such as symptomatic intracranial haemorrhage and early stroke recurrence, the cause of END remains unclear in more than a half of cases. [9][10][11]17 One influential hypothesis about unEND is the extension of "symptomatic" ischemic tissue into the surrounding "asymptomatic" tissue, because of secondary hemodynamic and/or metabolic events.…”

“…Previous studies have reported that END occurs in 20‐30% of perforator territory infarctions, leading to poor functional outcomes 5–8 . Symptomatic intracranial hemorrhage, malignant edema, early recurrent stroke, and post‐stroke seizure were all the known causes of END, while in over half of END cases, the exact cause yet incompletely understood, which is so‐called unexplained END (unEND) 9–11 . Thus, it is of great importance to identify relevant factors of unEND and conduct targeted interventions so as to improve the overall outcome in perforator territory infarction after IVT.…”

Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice

“…Baseline NIHSS and ASPECTS but not diabetes have been noticed as independent predictors of clinical response after MT in 2 single-center studies in prestroke-dependent patients. 2,8 In contrast, successful recanalization was the most powerful predictor of favorable outcome, fact broadly seen in stroke patients included in randomized clinical trials 1,12,13 and also reported in other samples of patients with preexisting disability. 4,6,8,9 The effect size of MT has been also shown in patients >80 years 1 although good functional outcome seems to decline with increased age after MT.…”

Impacts of stress hyperglycemia ratio on early neurological deterioration and functional outcome after endovascular treatment in patients with acute ischemic stroke

“…The underlying mechanism for SHR influencing END may be multifactorial. First, increased lactate productions may deteriorate ischemic condition, and disrupt neuron metabolism in penumbra areas ( 27 ). Second, stress hyperglycemia could aggravate hemorrhagic transformation after ischemic stroke by inducing mitochondrial dysfunction and endothelial cell apoptosis ( 28 ).…”