Pierre Seners1, Wagih Ben Hassen2, Bertrand Lapergue3, Caroline Arquizan4, Mirjam R Heldner5, Hilde Henon6, Claire Perrin1, Davide Strambo7, Jean-Philippe Cottier8, Denis Sablot9, Isabelle Girard Buttaz10, Ruben Tamazyan11, Cécile Preterre12, Pierre Agius12,13, Nadia Laksiri14, Laura Mechtouff15, Yannick Béjot16, Duc-Long Duong17, François Mounier-Vehier18, Gioia Mione19, Charlotte Rosso20, Ludovic Lucas21, Jérémie Papassin22,23, Andreea Aignatoaie24, Aude Triquenot25, Emmanuel Carrera26, Philippe Niclot27, Alexandre Obadia28, Aïcha Lyoubi29, Pierre Garnier30, Nicolae Crainic31, Valérie Wolff32, Clément Tracol33, Frédéric Philippeau34, Chantal Lamy35, Sébastien Soize36, Jean-Claude Baron1, Guillaume Turc1. 1. Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France. 2. Radiology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France. 3. Neurology Department, Foch University Hospital, Suresnes, France. 4. Neurology Department, CHRU Gui de Chauliac, Montpellier, France. 5. Neurology Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland. 6. Neurology Department, CHU Lille, Université de Lille, INSERM U1171, Lille, France. 7. Stroke Center, Neurology Service, CHU Vaudois, Lausanne University, Lausanne, Switzerland. 8. Neurology Department, Bretonneau Hospital, Tours, France. 9. Neurology Department, Perpignan Hospital, Perpignan, France. 10. Neurology Department, Valenciennes Hospital, Valenciennes, France. 11. Neurology Department, Saint Joseph Hospital, Paris, France. 12. Neurology Department, Nantes University Hospital, Nantes, France. 13. Neurology Department, St Nazaire Hospital, Saint-Nazaire, France. 14. Neurology Department, La Timone University Hospital, Marseille, France. 15. Department of Stroke Medicine, Hospices Civils de Lyon, Lyon, France. 16. Neurology Department, Dijon University Hospital, Dijon, France. 17. Neurology Department, Versailles University Hospital, Versailles, France. 18. Neurology Department, Lens Hospital, Lens, France. 19. Neurology Department, Nancy University Hospital, Nancy, France. 20. Sorbonne Université, Institut du Cerveau et de la Moelle épinière, ICM, INSERM U 1127, CNRS UMR 7225, AP-HP, Urgences Cérébro-Vasculaires, ICM Infrastructure Stroke Network, Hôpital Pitié-Salpêtrière, Paris, France. 21. Stroke Unit, Bordeaux University Hospital, Bordeaux, France. 22. Stroke Unit, Grenoble University Hospital, Grenoble, France. 23. Neurology Department, Centre Hospitalier Metropole-Savoie, Chambery, France. 24. Neurology Department, Centre Hospitalier Régional d'Orléans, Orléans, France. 25. Neurology Department, CHU Rouen, Rouen, France. 26. Neurology Department, Geneve University Hospital, Geneve, Switzerland. 27. Neurology Department, René Dubos Hospital, Pontoise, France. 28. Neurology Department, Fondation Adolphe de Rothschild, Paris, France. 29. Neurology Department, Delafontaine Hospital, Saint-Denis, France. 30. Stroke Unit, Saint-Etienne University Hospital, Saint-Etienne, France. 31. Neurology Department, Brest University Hospital, Brest, France. 32. Neurology Department, Strasbourg University Hospital, Strasbourg, France. 33. Neurology Department, Rennes University Hospital, Rennes, France. 34. Neurology Department, Fleyriat Hospital, Bourg-en-Bresse, France. 35. Neurology Department, Amiens University Hospital, Amiens, France. 36. Neuroradiology Department, Reims University Hospital, Reims, France.
Abstract
Importance: The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. Objective: To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO. Design, Setting, and Participants: This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019. Main Outcomes and Measures: ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause. Results: Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. Conclusions and Relevance: The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.
Importance: The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. Objective: To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO. Design, Setting, and Participants: This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019. Main Outcomes and Measures: ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause. Results: Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. Conclusions and Relevance: The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.
Authors: R McDonough; P Cimflova; N Kashani; J M Ospel; M Kappelhof; N Singh; A Sehgal; N Sakai; J Fiehler; M Chen; M Goyal Journal: AJNR Am J Neuroradiol Date: 2021-08-19 Impact factor: 4.966
Authors: Robert W Regenhardt; Amine Awad; Andrew W Kraft; Joseph A Rosenthal; Adam A Dmytriw; Justin E Vranic; Anna K Bonkhoff; Martin Bretzner; Mark R Etherton; Joshua A Hirsch; James D Rabinov; Aneesh B Singhal; Natalia S Rost; Christopher J Stapleton; Thabele M Leslie-Mazwi; Aman B Patel Journal: Stroke Vasc Interv Neurol Date: 2022-05-20