BackgroundEndovascular therapy seems to benefit a subset of patients with large vessel occlusion strokes. We aimed to develop a clinically useful tool to identify patients who are likely to benefit from endovascular therapy.MethodsIn a derivation cohort of consecutively treated patients with anterior circulation large vessel occlusion (Grady Memorial Hospital, N=247), independent predictors (p<0.1) of good outcome (90-day modified Rankin scale score (mRS) 0–2) were determined using logistic regression to derive the Pittsburgh Response to Endovascular therapy (PRE) score as a predictor of good outcome. The PRE score was validated in two institutional cohorts (University of Pittsburgh Medical Center (UPMC): N=393; Unitat d’Ictus Vall d’Hebron: N=204) and its discriminative power for good outcome was compared with other validated tools. Benefit of successful recanalization was assessed in PRE score groups.ResultsIndependent predictors of good outcome in the derivation cohort (age, baseline National Institute of Health Stroke Scale (NIHSS) score and Alberta Stroke Program Early CT Score (ASPECTS)) were used in the model: PRE score=age (years)+2×NIHSS−10×ASPECTS. PRE score was highly predictive of good outcome in the derivation cohort (area under the curve (AUC)=0.79) and validation cohorts (UPMC: AUC=0.79; UIVH: AUC=0.72) with comparable rates of good outcome in all PRE risk quartiles. PRE was superior to Totaled Health Risks In Vascular Events (THRIVE) (p=0.03) and Stroke Prognostication using Age and NIHSS (SPAN) (p=0.007), with a trend towards superiority to Houston Intra-Arterial Therapy 2 (HIAT2) (p=0.06) and iSCORE (p=0.051) in predicting good outcomes. Better outcomes were associated with successful recanalization in patients with PRE scores −24 to +49 but not in patients with PRE scores <−24 or ≥50.ConclusionsThe PRE score is a validated tool that predicts outcomes and may facilitate patient selection for endovascular therapy in anterior circulation large vessel occlusions.
Background and purpose Diffusion-weighted imaging (DWI) ASPECTS, a surrogate of infarct volume, predicts outcome in anterior large vessel occlusion (LVO) strokes. We aim to determine whether topological information captured by DWI ASPECTS contributes additional prognostic value. Methods Adults with intracranial ICA, M1 or M2 MCA occlusions who underwent endovascular therapy were included. The primary outcome measure was poor clinical outcome (3-month modified Rankin Scale score 3–6). Prognostic value of the 10 DWI ASPECTS regions in predicting poor outcome was determined by multivariable logistic regression, controlling for final infarct volume, age and laterality. Results 213 patients (mean age 66.1±14.5 years, median NIHSS 15) were included. Inter-rater reliability was good for DWI ASPECTS (Deep regions: Kappa=0.72, Cortical regions: Kappa=0.63). All DWI ASPECTS regions with the exception of the putamen were significant predictors (p<0.05) of poor outcome in univariate analyses. Statistical collinearity among ASPECTS regions was not observed. Using penalized multivariable logistic regression, only M4 (OR=2.82 95%CI 1.39–5.76) and M6 (OR=2.45, 95%CI 1.15–5.3) involvement were associated with poor outcome. M6 involvement independently predicted poor outcome in right hemispheric strokes (OR=5.8, 95%CI 1.9–20.3) whereas M4 (OR=4.3, 95%CI 1.3–15.0) involvement predicted poor outcome in left hemispheric strokes adjusting for infarct volume. Topologic information modestly improved the predictive ability of a prognostic score that incorporates age, infarct volume and hemorrhagic transformation. Conclusions Involvement of the right parieto-occipital (M6) and left superior-frontal (M4) regions impact clinical outcome in anterior LVOs over and above the effect of infarct volume and should be considered during prognostication.
A cute large vessel occlusion strokes (LVOS) account for 25% to 40% of all acute ischemic strokes, resulting in significant morbidity and mortality. Data from a natural history study of patients with LVOS with moderate-severe deficits (National Institutes of Health Stroke Scale [NIHSS] ≥10) also suggested low rates of good outcome (modified Rankin Score [mRS], 0-2) in internal carotid artery (14%) and M1 middle cerebral artery (23%) occlusions.1 Proximal occlusions are also less likely to recanalize with intravenous thrombolysis, and clinical trials are underway to determine whether endovascular therapy improves clinical outcome. 2,3 In anterior circulation LVOS patients, the final infarct volume (FIV) is a strong and independent predictor of clinical outcome. 4,5After endovascular therapy for LVOS, aggressive medical measures including continuation of life support and surgical therapies (hemicraniectomy, gastrostomy, and tracheostomy) are frequently considered. The decision to pursue aggressive treatment versus de-escalation of care often depends on an estimation of the chance of long-term functional independence. Stroke and critical care physicians are the ones guiding families in this complex decision-making process. Results from the Clinician Judgment vs Risk Score to Predict Stroke Outcomes Background and Purpose-Prognostication tools that predict good outcome in patients with anterior circulation large vessel occlusions after endovascular therapy are lacking. We aim to develop a tool that incorporates clinical and imaging data to predict outcomes after endovascular therapy. Methods-In a derivation cohort of anterior circulation large vessel occlusion stroke patients treated with endovascular therapy within 8 hours from time last seen well (n=247), we performed logistic regression to identify independent predictors of good outcome (90-day modified Rankin Scale, 0-2). Factors were weighted based on β-coefficients to derive the Pittsburgh Outcomes After Stroke Thrombectomy (POST) score. POST was validated in an institutional endovascular database (University of Pittsburgh Medical Center, n=393) and the Diffusion-Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 (DEFUSE-2) data set (n=105), as well as in patients treated beyond 8 hours (n=194) and in octogenarians (n=111). Results-In the derivation cohort, independent predictors (P<0.1) of good outcome included 24-to 72-hour final infarct volume (in cm 3 , P<0.001), age (years, P<0.001), and parenchymal hematoma types 1 and 2 (H, P=0.01). POST was calculated as age+0.5×final infarct volume+15×H. Patients with POST score <60 had a 91% chance of good outcome compared with 4% with POST score ≥120. POST accurately predicted good outcomes in the derivation (area under the curve [AUC]=0.85) and validation cohorts (University of Pittsburgh Medical Center, AUC=0.81; DEFUSE-2, AUC=0.86), as well as in patients treated beyond 8 hours (AUC, 0.85) and octogenarians (AUC=0.76). POST had better predictive accuracy for good and poor outcome than the isch...
Background and Purpose— To identify the specific post-endovascular stroke therapy (EVT) peak systolic blood pressure (SBP) threshold that best discriminates good from bad functional outcomes (a priori hypothesized to be 160 mm Hg), we conducted a prospective, multicenter, cohort study with a prespecified analysis plan. Methods— Consecutive adult patients treated with EVT for an anterior ischemic stroke were enrolled from November 2017 to July 2018 at 12 comprehensive stroke centers accross the United States. All SBP values within 24 hours post-EVT were recorded. Using Youden index, the threshold of peak SBP that best discriminated primary outcome of dichotomized 90-day modified Rankin Scale score (0–2 versus 3–6) was identified. Association of this SBP threshold with the outcomes was quantified using multiple logistic regression. Results— Among 485 enrolled patients (median age, 69 [interquartile range, 57–79] years; 51% females), a peak SBP of 158 mm Hg was associated with the largest difference in the dichotomous modified Rankin Scale score (absolute risk reduction of 19%). Having a peak SBP >158 mm Hg resulted in an increased likelihood of modified Rankin Scale score 3 to 6 (odds ratio, 2.24 [1.52–3.29], P <0.01; adjusted odds ratio, 1.29 [0.81–2.06], P =0.28, after adjustment for prespecified variables). Conclusions— A peak post-EVT SBP of 158 mm Hg was prospectively identified to best discriminate good from bad functional outcome. Those with a peak SBP >158 had an increased likelihood of having a bad outcome in unadjusted, but not in adjusted analysis. The observed effect size was similar to prior studies. This finding should undergo further testing in a future randomized trial of goal-targeted post-EVT antihypertensive treatment.
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