A Clinical Prediction Model for Patients with Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Stenosis

Abstract

Background Acute large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS-LVO) increases the difficulty of revascularization, resulting in frequent re-occlusion. The establishment of its pathogenesis before endovascular treatment (EVT) is beneficial for patients. We aimed at developing and validating a clinical prediction model for ICAS-LVO patients before EVT. Methods Patients with acute large vessel occlusion at Jining No. 1 People’s Hospital from January 2019 to September 2021 were retrospectively included as the training cohort. The 70 patients who met the inclusion and exclusion criteria were included in the validation cohort (October 2021 to May 2022). Demographics, onset form, medical history, digital subtraction angiography (DSA) imaging data, and laboratory test data were collected. Preprocedural parameters for the ICAS-LVO risk prediction model were established by stepwise logistic regression controlling for the confounding effects. Then, we constructed a nomogram model and evaluated its performance via the Hosmer-Lemeshow goodness-of-fit test, area under the ROC curve (AUC) analysis. Results The 231 acute LVO patients were included in the final analysis, 74 (32.3%) patients were ICAS-LVO. A preoperative diagnosis prediction model consisting of five predictors for ICAS-LVO, including fluctuating symptoms, NIHSS < 16, atrial fibrillation, tapered sign, and ASITN/SIR score ≥ 2. The model depicted an acceptable calibration (Hosmer-Lemeshow test, p = 0.451) and good discrimination (AUC, 0.941; 95% confidence interval, 0.910–0.971). The optimal cut-off value for the ICAS-LVO scale was 2 points, with 86.5% sensitivity, 91.1% specificity, and 90.5% accuracy. In the validation cohort, the discriminative ability was promising with an AUC value of 0.897, implying a good predictive performance. Conclusion The established ICAS-LVO scale, which is composed of five predictors: fluctuating symptoms, NIHSS < 16, atrial fibrillation, tapered sign, and ASITN/SIR score ≥ 2, has a good predictive value for ICAS-LVO in Chinese populations.

Development and internal-external validation of the ATHE Scale: predicting acute large vessel occlusion due to underlying intracranial atherosclerosis prior to endovascular treatment

“…15 AF is generally viewed as a negative predictor within ICAS-LVO prediction frameworks. This is reflected in several models, including the ISAT Scale (in situ atherosclerotic thrombosis), 18 ABC 2 D score (atrial fibrillation-blood pressure-clinical neurological deficit-computed tomography hyperdense sign-diabetes mellitus), 19 ICAS-LVO nomogram, 28 and our ATHE Scale. When it is challenging to ascertain a patient's AF history, an admission electrocardiogram diagnosis proves to be more accurate than relying on AF history alone.…”

“…However, the baseline NIHSS score threshold that differentiates ICAS-LVO from EMB-LVO varies across centers. The ABC 2 D score, ICAS-LVO nomogram, and our ATHE Scale set the thresholds at 6, 19 15, 28 groups rather than transforming it from a continuous variable, although the reasoning was not explicitly mentioned. Regardless, only 16% of their participants had an NIHSS score ≤ 6, 19 which may affect its diagnostic validity.…”

“…Firstly, we did not directly compare our findings with other predictive models in the external validation cohort, such as the ABC 2 D score 19 and the ICAS-LVO nomogram model. 28 This decision was influenced by differences in patient characteristics among the studies. The ABC 2 D score assessed the HAS using a range of 53-69 for the HU measurement, whereas our study utilized a visual assessment method.…”