Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry

Abstract

Background Mechanical thrombectomy with stentretrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70-83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40-55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods Logistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0-2 (good outcome) vs 3-6 ( poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance ( p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power. Results Of 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization ( p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80). Conclusions Age, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.

Predictors of Mortality in Acute Ischemic Stroke Intervention

“…These patients tend to present and get treated later, and their clinical outcome is worse compared with anterior circulation LVOs. 11 Similarly, tandem cervical ICA and middle cerebral artery occlusions are strongly associated with mortality and intracerebral hemorrhage. 12,13 These patients were also included in NASA.…”

“…[11][12][13] The correlation may result from a high initial infarct volume with proximal arterial occlusion and technical difficulties in recanalizing the occluded vessel, resulting in a longer time to achieve recanalization. Angioplasty and stenting of an occluded ICA in patients with tandem ICA+middle cerebral artery occlusion may result in good outcome.…”

Outcomes Are Not Different between Patients with Intermediate and High DWI-ASPECTS after Stent-Retriever Embolectomy for Acute Anterior Circulation Stroke

“…Several clinical and imaging factors are known to be associated with functional outcomes after endovascular treatment for acute anterior circulation stroke. [6][7][8][9] However, questions remain as to what benefits embolectomy provides to patients who present at extended time periods or those with considerable early ischemic changes on baseline imaging studies. Furthermore, the imaging technique that best determines candidacy for embolectomy in these patients remains unknown.…”

Shear-Activated Nanoparticle Aggregates Combined With Temporary Endovascular Bypass to Treat Large Vessel Occlusion

“…1,4 Patients with an mTICI 3 score (complete recanalization) have a 2-fold higher chance for good clinical outcome compared with those with a mTICI 2b score (perfusion of half or greater of the vascular distribution of the occluded artery). 26 However, in all major randomized clinical trials (comparing MT in ELVO to best medical treatment), successful recanalization is defined as a mTICI 2b or mTICI 3. Although TICI 2b recanalization means spectacular reperfusion, in many cases, it may be In this study, we explored whether a recently developed SA-NT drug delivery system could be used to selectively concentrate r-tPA at sites of complete carotid occlusion by temporarily placing a TEB through the clot and, thereby, greatly increasing fluid shear stress locally.…”