The SON2A2 score: A novel grading scale for predicting hemorrhage and outcomes after thrombolysis

Abstract

ObjectivesThis study aimed to develop a score including novel putative predictors for predicting the risk of sICH and outcomes after thrombolytic therapy with intravenous (IV) recombinant tissue-type plasminogen activator (r-tPA) in acute ischemic stroke patients.MethodsAll patients with acute ischemic stroke treated with IV r-tPA at three university-based hospitals in Chongqing, China, from 2014 to 2019 were retrospectively studied. Potential risk factors associated with sICH (NINDS criteria) were determined with multivariate logistic regression, and we developed our score according to the magnitude of logistic regression coefficients. The score was validated in another independent cohort. Area under the receiver operating characteristic curve (AUC-ROC) was used to assess the performance of the score. Calibration was evaluated using the Hosmer–Lemeshow goodness-of-fit method.ResultsThe SON2A2 score (0 to 8 points) consisted of history of smoking (no = 1, yes = 0, β = 0.81), onset-to-needle time (≥3.5 = 1,<3.5=0, β = 0.74), NIH Stroke Scale on admission (>10 = 2, ≤10 = 0, β = 1.22), neutrophil percentage (≥80.0% = 1, <80% = 0, β = 0.81), ASPECT score (≤11 = 2, >11 = 0, β = 1.30), and age (>65 years = 1, ≤65 years = 0, β = 0.89). The SON2A2 score was strongly associated with sICH (OR 1.98; 95%CI 1.675–2.34) and poor outcomes (OR 1.89; 95%CI 1.68–2.13). AUC-ROC in the derivation cohort was 0.82 (95%CI 0.77–0.86). Similar results were obtained in the validation cohort. The Hosmer–Lemeshow test revealed that predicted and observed event rates in derivation and validation cohorts were very close.ConclusionThe SON2A2 score is a simple, efficient, quick, and easy-to-perform scale for predicting the risk of sICH and outcome after intravenous r-tPA thrombolysis within 4.5 h in patients with ischemic stroke, and risk assessment using this test has the potential for early and personalized management of this disease in high-risk patients.

Commentary: The SON2A2 score: a novel grading scale for predicting hemorrhage and outcomes after thrombolysis

“…Data regarding the development of sICH after thrombolytic therapy for acute ischemic stroke are comparable in patients treated with tenecteplase compared to alteplase (8). However, in the study of Ren et al, the rate of sICH in the study was reported as 12.2% (68/556) in the derivation cohort and 8.7% (14/160) in the validation cohort (1). It is important to note that 167 patients were excluded from their analysis due to incomplete data, stroke in the posterior fossa, incomplete dose of r-tPA, or severe concomitant diseases.…”

“…In the validation cohort, the median (IQR) ASPECTS are 13 (13, 14) and 11 (10, 12) for the non-sICH and sICH groups (1). The cutoff of ASPECTS in the SON2A2 grading scale to predict a poor outcome is 11 (1). These numbers are all outside the possible range of ASPECTS scores, which again ranges between 10 and 0.…”

“…ASPECTS, using the same grading scale from 10 to 0, has also been used as an inclusion criterion in trials regarding the use of mechanical thrombectomy within the 6-h timeframe ( 3 – 5 ). In the original study of Ren et al, ASPECTS represents one of the six variables that compose the SON2A2 score ( 1 ). In the results of the study, the median (IQR) ASPECTS in the derivation cohort are 13 (12, 14) and 12 (10, 13) for the non-sICH and sICH groups.…”

“…I read with great interest the article titled “The SON2A2 score: a novel grading scale for predicting hemorrhage and outcomes after thrombolysis.” ( 1 ). In this original study, the authors developed a grading scale to stratify the risk of symptomatic intracranial hemorrhage and outcome in patients who are candidates to receive thrombolytic therapy for suspected acute ischemic stroke.…”

“…In this original study, the authors developed a grading scale to stratify the risk of symptomatic intracranial hemorrhage and outcome in patients who are candidates to receive thrombolytic therapy for suspected acute ischemic stroke. The SON2A2 score is an 8-point score that takes into account smoking, onset of symptoms, needle time, NIHSS score, neutrophil percentage, age, and ASPECTS ( 1 ). The development of an accurate and reliable grading scale that predicts which patients are at higher risk of developing complications from thrombolytics and having poor outcomes is greatly beneficial in clinical practice as an aiding tool in the discussion with patients and family regarding risks and benefits of thrombolytics, as well as triaging patients to specific levels of care after receiving thrombolytic therapy based on their risk of complications.…”