Unexplained early neurological deterioration after endovascular treatment for acute large vessel occlusion: incidence, predictors, and clinical impact: Data from ANGEL-ACT registry

Abstract

BackgroundEarly neurological deterioration (END) may occur in some patients with acute large vessel occlusion (LVO) undergoing endovascular treatment (EVT). Despite several clear causes of END, such as symptomatic intracranial hemorrhage, failure of recanalization, and intraprocedure complications, a particular END, termed unexplained END (ENDunexplained), exists. We aimed to investigate the incidence, independent predictors, and clinical impact of ENDunexplained after EVT in patients with acute LVO.MethodsSubjects were selected from the ANGEL-ACT registry. ENDunexplained was defined as ≥4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score between baseline and 24 hours after EVT, without the causes listed above. Logistic regression analyses were performed to determine the independent predictors of ENDunexplained, as well as the association between ENDunexplained and 90-day outcomes assessed by modified Rankin Scale (mRS) score.ResultsAmong the 1557 enrolled patients, the incidence of ENDunexplained was 4.3% (67/1557). Admission NIHSS ≤8 (OR=6.88, 95% CI 3.86 to 12.26, p<0.001), general anesthesia (OR=3.15, 95% CI 1.81 to 5.48, p<0.001), admission neutrophil to lymphocyte ratio >5 (OR=2.82, 95% CI 1.61 to 4.94, p<0.001), and number of EVT attempts >3 (OR=2.11, 95% CI 1.14 to 3.89, p=0.018) were associated independently with a high risk of ENDunexplained. Furthermore, patients with ENDunexplained were associated with a shift toward worse 90-day outcomes (mRS 5 vs 3, common OR=5.24, 95% CI 3.22 to 8.52, p<0.001).ConclusionsENDunexplained associated with poor 90day outcomes occurred in 4.3% of patients with acute LVO undergoing EVT. Several independent predictors of ENDunexplained were identified in this study, which should be considered in daily practice to improve acute LVO management.Clinical trial Registrationhttp://wwwclinicaltrialsgovNCT03370939.

Intravenous thrombolysis + endovascular thrombectomy versus thrombolysis alone in large vessel occlusion mild stroke: a propensity score matched analysis

“…In this scenario, the risk/benefit balance of EVT in mild LVO seems not favourable. It is worth noting that, beside obvious causes, END after EVT may remain unexplained (UnEND); interestingly, two recent studies on LVO AIS found that UnEND after EVT was independently associated with low initial NIHSS score [38,39]. These findings suggest that patients with mild symptoms may be at increased risk of UnEND after EVT and our results may support this hypothesis.…”

“…One possible explanation may be related to higher rates of non‐haemorrhagic END in the IVT + EVT group. END is reported after EVT and is associated with poor outcome [36–39]. Beside SICH, other obvious causes of EVT‐related END can only partially be addressed; intra‐procedural complications may therefore partially explain our findings.…”

Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease

“…8 Many groups adopted these diagnostic criteria for ICAD-LVO in clinical practice with subsequent studies. 3 9 10 11 12 However, in other studies, 50% was the cut-off value for the degree of fixed stenosis in the diagnosis of ICAD-LVO after MT. 13 14 15 16 Some studies also considered fixed stenosis degree < 50% but with flow and perfusion impairment on angiography or evidence of reocclusive tendency after MT as ICAD-LVO.…”

Predictors of parenchymal hemorrhage after endovascular treatment in acute ischemic stroke: data from ANGEL-ACT Registry

“…A high NLR is associated with an intense inflammatory reaction 16. When AIS occurs, the immune system is activated, lymphocytes are suppressed by systemic stress, and neutrophils migrate to the ischemic area 17. Then, the serum neutrophil counts increase, whereas lymphocyte counts decrease over time in patients undergoing EVT 18.…”