Background and purpose To investigate early clinical surrogates for long-term independency of patients treated with thrombectomy for large vessel occlusion stroke in daily clinical routine.
Methods All patients with anterior circulation stroke enrolled in the German Stroke Registry-Endovascular Treatment from 07/2015 to 04/2018 were analysed. National Institute of Health Stroke Scale (NIHSS) on admission, NIHSS percentage change, NIHSS delta and NIHSS at 24 hours as well as existing binary definitions of early neurological improvement (ENI; improvement of 8 (major ENI)/10 (dramatic ENI) NIHSS points or reaching 0/1 were compared for predicting functional outcome at 90 days using the modified Rankin Scale (mRS). Excellent and favourable outcome were defined as 0–1 and 0–2, respectively.
Results Among 2262 endovasculary treated patients with acute ischaemic anterior circulation stroke, NIHSS at 24 hours had the highest discriminative ability to predict excellent (receiver operator characteristics (ROC)NIHSS 24 hours area under the curve (AUC) 0.86 (0.84–0.88)) and favourable long-term functional outcome (ROCNIHSS 24 hours AUC 0.86 (0.85–0.88)) in comparison to NIHSS percentage change (ROC% change AUC mRS ≤1: 0.81 (0.78–0.83) mRS ≤2: 0.81 (0.79–0.83)), NIHSS delta change (ROCΔ change AUC mRS ≤1: 0.74 (0.72–0.77), mRS ≤2: 0.77 (0.74–0.79)) and NIHSS admission (ROCAdm AUC mRS ≤1: 0.70 (0.68–0.73), mRS ≤2: 0.67 (0.68–0.71)). Advanced age was the only independent predictor (adjusted OR 1.05, 95% CI 1.03 to 1.07, p<0.001) for turning the outcome prognosis from favourable (mRS ≤2) to poor (mRS ≥4) at 90 days.
Conclusion The NIHSS at 24 hours postintervention with a threshold of ≤8 points serves best as a surrogate for long-term functional outcome after thrombectomy for anterior circulation stroke in daily clinical practice. Only advanced age significantly decreases its predictive value.
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HK and UH contributed equally.
Collaborators GSR-ET Collaborators Tobias Boeckh-Behrens; Silke Wunderlich; Arno Reich; Martin Wiesmann; Ulrike Ernemann; Till-Karsten Hauser; Eberhard Siebert; Sarah Zweynert; Georg Bohner; Alexander Ludolph; Karl-Heinz Henn; Waltraud Pfeilschifter; Marlis Wagner; Joachim Röther; Bernd Eckert; Jörg Berrouschot; Albrecht Bormann; Christian Gerloff; Elke Hattingen; Gabor Petzold; Sven Thonke; Christopher Bangard; Christoffer Kraemer; Martin Dichgans; Frank Wollenweber; Lars Kellert; Franziska Dorn; Moriz Herzberg; Marios Psychogios; Jan Liman; Florian Stögbauer; Martina Petersen; Peter Kraft; Mirko Pham; Michael Braun; Gerhard F. Hamann; Andreas Kastrup; Christian Roth; Klaus Gröschel; Timo Uphaus; Volker Limmroth.
Contributors LM, HK and UH made substantial contributions to the conception and design of the work. LM, GS and HK performed the data analysis. Interpretation of the data was done by JF, GT, AA, CB, FF, UH, MB, HL, MD-C and GB. LM drafted the manuscript and all of the other authors revised it critically for important intellectual content. All authors approved the final version to be published. They agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the manuscript are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests JF: Research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; consultancy appointments; Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical; stock holdings for Tegus. GT: Consultant for Acandis, Bayer Healthcare, Boehringer Ingelheim, BristolMyersSquibb/Pfizer, Covidien, Glaxo Smith Kline; lead investigator of the WAKE-UP study; principal investigator of the THRILL study; Grants by the European Union (Grant No. 278276 und 634809) and Deutsche Forschungsgemeinschaft (SFB 936, Projekt C2).
GT: reports receiving consulting fees from Acandis, grant support and lecture fees from Bayer, lecture fees from Boehringer Ingelheim, BristolMyersSquibb/Pfizer, and DaiichiSankyo, and consulting fees and lecture fees from Portola and Stryker.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. The deidentified data analysed in this study will be available and shared on upon reasonable request from any qualified investigator for the purpose of replicating the results after clearance by the ethics and registry committee.