Early neurological deterioration as a predictor of outcomes after endovascular thrombectomy for stroke: A systematic review and meta-analysis

Factors Influencing the Association of 24-hour National Institutes of Health Stroke Scale & 90-day Modified Rankin Score

PURPOSE

The modified Rankin Scale (mRS) at 90 days is the primary outcome in most acute stroke studies, but the long follow-up period has disadvantages. The National Institutes of Health Stroke Scale (NIHSS) at 24 h shows a strong, but imperfect, association with 90-day mRS. This study examines the association between 24-hour NIHSS and 90-day mRS and reasons for discrepancies.

METHODS

Data are from the ESCAPE-NA1 thrombectomy patients. To address the non-normality distribution of the NIHSS and include deceased patients, a 7-point ordinal score was generated by grouping 24-hour NIHSS. The association of ordinal 24-hour NIHSS and 90-day mRS was assessed with adjusted ordinal logistic regression. Differences in baseline and treatment/post-treatment variables were compared between patients with discordant and concordant outcomes.

RESULTS

One-thousand-seventy-six patients with available 24-hour NIHSS and 90-day mRS were included (median 24-hour NIHSS 6[IQR: 2-14], median 90-day mRS 2[IQR: 1-4]). Ordinal 24-hour NIHSS was associated with 90-day mRS (adjusted cOR 2.53 [95%CI 2.33-2.74]). Forty-eight (4.5%) patients had discordant outcomes. Of those, 19(1.8%) had 24-hour NIHSS < 6 and 90-day mRS5-6; all of which had ≥ 1 severe adverse event, most commonly pneumonia (6[31.6%]) or recurrent stroke (4[21.1%]). Twenty-nine patients (2.7%) had 24-hour NIHSS > 14 and 90-day mRS 0-2. In these patients, baseline NIHSS and ASPECTS was lower, and collateral status was worse.

CONCLUSION

An ordinal NIHSS score that includes death at 24 h shows a strong association with 90-day mRS, suggesting that it could be used as an alternative outcome. Patients with discrepant outcomes differed from the remaining patients regarding their baseline NIHSS, ASPECTS, collateral status, and post-stroke complications.

Impact of post-thrombectomy isolated subarachnoid hemorrhage on neurological outcomes in patients with anterior ischemic stroke - a retrospective single-center observational study

PURPOSE

We aimed to investigate the impact of post-thrombectomy isolated subarachnoid hemorrhage (i-SAH) and other types of intracranial hemorrhage (o-ICH) on patient's neurological outcomes.

METHODS

Stroke data from 2018 to 2022 in a tertiary care center were retrospectively analyzed. Patients with large vessel occlusion from ICA to M2 branch were included. Post-thrombectomy intracranial hemorrhages at 24 h were categorized with Heidelberg Bleeding Classification. Neurological impairment of patients was continuously assessed at admission, at 24 h, 48 h and 72 h, and at discharge. Predictors of i-SAH and o-ICH were assessed.

RESULTS

297 patients were included. i-SAH and o-ICH were found in 12.1% (36/297) and 11.4% (34/297) of patients. Overall, NIHSS of i-SAH patients at discharge were comparable to o-ICH patients (median 22 vs. 21, p = 0.889) and were significantly higher than in non-ICH patients (22 vs. 7, p < 0.001). i-SAH often resulted in abrupt deterioration of patient's neurological symptoms at 24 h after thrombectomy. Compared to non-ICH patients, the occurrence of i-SAH was frequently associated with worse neurological outcome at discharge (median NIHSS increase of 4 vs. decrease of 4, p < 0.001) and higher in-hospital mortality (41.7% vs. 23.8%, p = 0.022). Regardless of successful reperfusion (TICI 2b/3), the beneficial impact of thrombectomy appeared to be outweighed by the adverse effect of i-SAH. Incomplete reperfusion and shorter time from symptom onset to admission were associated with higher probability of i-SAH, whereas longer procedure time and lower baseline ASPECTS were predictive for o-ICH occurrence.

CONCLUSION

Post-thrombectomy isolated subarachnoid hemorrhage is a common complication with significant negative impact on neurological outcome.

Early antithrombotic therapy in patients with postinterventional cerebral hyperdensity reduces early neurological deterioration after mechanical thrombectomy

BACKGROUND

Initiation of early antithrombotic therapy after acute ischemic stroke (AIS) is crucial. We aimed to investigate whether early antithrombotic therapy influences early neurological deterioration (END) in AIS patients with postinterventional cerebral hyperdensity (PCHD) immediately after mechanical thrombectomy (MT).

METHODS

We retrospectively analyzed 108 consecutive anterior circulation AIS patients with PCHD immediately after MT. All patients were divided into END group and non-END group and END was defined as an increase of four points or more on the postinterventional National Institutes of Health Stroke Scale (NIHSS) score within the first 72 h after MT. Early antithrombotic therapy was defined as patients with PCHD who received antithrombotic therapy within 24 h after MT. Statistical analyses were performed to evaluate the association between early antithrombotic therapy and the risk of END.

RESULTS

Among 108 patients, 27 (25%) patients developed END. Multivariate regression analysis revealed that early use of antithrombotic therapy (OR = 0.229, 95%CI = 0.083-0.626, P = 0.004) was an independent protector of END and postinterventional low density shadow exceeding 1/3 of the vascular territory (OR = 4.000, 95%CI = 1.157-13.834, P = 0.029) was an independent risk factor for END.

CONCLUSION

Antithrombotic therapy within 24 h after MT maybe associated with the reduced risk of END in anterior circulation AIS patients with PCHD.

Patient characteristics associated with delayed neurological improvement following acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Delayed neurological improvement (DNI) is a phenomenon that involves patient improvement in the absence of early neurological change following treatment for acute ischemic stroke. The patient characteristics associated with this condition are largely unexplored.

METHODS

Following the PRISMA guidelines, a systematic review of the English language literature was conducted using PubMed, Embase, Web of science, and Scopus. We calculated pooled odds ratios (ORs), mean differences (MDs), and their corresponding 95% confidence intervals (CIs) to test the association between patient characteristics and achievement of DNI.

RESULTS

Seven studies, with 3266 patients, were included in our analysis. All studies reported a different definition of DNI, with five studies focusing on rates of good functional outcome at 90 days post-treatment in the absence of early neurological improvement. Use of intravenous thrombolytics was associated with increased rates of DNI (OR 1.96, 95% CI 1.28 to 3.00; p = 0.002). Atrial fibrillation was associated with decreased rates of DNI (OR 0.69, 95% CI 0.57 to 0.82; p < 0.001), as was hypertension (OR 0.66, 95% CI 0.53 to 0.83, p < 0.001), and diabetes mellitus (OR 0.71, 95% CI 0.56 to 0.90; p = 0.005). On average, patients who achieved DNI were 6.30 years younger than their non-DNI counterparts (MD -6.30, 95% CI -9.19 to -3.41; p < 0.001). There were modest associations between male sex and DNI (OR 1.36, 95% CI 1.01 to 1.74, p = 0.042), and smoking and DNI (OR 1.28, 95% CI 1.03 to 1.59, p = 0.027).

CONCLUSIONS

DNI is a phenomenon that is not presently well understood. Lack of uniformity among definitions of DNI hinders efforts to explore DNI and the factors associated with its occurrence. Future studies should work to establish a consensus definition of DNI to determine its causes and significance more accurately.