Vol 58, No 2 (2024)
Research Paper
Published online: 2024-02-07

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Predictors of good functional outcome in ischaemic stroke patients without delayed neurological improvement after mechanical thrombectomy

Paweł Wrona12, Dominik Wróbel3, Viktoriia Popadynets3, Joanna Jóźwik3, Katarzyna Sawczyńska12, Tomasz Homa2, Ewa Włodarczyk2, Roman Pułyk12, Tadeusz Popiela45, Agnieszka Słowik12, Wojciech Turaj12
Pubmed: 38324116
Neurol Neurochir Pol 2024;58(2):185-192.

Abstract

Introduction. This study aimed to identify predictors of 90-day good functional outcome (GFO) in patients with acute ischaemic stroke (AIS) who were treated with mechanical thrombectomy but did not achieve a delayed neurological improvement (DNI).

Clinical rationale for the study. In-hospital neurological improvement in patients with AIS is consistently associated with long- -term GFO. Patients who experience neither early nor delayed neurological improvement can still achieve long-term GFO, but predictors of such an outcome have not been studied.

Material and methods. This single-centre retrospective study involved 307 patients with anterior circulation AIS treated with mechanical thrombectomy. Multiple clinical, biochemical, radiological, and treatment-related variables were collected and analysed. DNI on day 7 was defined as at least a 10-point reduction in the National Institutes of Health Stroke Scale (NIHSS) score or NIHSS score < 2. GFO on day 90 was defined as a modified Rankin Scale (mRS) score ≤ 2. We compared the characteristics of patients with and without DNI, with special attention paid to patients who achieved 90-GFO despite a lack of DNI. Multivariate analyses were then performed to establish independent predictors of 90-day GFO among patients without DNI.

Results. DNI occurred in 150 out of 307 patients (48.7%) and significantly increased the odds for 90-day GFO (odds ratio [OR]: 13.99; p < 0.001). Among patients without DNI, 41.4% achieved 90-day GFO. Younger age (OR: 0.96; 95% confidence interval [CI]: 0.93–0.99; p = 0.008), lower baseline NIHSS score (OR: 0.80; 95% CI: 0.73–0.89; p < 0.001), treatment with intravenous thrombolysis (OR: 3.06; 95% CI: 1.25–7.49; p = 0.014), lack of an undetermined aetiology (OR: 0.40; 95% CI: 0.16–0.998; p = 0.050), lack of pneumonia (OR: 0.08; 95% CI: 0.02–0.31; p < 0.001), and higher haemoglobin concentration on admission (OR: 1.31; 95% CI: 1.04–1.69; p = 0.024) were identified as predictors of 90-day GFO in this subgroup.

Conclusion. Almost half of patients with AIS in anterior circulation treated with mechanical thrombectomy experience DNI, which is a good predictor of 90-day GFO. Furthermore, 40% of patients without DNI achieve 90-day GFO which can be independently predicted by younger age, lower baseline NIHSS score, treatment with intravenous thrombolysis, higher haemoglobin concentration on admission, lack of undetermined ischaemic stroke aetiology, and lack of pneumonia.

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References

  1. Kobeissi H, Ghozy S, Bilgin C, et al. Early neurological improvement as a predictor of outcomes after endovascular thrombectomy for stroke: a systematic review and meta-analysis. J Neurointerv Surg. 2023; 15(6): 547–551.
  2. Guettier S, Cogez J, Bonnet AL, et al. Factors associated with timing of early neurological improvement after thrombolysis for ischaemic stroke. Eur J Neurol. 2016; 23(3): 664–667.
  3. Cai H, Han Y, Sun W, et al. Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients. Interv Neuroradiol. 2022; 28(4): 404–410.
  4. Pu J, Wang H, Tu M, et al. Combination of 24-hour and 7-day relative neurological improvement strongly predicts 90-day functional outcome of endovascular stroke therapy. J Stroke Cerebrovasc Dis. 2018; 27(5): 1217–1225.
  5. Smith CJ, Kishore AK, Vail A, et al. Diagnosis of stroke-associated pneumonia: recommendations from the pneumonia in stroke consensus group. Stroke. 2015; 46(8): 2335–2340.
  6. Aslanyan S, Weir CJ, Diener HC, et al. GAIN International Steering Committee and Investigators. Pneumonia and urinary tract infection after acute ischaemic stroke: a tertiary analysis of the GAIN International trial. Eur J Neurol. 2004; 11(1): 49–53.
  7. Talavera B, Gómez-Vicente B, Martínez-Galdámez M, et al. NORDICTUS Investigators*. Delayed neurological improvement after full endovascular reperfusion in acute anterior circulation ischemic stroke. Stroke. 2021; 52(7): 2210–2217.
  8. Sacco RL, Kasner SE, Broderick JP, et al. American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013; 44(7): 2064–2089.
  9. Turc G, Bhogal P, Fischer U, et al. European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE). Eur Stroke J. 2019; 4(1): 6–12.
  10. European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008; 25(5): 457–507.
  11. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013; 310(20): 2191–2194.
  12. Adams HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of org 10172 in acute stroke treatment. Stroke. 1993; 24(1): 35–41.
  13. Nowak K, Derbisz J, Pęksa J, et al. Post-stroke infection in acute ischemic stroke patients treated with mechanical thrombectomy does not affect long-term outcome. Postepy Kardiol Interwencyjnej. 2020; 16(4): 452–459.
  14. Fonarow GC, Reeves MJ, Zhao X, et al. Get With the Guidelines-Stroke Steering Committee and Investigators. Age-related differences in characteristics, performance measures, treatment trends, and outcomes in patients with ischemic stroke. Circulation. 2010; 121(7): 879–891.
  15. Desai SM, Tonetti DA, Morrison AA, et al. Delayed functional independence after thrombectomy: temporal characteristics and predictors. J Neurointerv Surg. 2020; 12(9): 837–841.
  16. Jadhav AP, Desai SM, Gupta R, et al. Delayed Functional Independence After Neurothrombectomy (DEFIANT) score: analysis of the Trevo Retriever Registry. J Neurointerv Surg. 2023; 15(e1): e148–e153.
  17. Junttola U, Lahtinen S, Liisanantti J, et al. Medical complications and outcome after endovascular therapy for acute ischemic stroke. Acta Neurol Scand. 2021; 144(6): 623–631.
  18. Lyden P. Using the National Institutes of Health Stroke Scale: a cautionary tale. Stroke. 2017; 48(2): 513–519.
  19. Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021; 6(1): I–LXII.
  20. Barlas RS, Honney K, Loke YK, et al. Impact of hemoglobin levels and anemia on mortality in acute stroke: analysis of UK regional registry data, systematic review, and meta-analysis. J Am Heart Assoc. 2016; 5(8).
  21. Park YHo, Kim BJ, Kim JS, et al. Impact of both ends of the hemoglobin range on clinical outcomes in acute ischemic stroke. Stroke. 2013; 44(11): 3220–3222.
  22. Dexter F, Hindman BJ. Effect of haemoglobin concentration on brain oxygenation in focal stroke: a mathematical modelling study. Br J Anaesth. 1997; 79(3): 346–351.
  23. Ferrucci L, Guralnik JM, Woodman RC, et al. Proinflammatory state and circulating erythropoietin in persons with and without anemia. Am J Med. 2005; 118(11): 1288.
  24. Zhu H, Hu S, Li Y, et al. Interleukins and ischemic stroke. Front Immunol. 2022; 13: 828447.
  25. Langhorne P, Stott DJ, Robertson L, et al. Medical complications after stroke: a multicenter study. Stroke. 2000; 31(6): 1223–1229.
  26. Quyet Do, Hien NM, Khan MX, et al. Risk factors for stroke associated pneumonia. Open Access Maced J Med Sci. 2019; 7(24): 4416–4419.
  27. Camm AJ. Atrial fibrillation. Cryptogenic stroke--can we abandon this apologetic diagnosis? Nat Rev Cardiol. 2014; 11(9): 504–505.
  28. Jabaudon D, Sztajzel J, Sievert K, et al. Usefulness of ambulatory 7-day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack. Stroke. 2004; 35(7): 1647–1651.
  29. Gladstone DJ, Spring M, Dorian P, et al. EMBRACE Investigators and Coordinators. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014; 370(26): 2467–2477.
  30. Sinha AM, Diener HC, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation (CRYSTAL AF): design and rationale. Am Heart J. 2010; 160(1): 36–41.e1.
  31. Hellwig S, Grittner U, Audebert H, et al. Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation. Europace. 2018; 20(4): 569–574.
  32. Johnsen SP, Svendsen ML, Hansen ML, et al. Preadmission oral anticoagulant treatment and clinical outcome among patients hospitalized with acute stroke and atrial fibrillation: a nationwide study. Stroke. 2014; 45(1): 168–175.
  33. Tomaszewska-Lampart I, Wiącek M, Bartosik-Psujek H. Risk factors for infarct growth and haemorrhagic or oedematous complications after endovascular treatment - a literature review. Neurol Neurochir Pol. 2022; 56(5): 389–398.
  34. Lasek-Bal A, Żak A, Binek Ł, et al. Relevance of admission hyperglycaemia and diabetes mellitus to efficacy and safety of mechanical thrombectomy in stroke patients. Neurol Neurochir Pol. 2022; 56(6): 472–479.



Neurologia i Neurochirurgia Polska