Early prediction of the 3-month outcome for individual acute ischemic stroke patients who received intravenous thrombolysis using the N2H3 nomogram model

 In what magical universe do you live in where ANYTHING here is going to get survivors better recovery?

Early prediction of the 3-month outcome for individual acute ischemic stroke patients who received intravenous thrombolysis using the N2H3 nomogram model

Show all authors

Shan Lv, Yu Song, Fu-Liang Zhang, ...

First Published September 4, 2020 Research Article 

https://doi.org/10.1177/1756286420953054

Article information

 

Abstract

Background:

The aim of this study was to establish a nomogram model for individualized early prediction of the 3-month prognosis in patients with acute ischemic stroke (AIS) who were treated with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis.

Methods:

A total of 691 patients were included in this study; 564 patients were included in the training cohort, while 127 patients were included in the test cohort. The main outcome measure was a 3-month unfavorable outcome (modified Rankin Scale 3–6). To construct the nomogram model, stepwise logistic regression analysis was applied to select the significant predictors of the outcome. The discriminative performance of the model was assessed by calculating the area under the receiver operating characteristic curve (AUC-ROC). A decision curve analysis was used to evaluate prognostic value of the model.

Results:

The initial National Institutes of Health Stroke Scale [NIHSS, odds ratio (OR), 1.35; 95% confidence interval (CI), 1.28–1.44; p < 0.001], delta NIHSS (changes in the NIHSS score from baseline to 24 h, OR, 0.75; 95% CI, 0.70–0.79; p < 0.001), hypertension (OR, 2.07; 95% CI, 1.32–3.31; p = 0.002), hyperhomocysteinemia (Hhcy, OR, 2.18; 95% CI, 1.20–4.11; p = 0.013), and the ratio of high-density lipoprotein cholesterol (HDL-C) to low-density lipoprotein cholesterol (LDL-C) (HDL-C/LDL-C, OR, 3.29; 95% CI, 1.00–10.89; p = 0.049) (N2H3) were found to be independent predictors of a 3-month unfavorable outcome from multivariate logistic regression analysis and were incorporated in the N2H3 nomogram model. The AUC-ROC of the training cohort was 0.872 (95% CI, 0.841–0.902), and the AUC-ROC of the test cohort was 0.900 (95% CI, 0.848–0.953).

Conclusion:

The study presented the N2H3 nomogram model, with initial NIHSS score, delta NIHSS, hypertension, Hhcy, and HDL-C/LDL-C as predictors. It therefore provides an individualized early prediction of the 3-month unfavorable outcome in AIS patients treated with intravenous rt-PA thrombolysis.

Keywords acute ischemic stroke, intravenous thrombolysis, nomogram, prognosis

Introduction

Ischemic stroke is highly prevalent worldwide. As one of the leading causes of disability and mortality, ischemic stroke places a significant burden on patients and caregivers. Thrombolysis has been found to be the most effective medical treatment for acute ischemic stroke (AIS) patients. The primary thrombolytic agent, recombinant tissue plasminogen activator (rt-PA), is the most widely used thrombolytic drug worldwide.^1–4 Unfortunately, some patients still experience functional deficits after rt-PA thrombolysis. Accurate and early prediction of the clinical outcome for individual AIS patients who receive rt-PA treatment is needed to provide a reasonable approach to patient management.⁵

A series of prognostic models established using various statistical methods have been reported in the past few decades with the aim of predicting long-term patient outcome after intravenous thrombolysis.^6–11 As a graphical statistical instrument, nomograms make it possible to individually predict outcomes by calculating the scores of each individual based on their own characteristics. The nomogram has been used widely for clinical decision making in multiple clinical conditions, including ischemic stroke, myocardial infarction, and cancer.^5,12–16 Nomograms have also been used to predict outcome of patients receiving thrombolysis, including the START (National Institutes of Health Stroke Scale score, age, pre-stroke mRS score, onset-to-treatment time) nomogram for prediction of unfavorable outcome and the STARTING-SICH (systolic blood pressure, age, onset-to-treatment time for thrombolysis, National Institutes of Health Stroke Scale score, glucose, aspirin alone, aspirin plus clopidogrel, anticoagulant with INR ⩽1.7, current infarction sign, hyperdense artery sign) nomogram for prediction of symptomatic intracerebral hemorrhage.^5,17

The aim of this present study was to develop and validate a simple and reliable nomogram model for early and individual prediction of 3-month prognosis in AIS patients who treated with intravenous thrombolysis. To obtain a stronger power of prediction, we use both clinical characteristics and laboratory tests as variables.