Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

WHO THE FUCK CARES ABOUT PREDICTING DETERIORATION RATHER THAN PRODUCING INTERVENTIONS THAT PREVENT SUCH DETERIORATION? Such stupid research is approved by whom?

Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

Pierre Seners, MD¹; Wagih Ben Hassen, MD²; Bertrand Lapergue, MD³; et al Caroline Arquizan, MD⁴; Mirjam R. Heldner, MD⁵; Hilde Henon, MD⁶; Claire Perrin, MSc¹; Davide Strambo, MD⁷; Jean-Philippe Cottier, MD⁸; Denis Sablot, MD⁹; Isabelle Girard Buttaz, MD¹⁰; Ruben Tamazyan, MD¹¹; Cécile Preterre, MD¹²; Pierre Agius, MD^12,13; Nadia Laksiri, MD¹⁴; Laura Mechtouff, MD¹⁵; Yannick Béjot, MD¹⁶; Duc-Long Duong, MD¹⁷; François Mounier-Vehier, MD¹⁸; Gioia Mione, MD¹⁹; Charlotte Rosso, MD²⁰; Ludovic Lucas, MD²¹; Jérémie Papassin, MD^22,23; Andreea Aignatoaie, MD²⁴; Aude Triquenot, MD²⁵; Emmanuel Carrera, MD²⁶; Philippe Niclot, MD²⁷; Alexandre Obadia, MD²⁸; Aïcha Lyoubi, MD²⁹; Pierre Garnier, MD³⁰; Nicolae Crainic, MD³¹; Valérie Wolff, MD³²; Clément Tracol, MD³³; Frédéric Philippeau, MD³⁴; Chantal Lamy, MD³⁵; Sébastien Soize, MD³⁶; Jean-Claude Baron, MD¹; Guillaume Turc, MD¹; for the MINOR-STROKE Collaborators

Author Affiliations

JAMA Neurol. Published online January 11, 2021. doi:10.1001/jamaneurol.2020.4557

Key Points

Question  Is early neurological deterioration of ischemic origin (END_i) predictable in patients with minor stroke and large vessel occlusion (LVO) treated with intravenous thrombolysis (IVT)?

Findings  In this cohort of 729 patients with minor stroke (National Institutes of Health Stroke Scale score of 5 or less) and LVO intended for IVT alone, an easily applicable score based on occlusion site and thrombus length—2 independent predictors of END_i—showed good discriminative power for END_i risk prediction and was successfully validated in an independent cohort of 347 patients.

Meaning  END_i can be reliably predicted in patients with IVT-treated minor strokes and LVO, which may help to select the best candidates for direct transfer for additional thrombectomy.

Abstract

Importance  The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (END_i) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy.

Objective  To develop and validate an easily applicable predictive score of END_i following IVT in patients with minor stroke and LVO.

Design, Setting, and Participants  This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of END_i. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019.

Main Outcomes and Measures  END_i, defined as 4 or more points’ deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause.

Results  Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). END_i occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with END_i. A 4-point score derived from these variables—1 point for thrombus length and 3 points for occlusion site—showed good discriminative power for END_i (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (END_i rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, END_i probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively.

Conclusions and Relevance  The substantial END_i rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for END_i risk prediction that may assist decision-making was derived and externally validated.(Do you really think survivors want to hear your predictions of their failure to recover? What fucking universe do you live in?)

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