Sarcopenia and ischemic stroke outcomes after endovascular revascularization: results of a retrospective, cohort study

What is your competent? doctors EXACT PROTOCOL to prevent sarcopenia(muscle loss)! NOTHING?

Let's see how long everyone related to stroke has been incompetent!

sarcopenia (31 posts to March 2016) (Almost a decade and managed not to get fired? Your board of directors is woefully incompetent!)

Sarcopenia and ischemic stroke outcomes after endovascular revascularization: results of a retrospective, cohort study

Lea Maria Bumann¹Bijan Zendeh Zartoshti¹Ulrike Voßmann¹Daniel Cantré²Artem Rafaelian³Daniel Dubinski³Alexander Storch¹Matthias Wittstock^1*†

• ¹Department of Neurology, University Medical Center Rostock, Rostock, Germany
• ²Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
• ³Department of Neurosurgery, University Medical Center Rostock, Rostock, Germany

Stroke is a major cause of disability and mortality, with its incidence increasing with age. Despite advances in acute stroke treatment, functional outcomes in elderly patients are not always as favorable as expected. Therefore, additional efforts are required to identify reliable prognostic markers and improve patient outcomes. Sarcopenia has been recognized as a negative factor influencing functional outcomes after ischemic stroke. Temporalis muscle thickness (TMT), assessed on routine imaging, has emerged as a potential surrogate marker for sarcopenia; however, its prognostic value in stroke patients has not yet been conclusively established. This study aimed to evaluate the association between TMT and functional outcome, assessed using the modified Rankin Scale (mRS) at hospital discharge, and in-hospital death. In this retrospective cohort study, we included 152 consecutive patients (median age, 74 years [IQR, 63–83]; 53% male) admitted to the Department of Neurology at the University of Medicine Rostock who underwent endovascular revascularization (EVT) for acute ischemic stroke. TMT was determined from initial cranial CT scans. Due to the small sample size, we used a uniform TMT cutoff value (5.78 mm) for sarcopenia. The primary endpoint was the mRS at discharge. Sarcopenic patients were older (p < 0.001), more often female (p < 0.001), and had a lower BMI (p = 0.045). They also had significantly worse functional outcomes (p = 0.006) and higher comorbidity burdens (atrial fibrillation, p = 0.023; arterial hypertension, p = 0.024; smoking, p = 0.020). Poor outcome was significantly associated with sarcopenia, but this association lost significance after adjustment. In the group comparison regarding mortality, deceased patients had lower TMT and were more frequently sarcopenic. However, these associations also lost significance in the multivariate model.

Introduction

Stroke is a major cause of disability and mortality worldwide (1). Its incidence increases with age (2). Despite improvements in care and treatment, the functional outcome in elderly stroke patients is not always as favorable as expected. Sarcopenia has been discussed as a contributing factor in this context (3, 4). Sarcopenia—defined as the loss of skeletal muscle mass—has been shown to increase after stroke. Both sarcopenia and stroke have been associated with worse functional outcomes (3, 4). This highlights the importance of measuring skeletal muscle mass as a measure of sarcopenia in older stroke patients with respect to functional outcomes.

Diagnostic tools for assessing sarcopenia rely on methods that estimate muscle quantity, including magnetic resonance imaging (MRI) and computed tomography (CT) scans of the lumbar muscles obtained during abdominal scans (5–7). More recently, estimation of temporalis muscle thickness (TMT) has become a favorable approach for sarcopenia measurement, as it can be easily, quickly, and reliably performed during routine imaging. This has been demonstrated in cerebellar ischemia and traumatic brain injury (8, 9). Evidence of the prognostic value of TMT in EVT for ischemic stroke is limited, and the relevance of TMT measurements is not fully clarified (10, 11). The current study aimed to investigate the association between TMT, as a measure of sarcopenia, and functional outcomes and to assess mortality in elderly patients undergoing EVT for acute ischemic stroke at hospital discharge.

Methods

Study design

In this retrospective cross-sectional cohort study, we screened the hospital charts of 220 consecutive patients admitted to the Department of Neurology of the University Medicine Rostock between January 2022 and December 2023 undergoing revascularization procedures (thrombolysis, endovascular thrombectomy, or both) for acute ischemic stroke. After exclusion of patients with insufficient clinical data due to wrong coding or duplicate records, a total of 152 patients were included in the final analysis (see Figure 1 for study flowchart). This study was conducted in accordance with the amended Declaration of Helsinki and was approved by the local ethics committee (A 2024–0039).

Figure 1

Figure 1. Study flowchart.

Patients

All patients received standard-of-care treatment according to the European Stroke Organization Guidelines for ischemic stroke (12). Basic characteristics such as age, sex, body mass index (BMI), pre-morbid disability measured by the individual’s category in the Clinical Frailty Scale (CFS) from the Canadian Study of Health and Aging (CSHA) (13), cardiovascular risk factors, presence of advance directive, and imaging data, as well as therapeutic procedures of the acute phase and length of hospitalization were obtained. Clinical severity of stroke was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the ASPECTS score (14).

The topology of stroke was assessed by an experienced board-certified neuroradiologist (D.C.) who was blinded to the hypothesis investigated in this study using cerebral CT or MRI. The occurrence of large vessel occlusion (LVO) was determined. Stroke volumes were measured on CT or MRI scans using Brainlab software (Brainlab AG), and the ASPECTS score was determined (14). After EVT, flow restoration at the end of each procedure was graded using the modified Treatment In Cerebral Infarction (mTICI) scale, with optimal recanalization corresponding to a score of 2b-3 (15).

The mRS score at discharge from the hospital represents the primary outcome measure. An mRS score between 0 and 3 was considered a good functional outcome, scores between 4 and 6 represented a bad outcome, and a score of 6 represented in-hospital death, which was assessed separately (16). A 24-h follow-up CT scan was assessed to identify complications such as brain bleeding events (secondary intracranial hemorrhage ICH), defined according to the European Cooperative Acute Stroke Study (ECASS II) classification (17).

TMT measurement

TMT was assessed on CT or MRI scans at admission according to the method presented previously by Ravera et al. and Steindl et al. (18, 19). In detail, TMT was manually measured on the patient’s baseline brain CT scan using the method introduced by Katsuki et al. (20). Slice thickness was set at 5 mm, and the CT axial image was manually adjusted to obtain a symmetric cross-section. TMT was measured bilaterally, perpendicular to the long axis of the temporal muscle. Three determinations were taken for each side: one at the level of the orbital roof, identified by comparing a sagittal view, another 5 mm above the orbital roof, and the last at 5 mm below the orbital roof. The arithmetic mean of the three measurements was calculated for both the left and right sides. Once the right and left means were obtained, the final TMT, expressed in millimeters, was measured by calculating the arithmetic mean between the two values. Based on the mean TMT values, patients were further divided into two groups: sarcopenic (TMT < 5.78 mm) and non-sarcopenic (TMT ≥ 5.78 mm). Because of the small sample size, female and male patients were analyzed together in each group. An analysis of sex-specific differences according to sex-specific TMT cutoffs was performed according to Steindl et al. The results are provided in Supplementary Tables S1, S2.

Statistical analysis

For statistical comparisons between groups, the Mann–Whitney U-test or Kruskal–Wallis test was used for comparison of parametric data, and the Pearson’s chi-squared test or Fisher’s exact test for comparison of non-parametric data, as appropriate. For ordinal data, the Jonckheere–Terpstra test was applied. To test whether there was an association between categorical clinical variables and the outcome of interest, univariate and multivariate binary logistic (for in-hospital death as the dependent outcome variable) or ordinal regression analyses (for mRS as the dependent outcome measure) were performed. To select relevant covariates, we performed the Mann–Whitney U-test and the chi-squared/Fisher’s exact test in combination with univariate regression models to determine the predictive values and odds ratios (ORs) with 95% confidence intervals (95% CIs) of the candidate covariates age, sex, NIHSS at admission, stroke volume, intracerebral hemorrhage, length of hospital stay, aspiration pneumonia, and atrial fibrillation (for detailed information, see Supplementary Tables S3, S4). Before calculating multivariate regressions, assumptions of normality, homoscedasticity, independence of errors, and absence of multicollinearity were checked. The results (variance inflation factor values) are shown in the Supplementary Tables S5, S6.

Analyses were conducted using R software, version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria) via RStudio version 2024.09.0 (Posit Software, PBC), and all p-values were two-sided, and values of P less than 0.05 were considered statistically significant. Due to the limited sample size in our retrospective study, adjustment of p-values was not carried out to preserve statistical power.

Results

Demographic and clinical characteristics

A total of 220 consecutive patients treated by EVT for LVO in ischemic stroke were screened; 68 were excluded due to wrong coding or unavailable clinical data (Figure 1). At admission, all patients except one received CT imaging (1 patient underwent MR imaging, 0.7%). A total of 152 ischemic stroke patients with LVO were included (median age 74 years [IQR 63–83 years]; 53.0% men). The median value of NIHSS at admission was 16 (IQR 10–19). Detailed demographic and clinical characteristics are illustrated in Table 1.