scholarly journals Mechanical Thrombectomy Beyond 2b Reperfusion: Should We Pursue a Higher Reperfusion Grade after Achievement of 2b?

2022 ◽  
Vol 2 (1) ◽  
Author(s):  
Junpei Koge ◽  
Kanta Tanaka ◽  
Takeshi Yoshimoto ◽  
Masayuki Shiozawa ◽  
Tsuyoshi Ohta ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
Primary Motor Cortex ◽  
Mechanical Thrombectomy ◽  
Favorable Outcome ◽  
Anterior Circulation ◽  
Clinical Trial Registration ◽  
Neurological Improvement ◽  
Symptomatic Intracranial Hemorrhage

Background Extended thrombolysis in cerebral infarction (eTICI) 2c/3 reperfusion after mechanical thrombectomy (MT) is associated with better stroke outcomes than eTICI 2b. Whether additional MT attempt after achieving eTICI 2b (beyond 2b attempt) leads to better outcomes is unknown. Methods Consecutive patients with acute anterior circulation stroke who achieved eTICI 2b during MT were divided into 2 groups: those who further tried MT (beyond‐2b group) and those without (nonbeyond‐2b group). The patients who directly achieved eTICI 2c/3 without experiencing 2b (direct‐2c/3 group) were also studied. The outcomes included the reperfusion status, favorable outcome (3‐month modified Rankin scale score of 0–2), neurological improvement (a ≥10‐point decrease of the National Institutes of Health Stroke Scale score from baseline or the score of 0) at 24 hours and symptomatic intracranial hemorrhage. Results Of 308 patients, 50 were in the beyond‐2b group, 87 in the nonbeyond‐2b group, and the remaining 171 in the direct‐2c/3 group. Perfusion of middle cerebral artery branches supplying the primary motor cortex was worse in the beyond‐2b than the nonbeyond‐2b group at the time of eTICI 2b ( P =0.007). Favorable outcome was similarly common (48% for each, P =0.40). Neurological improvement was more frequent (52% versus 37%; P =0.04) and symptomatic intracranial hemorrhage tended to be more common (6% versus 1%, P =0.11) in the beyond‐2b than the nonbeyond‐2b group. Eighteen patients (36%) in the beyond‐2b group finally achieved eTICI 2c/3; 10 of these (56%) and 14 of the remaining 32 (44%) had favorable outcome ( P =0.83). The former rate was similar to that in the direct‐2c/3 group (58%; P =0.99). Conclusions Patients undergoing additional MT attempt after achieving eTICI 2b had numerically but not significantly more symptomatic intracranial hemorrhage and showed a similar level of functional outcome at 3 months than those who did not. When eTICI 2c/3 was finally achieved by additional attempts, functional outcome was similar with that of patients who directly achieved eTICI 2c/3 without experiencing 2b. Clinical Trial Registration Information URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.

Mechanical thrombectomy in nonagenarians with acute ischemic stroke

2019 ◽  
Vol 11 (11) ◽  
pp. 1091-1094 ◽  
Author(s):  
Lukas Meyer ◽  
Maria Alexandrou ◽  
Hannes Leischner ◽  
Fabian Flottmann ◽  
Milani Deb-Chatterji ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Functional Outcome ◽  
Mechanical Thrombectomy ◽  
Very Elderly ◽  
Anterior Circulation ◽  
Serious Adverse Events ◽  
Good Functional Outcome ◽  
Symptomatic Intracranial Hemorrhage

BackgroundMechanical thrombectomy (MT) is a safe and effective therapy for ischemic stroke. Nevertheless, very elderly patients aged ≥90 years were either excluded or under-represented in previous trials. It remains uncertain whether MT is warranted for this population or whether there should be an upper age limit.MethodsWe retrospectively reviewed 79 patients with stroke aged ≥90 years from three neurointerventional centers who underwent MT between 2013 and 2017. Good functional outcome was defined as modified Rankin scale (mRS) ≤2 and assessed at 90-day follow-up. Successful recanalization was graded by Thrombolysis in Cerebral Infarction Scale (TICI) ≥2 b. Feasibility and safety assessments included unsuccessful recanalization attempts (TICI 0), time from groin puncture to recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and intervention-related serious adverse events.ResultsOnly occlusions within the anterior circulation were included. Median time from groin puncture to recanalization was 39 min (IQR 25–57 min). The rate of successful recanalization (TICI ≥2 b) was 69.6% (55/79). Good functional outcome (mRS ≤2) at 90 days was observed in 16% (12/75) of patients. In-hospital mortality was 29.1% (23/79) and increased significantly at 90 days (46.7%, 35/75; p<0.001). sICH occurred in 5.1% (4/79) of patients. No independent predictor for good functional outcome (mRS ≤2) at 90 days was identified through logistic regression analysis.ConclusionMT in nonagenarians leads to high mortality rates and less frequently good functional outcome compared with younger patient cohorts in previous large randomized trials. However, MT appears to be safe and beneficial for a certain number of very elderly patients and therefore should generally not be withheld from nonagenarians.

Acute endovascular treatment delivery to ischemic stroke patients transferred within a telestroke network: a retrospective observational study

2016 ◽  
Vol 12 (5) ◽  
pp. 502-509 ◽  
Author(s):  
Jessica Barlinn ◽  
Johannes Gerber ◽  
Kristian Barlinn ◽  
Lars-Peder Pallesen ◽  
Timo Siepmann ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Intravenous Tissue Plasminogen Activator ◽  
Symptomatic Intracranial Hemorrhage ◽  
Stroke Center ◽  
Favorable Functional Outcome

Background Five randomized controlled trials recently demonstrated efficacy of endovascular treatment in acute ischemic stroke. Telestroke networks can improve stroke care in rural areas but their role in patients undergoing endovascular treatment is unknown. Aim We compared clinical outcomes of endovascular treatment between anterior circulation stroke patients transferred after teleconsultation and those directly admitted to a tertiary stroke center. Methods Data derived from consecutive patients with intracranial large vessel occlusion who underwent endovascular treatment from January 2010 to December 2014 at our tertiary stroke center. We compared baseline characteristics, onset-to-treatment times, symptomatic intracranial hemorrhage, in-hospital mortality, reperfusion (modified Treatment in Cerebral Infarction 2b/3), and favorable functional outcome (modified Rankin scale ≤ 2) at discharge between patients transferred from spoke hospitals and those directly admitted. Results We studied 151 patients who underwent emergent endovascular treatment for anterior circulation stroke: median age 70 years (interquartile range, 62–75); 55% men; median National Institutes of Health Stroke Scale score 15 (12–20). Of these, 48 (31.8%) patients were transferred after teleconsultation and 103 (68.2%) were primarily admitted to our emergency department. Transferred patients were younger (p = 0.020), received more frequently intravenous tissue plasminogen activator (p = 0.008), had prolonged time from stroke onset to endovascular treatment initiation (p < 0.0001) and tended to have lower rates of symptomatic intracranial hemorrhage (4.2% vs. 11.7%; p = 0.227) and mortality (8.3% vs. 22.6%; p = 0.041) than directly admitted patients. Similar rates of reperfusion (56.2% vs. 61.2%; p = 0.567) and favorable functional outcome (18.8% vs. 13.7%; p = 0.470) were observed in telestroke patients and those who were directly admitted. Conclusions Telestroke networks may enable delivery of endovascular treatment to selected ischemic stroke patients transferred from remote hospitals that is equitable to patients admitted directly to tertiary hospitals.

Mechanical Thrombectomy in Acute Stroke Due to Carotid Occlusion: A Series of 153 Consecutive Patients

2018 ◽  
Vol 46 (3-4) ◽  
pp. 130-139 ◽  
Author(s):  
Jose Díaz-Pérez ◽  
Guillermo Parrilla ◽  
Mariano Espinosa de Rueda ◽  
Jose María Cabrera-Maqueda ◽  
Blanca García-Villalba ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Perfusion Ct ◽  
Clinical Prognosis ◽  
Symptomatic Intracranial Hemorrhage ◽  
Baseline Characteristics

Background: Strokes due to carotid artery occlusion (CAO) are associated with bad clinical prognosis and poor response to intravenous thrombolysis. Several studies in the past have shown the benefits of mechanical thrombectomy (MT) and compared bridging therapy (BT) and primary MT (PMT) in large vessel occlusions, but only a few studies have focused on the specific population of CAO and their response to endovascular treatment. Methods: Retrospective review of patients treated at our center between January 2010 and June 2017 that (1) presented with acute ischemic stroke caused by CAO in the first 4.5 h since symptom onset, and (2) were treated with MT (BT or PMT). Baseline characteristics of the population, comparison between BT and PMT, intrahospital mortality, symptomatic intracranial hemorrhage, and functional outcome were investigated. Results: A total of 153 patients were included. Baseline characteristics: 51.6% were male, and the median age was 71 years. The most frequent risk factor was hypertension (71.9%). The main stroke etiology was atherothrombotic (40.5%). The mean admission National Institute of Health Severity Score (NIHSS) was 19, mean discharge NIHSS was 7. Isolated occlusion of the Extracranial or Intracranial Internal Carotid Artery was the most frequent occlusion location (52.3%). TICI 2b-3 was achieved in 87.6%, intrahospital mortality was 26.8%, symptomatic hemorrhage was 8.5%, and 3 months-modified Rankin Score (mRS) 0–2 was 26.8%. Definitive carotid stenting was needed in 33.3% of the cases. BT versus PMT: Patients treated with PMT presented a higher incidence of atrial fibrillation, anticoagulation, and cardioembolic stroke compared to those treated with BT. No differences in TICI 2b-3, 3 months-mRS or symptomatic hemorrhage were found between both groups. Intrahospital mortality: Poor perfusion-CT mismatch (p = 0.005), isolated Internal carotid artery location (p = 0.024), and symptomatic hemorrhage (p < 0.001) were independent predictors. Symptomatic intracranial hemorrhage: Patients with post-treatment symptomatic hemorrhage had higher intrahospital mortality (p < 0.001) and worse 3 months-mRS (p = 0.033). Functional outcome: Admission NIHSS (p = 0.012) independently predicted 3 months-mRS. Conclusions: In our population, patients with CAO clinically present with severe strokes. Isolated occlusions of the extra- or intracranial segments of the carotid are more frequent than tandem occlusions. Successful recanalization after thrombectomy is achieved in most of the patients, but association with favorable functional outcome is poor. Clinical evolution is similar in patients treated with PMT and BT. Intracranial symptomatic hemorrhage after treatment is associated with higher intrahospital mortality and worse 3 months-mRS. Poor perfusion-CT mismatch, symptomatic hemorrhage, and isolated CAO are independent predictors of intrahospital mortality. Admission NIHSS is an independent predictor of 3 months-mRS.

scholarly journals Outcomes of Large Vessel Occlusion Stroke in Patients Aged ≥90 Years

Stroke ◽  
2021 ◽  
Author(s):  
Kyohei Fujita ◽  
Kanta Tanaka ◽  
Hiroshi Yamagami ◽  
Takeshi Yoshimoto ◽  
Kazutaka Uchida ◽  
...  
Keyword(s):  
Scale Score ◽  
Intracranial Hemorrhage ◽  
Medical Management ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Management Group ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: Outcomes in patients ≥90 years of age with stroke due to large vessel occlusion were compared between endovascular therapy (EVT) and medical management. Methods: Of 2420 acute ischemic stroke patients with large vessel occlusion in a prospective, multicenter, nationwide registry in Japan, patients aged ≥90 years with occlusion of the internal carotid artery or M1 segment of the middle cerebral artery were included. The primary effectiveness outcome was a favorable outcome at 3 months, defined as achieving a modified Rankin Scale score of 0 to 2 or return to at least the prestroke modified Rankin Scale score at 3 months. Safety outcomes included symptomatic intracranial hemorrhage within 72 hours after onset. Intergroup biases were adjusted by multivariable adjustment with inverse probability of treatment weighting. Results: A total of 150 patients (median age, 92 [interquartile range, 90–94] years; median prestroke modified Rankin Scale score, 2 [interquartile range, 0–4]) were analyzed. EVT was performed in 49 patients (32.7%; mechanical thrombectomy, n=43). The EVT group showed shorter time from onset to hospital arrival ( P =0.03), higher Alberta Stroke Program Early Computed Tomography Score ( P <0.01), and a higher rate of treatment with intravenous thrombolysis ( P <0.01) than the medical management group. The favorable outcome was seen in 28.6% of the EVT group and 6.9% of the medical management group ( P <0.01). EVT was associated with the favorable outcome (adjusted odds ratio, 8.44 [95% CI, 1.88–37.97]). Rates of symptomatic intracranial hemorrhage were similar between the EVT group (0.0%) and the medical management group (3.9%; P =0.30). Conclusions: Patients who underwent EVT showed better functional outcomes than those with medical management without increased symptomatic intracranial hemorrhages. Given proper patient selection, withholding EVT solely on the basis of the age of patients may not offer the best chance of good outcome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

Influence of prior intravenous thrombolysis on outcome after failed mechanical thrombectomy: ETIS registry analysis

2021 ◽  
pp. neurintsurg-2021-017867
Author(s):  
Claire Rozes ◽  
Benjamin Maier ◽  
Benjamin Gory ◽  
Romain Bourcier ◽  
Maeva Kyheng ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Statistical Significance ◽  
Intravenous Thrombolysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Shift Analysis ◽  
Secondary Endpoints ◽  
The Difference

BackgroundDespite constant improvements in recent years, sufficient reperfusion after mechanical thrombectomy (MT) is not reached in up to 15% of patients with large vessel occlusion stroke (LVOS). The outcome of patients with unsuccessful reperfusion after MT especially after intravenous thrombolysis (IVT) use is not known. We investigated the influence of initial IVT in this particular group of patients with failed intracranial recanalization.MethodsWe conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry from January 2015 to December 2019. Patients presenting with LVOS of the anterior circulation and final modified Thrombolysis in Cerebral Infarction score (mTICI) of 0, 1 or 2a were included. Posterior circulation, isolated cervical carotid occlusions and successful reperfusions (mTICI 2b, 2c or 3) were excluded. The primary endpoint was favorable outcome (modified Rankin Scale score of 0–2) after 3 months. Secondary endpoints were safety outcomes including mortality, any intracranial hemorrhage (ICH), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) rates.ResultsAmong 5076 patients with LVOS treated with MT, 524 patients with insufficient recanalization met inclusion criteria, of which 242 received IVT and 282 did not. Functional outcome was improved in the MT+IVT group compared with the MT alone group, although the difference did not reach statistical significance (23.0% vs 12.9%; adjusted OR=1.82; 95% CI 0.98 to 3.38; p=0.058). However, 3 month mRS shift analysis showed a significant benefit of IVT (adjusted OR=1.68; 95% CI 1.56 to 6.54). ICH and sICH rates were similar in both groups, although PH rate was higher in the MT+IVT group (adjusted OR=3.20; 95% CI 1.56 to 6.54).ConclusionsAmong patients with LVOS in the anterior circulation and unsuccessful MT, IVT was associated with improved functional outcome even after unsuccessful MT. Despite recent trials questioning the place of IVT in the LVOS reperfusion strategy, these findings emphasize a subgroup of patients still benefiting from IVT.

Abstract P471: Ipsilateral Asymmetrical Internal Cerebral Vein on Multiphasic Computed Tomography for Acute Anterior Circulation Ischemic Stroke Thrombectomy is an Independent Predictor of Poor Functional Outcome

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
May Zin Myint ◽  
Benjamin Yong Qiang Tan ◽  
Aloysius Sheng Ting Leow ◽  
Ei Zune The ◽  
Cunli Yang ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Multivariate Analysis ◽  
Ischemic Stroke ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Collateral Circulation ◽  
Poor Functional Outcome ◽  
Anterior Circulation ◽  
Symptomatic Intracranial Hemorrhage

Background: National Institute of health stroke scale(NIHSS) and collateral circulation are well-established predictors for functional outcomes of endovascular thrombectomy (EVT) patients in acute ischemic stroke (AIS), nonetheless additional prognostic markers can improve the prediction of stroke outcomes. The inflow and drainage into the internal cerebral veins (ICV) can be seen consistently on multiphasic computed tomography angiography (mCTA). Thus, we hypothesize that asymmetry of ICV in the mCTA in large vessel occlusion AIS can be used as an adjunctive predictor of functional outcomes and complications. Method: We enrolled 185 consecutive anterior circulation AIS patients who underwent EVT that presented to our hospital between 2017 and 2019. The collateral circulation was defined by the university of Calgary mCTA collateral flow assessment in stroke. The ICV on the ipsilateral occlusion side was compared with the contralateral side according to a binary scale: 1 (less than contralateral or absent) or 2(equal or greater than contralateral). The primary outcome was modified Rankin scale at 3 months (mRS), and secondary outcomes included symptomatic intracranial hemorrhage and mortality. Result: Among 185 patients, 53% were men, the median age 70 years (range 29-91) and the median NIHSS score on arrival (NIHSS OA) was 19 (range 4-34). 82 patients (44.3%) had good functional outcomes at 3 months. Ipsilateral asymmetry in all three stages of mCTA were statistically significantly associated with good functional outcomes. The 1 st delay phase of mCTA showed the strongest association. On multivariate analysis, high NIHSS OA (OR 1.09, 95% CI 1.02-1.15, P = 0.007), good mCTA collateral score (OR 0.30, 95% CI .16- .53, P < .001), ipsilateral asymmetrical ICV on the 1 st delay phase of mCTA (OR 2.64, 95% CI 1.17-5.96, P = 0.01) were independent predictors of poor functional outcome. Ipsilateral asymmetry was not associated with mortality or symptomatic intracranial hemorrhage on multivariate analysis. Conclusion: Ipsilateral assymetrical ICV is a novel radiological marker associated with functional outcomes after thrombectomy even after correction for the collateral circulation. Further studies should be done to validate this finding in different datasets.

scholarly journals High Admission Glucose Is Associated With Poor Outcome After Endovascular Treatment for Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (11) ◽  
pp. 3215-3223
Author(s):  
Leon A. Rinkel ◽  
T. Truc My Nguyen ◽  
Valeria Guglielmi ◽  
Adrien E. Groot ◽  
Laura Posthuma ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Outcome ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Modified Rankin Scale ◽  
Poor Outcome ◽  
Increased Risk ◽  
Symptomatic Intracranial Hemorrhage ◽  
Admission Glucose

Background and Purpose: High-serum glucose on admission is a predictor of poor outcome after stroke. We assessed the association between glucose concentrations and clinical outcomes in patients who underwent endovascular treatment. Methods: From the MR CLEAN Registry, we selected consecutive adult patients with a large vessel occlusion of the anterior circulation who underwent endovascular treatment and for whom admission glucose levels were available. We assessed the association between admission glucose and the modified Rankin Scale score at 90 days, symptomatic intracranial hemorrhage and successful reperfusion rates. Hyperglycemia was defined as admission glucose ≥7.8 mmol/L. We evaluated the association between glucose and modified Rankin Scale using multivariable ordinal logistic regression and assessed whether successful reperfusion (extended Thrombolysis in Cerebral Infarction 2b-3) modified this association. Results: Of 3637 patients in the MR CLEAN Registry, 2908 were included. Median admission glucose concentration was 6.8 mmol/L (interquartile range, 5.9–8.1) and 882 patients (30%) had hyperglycemia. Hyperglycemia on admission was associated with a shift toward worse functional outcome (median modified Rankin Scale score 4 versus 3; adjusted common odds ratio, 1.69 [95% CI, 1.44–1.99]), increased mortality (40% versus 23%; adjusted odds ratio, 1.95 [95% CI, 1.60–2.38]), and an increased risk of symptomatic intracranial hemorrhage (9% versus 5%; adjusted odds ratio, 1.94 [95% CI, 1.41–2.66]) compared with nonhyperglycemic patients. The association between admission glucose levels and poor outcome (modified Rankin Scale score 3–6) was J -shaped. Hyperglycemia was not associated with the rate of successful reperfusion nor did successful reperfusion modify the association between glucose and functional outcome. Conclusions: Increased admission glucose is associated with poor functional outcome and an increased risk of symptomatic intracranial hemorrhage after endovascular treatment.

scholarly journals Intravenous Thrombolysis Before Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta‐Analysis

2021 ◽  
Author(s):  
Houwei Du ◽  
Hanhan Lei ◽  
Gareth Ambler ◽  
Shuangfang Fang ◽  
Raoli He ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Bridging Therapy ◽  
Randomized Controlled ◽  
Symptomatic Intracranial Hemorrhage

Background Whether intravenous thrombolysis before mechanical thrombectomy provides additional benefit for functional outcome in acute ischemic stroke remains uncertain. We performed a meta‐analysis to compare the outcomes of direct mechanical thrombectomy (dMT) to mechanical thrombectomy with bridging using intravenous thrombolysis (bridging therapy [BT]) in patients with acute ischemic stroke. Methods and Results We performed a literature search in the PubMed, Excerpta Medica database, and Cochrane Central Register of Controlled Trials from January 1, 2003, to April 26, 2021. We included randomized clinical trials and observational studies that reported the 90‐day functional outcome in patients with acute ischemic stroke undergoing dMT compared with BT. The 12 included studies (3 randomized controlled trials and 9 observational studies) yielded 3924 participants (mean age, 68.0 years [SD, 13.1 years]; women, 44.2%; 1887 participants who received dMT and 2037 participants who received BT). A meta‐analysis of randomized controlled trial and observational data revealed similar 90‐day functional independence (odds ratio [OR], 1.04; 95% CI, 0.90–1.19), mortality (OR, 1.03; 95% CI, 0.78–1.36), and successful recanalization (OR, 0.93; 95% CI, 0.76–1.14) for patients treated with dMT or BT. Compared with those in the BT group, patients in the dMT group were less likely to experience symptomatic intracranial hemorrhage (OR, 0.68; 95% CI, 0.51–0.91; P =0.008) or any intracranial hemorrhage (OR, 0.71; 95% CI, 0.61–0.84; P <0.001). Conclusions In this meta‐analysis of patients with acute ischemic stroke, we found no significant differences in 90‐day functional outcome or mortality between dMT and BT, but a lower rate of symptomatic intracranial hemorrhage for dMT. These findings support the use of dMT without intravenous thrombolysis bridging therapy. Registration URL: https://www.crd.york.ac.uk/prospero/ ; Unique identifier: 42021234664.

scholarly journals Severity assessment in maximally treated ICH patients

Neurology ◽  
2017 ◽  
Vol 89 (5) ◽  
pp. 423-431 ◽  
Author(s):  
Jochen A. Sembill ◽  
Stefan T. Gerner ◽  
Bastian Volbers ◽  
Tobias Bobinger ◽  
Hannes Lücking ◽  
...  
Keyword(s):  
Propensity Score ◽  
Functional Outcome ◽  
Propensity Score Matching ◽  
Scale Score ◽  
Predictive Validity ◽  
Assessment Tool ◽  
Favorable Outcome ◽  
Severity Assessment ◽  
Poor Outcome ◽  
Ich Score

Objective:As common prognostication models in intracerebral hemorrhage (ICH) are developed variably including patients with early (<24 hours) care limitations (ECL), we investigated its interaction with prognostication in maximally treated patients and sought to provide a new unbiased severity assessment tool.Methods:This observational cohort study analyzed consecutive ICH patients (n = 583) from a prospective registry over 5 years. We characterized the influence of ECL on overall outcome by propensity score matching and on conventional prognostication using receiver operating characteristic analyses. We established the max-ICH score based on independent predictors of 12-month functional outcome in maximally treated patients and compared it to existing models.Results:Prevalence of ECL was 19.2% (n = 112/583) and all of these patients died. Yet propensity score matching displayed that 50.7% (n = 35/69) theoretically could have survived, with 18.8% (n = 13/69) possibly reaching favorable outcome (modified Rankin Scale score 0–3). Conventional prognostication seemed to be confounded by ECL, documented by a decreased predictive validity (area under the curve [AUC] 0.67, confidence interval [CI] 0.61–0.73 vs AUC 0.80, CI 0.76–0.83; p < 0.01), overestimating poor outcome (mortality by 44.8%, unfavorable outcome by 10.1%) in maximally treated patients. In these patients, the novel max-ICH score (0–10) integrates strength-adjusted predictors, i.e., NIH Stroke Scale score, age, intraventricular hemorrhage, anticoagulation, and ICH volume (lobar and nonlobar), demonstrating improved predictive accuracy for functional outcome (12 months: AUC 0.81, CI 0.77–0.85; p < 0.01). The max-ICH score may more accurately delineate potentials of aggressive care, showing favorable outcome in 45.4% (n = 214/471) and a long-term mortality rate of only 30.1% (n = 142/471).Conclusions:Care limitations significantly influenced the validity of common prognostication models resulting in overestimation of poor outcome. The max-ICH score demonstrated increased predictive validity with minimized confounding by care limitations, making it a useful tool for severity assessment in ICH patients.

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