Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients

Objectives This study aims at exploring the 3-month outcome predicting ability of delayed neurological improvement and the cause of delayed neurological improvement. Materials and methods Early neurological improvement and delayed neurological improvement were calculated to represent the neurological improvements. Good functional outcome was defined as a 90-day modified Rankin Scale score 0–2. We used multivariant logistic regression to explore the influential factors of good functional outcome as well as delayed neurological improvement. We applied net reclassification improvement and integrated discrimination improvement to assess the quantitative improvement of the predictive model. Results Early neurological improvement was observed in 50 (23%) patients and delayed neurological improvement exhibited in 67 (30%) patients. Early neurological improvement and delayed neurological improvement were both independent predictive factors to good functional outcome. In the basic model (adjusted for age, admission glucose level, baseline National Institute of Health Stroke Scale, and complications and number of retrieval attempts), early neurological improvement and delayed neurological improvement statistically improved the predictive ability (early neurological improvement: net reclassification improvement = 0.34, 95% confidence interval, 95% confidential interval (0.06, 0.69); integrated discrimination improvement = 0.05, p < 0.001; delayed neurological improvement: net reclassification improvement = 0.79, 95% confidential interval (0.47, 1.12); integrated discrimination improvement = 0.14, p < 0.001) delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement (early neurological improvement vs. delayed neurological improvement: integrated discrimination improvement = 0.09, p < 0.001). Moreover, delayed neurological improvement was affected by hypertension (odds ratio = 0.40, 95% CI (0.18, 0.88), p = 0.02), early neurological improvement (odds ratio = 20.10, 95% confidential interval (8.24, 19.02), p < 0.001), number of retrieval attempts (odds ratio = 0.39, 95% confidential interval (0.24, 0.66), p < 0.001), and complication (odds ratio = 0.25, 95% confidential interval (0.12, 0.54), p < 0.001). Conclusions Delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement. Hypertension, early neurological improvement, numbers of retrieval attempts, and complications were all predicting factors to delayed neurological improvement.

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Eosinophil-to-monocyte ratio is a potential biomarker in the prediction of functional outcome among patients with acute ischemic stroke

BMC Neuroscience ◽

10.1186/s12868-021-00610-x ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Shuhong Yu ◽

Yi Luo ◽

Tan Zhang ◽

Chenrong Huang ◽

Yu Fu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Odds Ratio ◽

Poor Outcome ◽

Net Reclassification Improvement ◽

Potential Biomarker ◽

The Impact ◽

The Relationship ◽

Integrated Discrimination Improvement

Abstract Background It has been shown that eosinophils are decreased and monocytes are elevated in patients with acute ischemic stroke (AIS), but the impact of eosinophil-to-monocyte ratio (EMR) on clinical outcomes among AIS patients remains unclear. We aimed to determine the relationship between EMR on admission and 3-month poor functional outcome in AIS patients. Methods A total of 521 consecutive patients admitted to our hospital within 24 h after onset of AIS were prospectively enrolled and categorized in terms of quartiles of EMR on admission between August 2016 and September 2018. The endpoint was the poor outcome defined as modified Rankin Scale score of 3 to 6 at month 3 after admission. Results As EMR decreased, the risk of poor outcome increased (p < 0.001). Logistic regression analysis revealed that EMR was independently associated with poor outcome after adjusting potential confounders (odds ratio, 0.09; 95% CI 0.03–0.34; p = 0.0003), which is consistent with the result of EMR (quartile) as a categorical variable (odds ratio, 0.23; 95% CI 0.10–0.52; ptrend < 0.0001). A non-linear relationship was detected between EMR and poor outcome, whose point was 0.28. Subgroup analyses further confirmed these associations. The addition of EMR to conventional risk factors improved the predictive power for poor outcome (net reclassification improvement: 2.61%, p = 0.382; integrated discrimination improvement: 2.41%, p < 0.001). Conclusions EMR on admission was independently correlated with poor outcome in AIS patients, suggesting that EMR may be a potential prognostic biomarker for AIS.

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Tenecteplase Versus Alteplase Between 3 and 4.5 Hours in Low National Institutes of Health Stroke Scale

Stroke ◽

10.1161/strokeaha.118.024223 ◽

2019 ◽

Vol 50 (2) ◽

pp. 498-500 ◽

Cited By ~ 4

Author(s):

Ole Morten Rønning ◽

Nicola Logallo ◽

Bente Thommessen ◽

Håkon Tobro ◽

Vojtech Novotny ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Odds Ratio ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Unique Identifier ◽

Clinical Trial Registration ◽

Intention To Treat ◽

Good Functional Outcome

Background and Purpose— Thrombolysis with alteplase has beneficial effect on outcome and is safe within 4.5 hours. The present study compares the efficacy and safety of tenecteplase and alteplase in patients treated 3 to 4.5 hours after ischemic stroke. Methods— The data are from a prespecified substudy of patients included in The NOR-TEST (Norwegian Tenecteplase Stroke Trial), a randomized control trial comparing tenecteplase with alteplase. Results— The median admission National Institutes of Health Stroke Scale for this study population was 3 (interquartile range, 2–6). In the intention-to-treat analysis, 57% of patients that received tenecteplase and 53% of patients that received alteplase reached good functional outcome (modified Rankin Scale score of 0–1) at 3 months (odds ratio, 1.19; 95% CI, 0.68–2.10). The rates of intracranial hemorrhage in the first 48 hours were 5.7% in the tenecteplase group and 6.7% in the alteplase group (odds ratio, 0.84; 95% CI, 0.26–2.70). At 3 months, mortality was 5.7% and 4.5%, respectively. After excluding stroke mimics and patients with modified Rankin Scale score of >1 before stroke, the proportion of patients with good functional outcome was 61% in the tenecteplase group and 57% in the alteplase group (odds ratio, 1.24; 95% CI, 0.65–2.37). Conclusions— Tenecteplase is at least as effective as alteplase to achieve a good clinical outcome in patients with mild stroke treated between 3 and 4.5 hours after ischemic stroke. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01949948.

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FGF21/adiponectin ratio predicts deterioration in glycemia: a 4.6-year prospective study in China

Cardiovascular Diabetology ◽

10.1186/s12933-021-01351-1 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Dan Liu ◽

Liang Wu ◽

Qiongmei Gao ◽

Xiaoxue Long ◽

Xuhong Hou ◽

...

Keyword(s):

Cohort Study ◽

Odds Ratio ◽

Multiple Logistic Regression Analysis ◽

Normal Glucose Tolerance ◽

Net Reclassification Improvement ◽

Onset Diabetes ◽

Normal Glucose ◽

Traditional Risk Factors ◽

Integrated Discrimination Improvement ◽

New Onset

Abstract Background The fibroblast growth factor (FGF) 21-adiponectin pathway is involved in the regulation of insulin resistance. However, the relationship between the FGF21-adiponectin pathway and type 2 diabetes in humans is unclear. Here, we investigated the association of FGF21/adiponectin ratio with deterioration in glycemia in a prospective cohort study. Methods We studied 6361 subjects recruited from the prospective Shanghai Nicheng Cohort Study in China. The association between baseline FGF21/adiponectin ratio and new-onset diabetes and incident prediabetes was evaluated using multiple logistic regression analysis. Results At baseline, FGF21/adiponectin ratio levels increased progressively with the deterioration in glycemic control from normal glucose tolerance to prediabetes and diabetes (p for trend < 0.001). Over a median follow-up of 4.6 years, 195 subjects developed new-onset diabetes and 351 subjects developed incident prediabetes. Elevated baseline FGF21/adiponectin ratio was a significant predictor of new-onset diabetes independent of traditional risk factors, especially in subjects with prediabetes (odds ratio, 1.367; p = 0.001). Moreover, FGF21/adiponectin ratio predicted incident prediabetes (odds ratio, 1.185; p = 0.021) while neither FGF21 nor adiponectin were independent predictors of incident prediabetes (both p > 0.05). Furthermore, net reclassification improvement and integrated discrimination improvement analyses showed that FGF21/adiponectin ratio provided a better performance in diabetes risk prediction than the use of FGF21 or adiponectin alone. Conclusions FGF21/adiponectin ratio independently predicted the onset of prediabetes and diabetes, with the potential to be a useful biomarker of deterioration in glycemia.

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Predictor of 90-day functional outcome after mechanical thrombectomy for large vessel occlusion stroke: NIHSS score of 10 or less at 24 hours

Journal of Neurosurgery ◽

10.3171/2019.10.jns191991 ◽

2019 ◽

pp. 1-7

Author(s):

Mirja M. Wirtz ◽

Philipp Hendrix ◽

Oded Goren ◽

Lisa A. Beckett ◽

Heather R. Dicristina ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Mechanical Thrombectomy ◽

Characteristic Curve ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Neurological Improvement ◽

Good Functional Outcome

OBJECTIVEMechanical thrombectomy is the established treatment for acute ischemic stroke due to large vessel occlusion (LVO). The authors sought to identify early predictors of a favorable outcome in stroke patients treated with mechanical thrombectomy.METHODSConsecutive patients with ischemic stroke due to LVO who underwent mechanical thrombectomy at a Comprehensive Stroke Center in the US between 2016 and 2018 were retrospectively reviewed. Demographics, stroke and treatment characteristics, as well as functional outcome at 90 days were collected. Clinical predictors of 90-day functional outcome were assessed and compared to existing indices for prompt neurological improvement. Analyses of area under the receiver operating characteristic curve were performed to estimate the optimal thresholds for absolute 24-hour and delta (change in) National Institutes of Health Stroke Scale (NIHSS) scores for functional outcome prediction.RESULTSA total of 156 patients (median age 71.5 years) underwent 159 mechanical thrombectomies. The M1 segment of the middle cerebral artery was the most frequent site of occlusion (57.2%). The median NIHSS score before thrombectomy was 18 (IQR 14–24). A postthrombectomy Thrombolysis in Cerebral Infarction score of 2B or 3 was achieved in 147 procedures (92.4%). The median NIHSS score 24 hours after thrombectomy was 14 (IQR 6–22). Good functional outcome at 90 days (modified Rankin Scale score 0–2) was achieved in 37 thrombectomies (23.9%). An absolute 24-hour NIHSS score ≤ 10 (OR 25.929, 95% CI 8.448–79.582, p < 0.001) and a delta NIHSS score ≥ 8 between baseline and 24 hours (OR 4.929, 95% CI 2.245–10.818, p < 0.001) were associated with good functional outcome at 90 days. The 24-hour NIHSS score cutoff of 10 outperformed existing indices for prompt neurological improvement in the ability to predict 90-day functional outcome.CONCLUSIONSAn NIHSS score ≤ 10 at 24 hours after mechanical thrombectomy was independently associated with good functional outcome at 90 days.

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Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data

Stroke ◽

10.1161/strokeaha.121.034331 ◽

2021 ◽

Author(s):

Ashutosh P. Jadhav ◽

Mayank Goyal ◽

Johanna Ospel ◽

Bruce C. Campbell ◽

Charles B.L.M. Majoie ◽

...

Keyword(s):

Computed Tomography ◽

Functional Outcome ◽

Odds Ratio ◽

Time Window ◽

Early Time ◽

Computed Tomography Perfusion ◽

Patient Level Data ◽

Patient Level ◽

Good Functional Outcome ◽

Level Data

Background and Purpose: The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0–6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. Methods: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. Results: We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0–2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82–1.33], adjusted odds ratio, 1.04, [95% CI, 0.80–1.35]). Conclusions: Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.

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Abstract TP305: Effect of Door to Needle Times on Clinical Outcomes in a Community Cohort

Stroke ◽

10.1161/str.51.suppl_1.tp305 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mai N Nguyen-Huynh ◽

Janet Alexander ◽

Catherine Lee ◽

Melissa Meighan ◽

Alexander Flint ◽

...

Keyword(s):

Length Of Stay ◽

Functional Outcome ◽

Clinical Outcomes ◽

Published Data ◽

Study Cohort ◽

Post Discharge ◽

Vessel Occlusion ◽

Full Cohort ◽

Good Functional Outcome ◽

Discharge Outcomes

Background: Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. It is not clear that reducing door-to-needle (DTN) time by 15 minutes (from 60 to 45 to 30) is associated with better functional outcome and/or less mortality. In a real-world practice setting, we assessed the effect of different DTN times on clinical outcomes. Methods: In 2016, a new standardized telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic study, and expedited transfer and treatment for patients with large vessel occlusion. From 2/15/18 to 2/25/19, we collected 90-day modified Rankin Score (mRS) for adult members who received IV alteplase. We also collected data on demographics, NIHSS, DTN times, thrombectomy, length of stay, discharge outcomes, 90-day mRS and mortality in those treated with IV alteplase stratified by the DTN time (60 vs. 45 vs. 30 minutes). Multivariate logistic regression was used to examine whether DTN category was predictive of good functional outcome (mRS=0-2) adjusted for age, gender, race, and NIHSS. Results: During the study period, the full cohort had 784 patients treated with IV alteplase. Average age was 71.5 ± 14.9 years with 51.8% female. Median NIHSS was 6. Median DTN time was 34 minutes. Those with faster DTN arrived more by EMS, had higher NIHSS, higher rate of thrombectomy, and shorter length of stay. A smaller cohort of 340 patients had a 90-day mRS. Multivariate models revealed a trend for faster DTN time being associated with less 90-day mortality (OR=0.81, p=0.24) and good functional outcome (OR=1.73, p=0.07) among EMS arrival (Table). Conclusions: In our study cohort, every 15-minute reduction in DTN had stronger association with better outcomes. Further efforts are underway to capture more complete mRS data for the full cohort.

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Eosinophil-to-monocyte ratio is a potential biomarker in the prediction of functional outcome among patients with acute ischemic stroke

10.21203/rs.2.24393/v1 ◽

2020 ◽

Author(s):

Shuhong Yu ◽

Yi Luo ◽

Tan Zhang ◽

Chenrong Huang ◽

Yu Fu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Odds Ratio ◽

Area Under The Curve ◽

Characteristic Analysis ◽

Poor Outcome ◽

Net Reclassification Improvement ◽

Potential Biomarker ◽

The Impact

Abstract Background and PurposeIt has been showed that eosinophils are decreased and monocytes are elevated in patients with ischemic stroke, but the impact of eosinophil-to-monocyte ratio (EMR) on clinical outcomes among patients with acute ischemic stroke remains unclear. The aim of this study is to determine the relationship between EMR on admission and three-month poor functional outcome in patients with acute ischemic stroke.MethodsA total of 521 consecutive patients admitted to our hospital within 24 hours after onset of acute ischemic stroke were prospectively enrolled and categorized in terms of quartiles of EMR on admission between August 2016 and September 2018. The endpoint was the poor outcome defined as modified Rankin Scale score of 3 to 6 at month 3 after admission.ResultsAs EMR decreased, the risk of poor outcome increased (P<0.001). Logistic regression analysis revealed that EMR was independently associated with poor outcome after adjusting potential confounders (odds ratio, 0.10; 95% CI, 0.03–0.36; P=0.0004), which is consistent with the result of EMR (quartile) as a categorical variable (odds ratio, 0.24; 95% CI, 0.10–0.53; Ptrend<0.0001). A non-linear relationship was detected between EMR and poor outcome, whose point was 0.28. Subgroup analyses further confirmed these associations. The area under the curve of EMR for the prediction of poor outcome in receiver operating characteristic analysis was 0.653 (95% CI, 0.603–0.703; P=0.003). Furthermore, the addition of EMR to conventional risk factors improved the predictive power for poor outcome (net reclassification improvement: 3.54%, P=0.230; integrated discrimination improvement: 2.11%, P=0.001).ConclusionEMR on admission was independently correlated with poor outcome in patients with acute ischemic stroke, suggesting that EMR may be a potential prognostic biomarker for ischemic stroke.

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Selected nasogastric lavage in patients with nonvariceal upper gastrointestinal bleeding

BMC Gastroenterology ◽

10.1186/s12876-021-01690-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Eun Jeong Gong ◽

Li-chang Hsing ◽

Hyun Il Seo ◽

Myeongsook Seo ◽

Baek Gyu Jun ◽

...

Keyword(s):

Risk Stratification ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Predictive Ability ◽

Endoscopic Examination ◽

Net Reclassification Improvement ◽

Coffee Ground ◽

Risk Patients ◽

Integrated Discrimination Improvement ◽

Upper Gastrointestinal

Abstract Background Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination. Methods From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow–Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement. Results Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8 %), coffee-ground in 227 patients (46.6 %), and clear in 193 patients (39.6 %). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS ≤ 11, whereas no additive value was found when the GBS was greater than 11. Conclusions Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.

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Time Matters

Stroke ◽

10.1161/strokeaha.119.028586 ◽

2020 ◽

Vol 51 (6) ◽

pp. 1766-1771 ◽

Cited By ~ 2

Author(s):

Manuel Requena ◽

Marta Olivé ◽

Álvaro García-Tornel ◽

Noelia Rodríguez-Villatoro ◽

Matías Deck ◽

...

Keyword(s):

Computed Tomography ◽

Endovascular Treatment ◽

Functional Outcome ◽

Scale Score ◽

Odds Ratio ◽

Hemorrhagic Transformation ◽

National Institutes Of Health ◽

Retrospective Case ◽

Good Functional Outcome ◽

Angiography Suite

Background and Purpose— Direct transfer to angiography-suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The magnitude of the improvement of good outcome rates in function of time depends of several factors. We aim to analyze the benefit of DTAS according to time from symptom onset. Methods— Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to computed tomography (directly transferred to computed tomography) from February 2016 to June 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline National Institutes of Health Stroke Scale score (±2 points), and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (modified Rankin Scale score, 0–2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results— There were no significant differences regarding age, sex, or baseline National Institutes of Health Stroke Scale score. Median door-to-groin time was shorter in the DTAS patients (16 [3–21] minutes versus 70 [41.5–98.5]; P <0.01). DTAS patients presented lower National Institutes of Health Stroke Scale score at 24 hours (9 [3.5–17] versus 14 [5–19]; P =0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, P <0.03). At 90 days, DTAS patients had a higher rate of good functional outcome (43% versus 29%; odds ratio, 1.81 [95% CI, 1.14–2.87]; P =0.01). Better outcome in DTAS was observed in patients admitted in the 0 to 3 hours form onset window (n=156, odds ratio 2.63 [95% CI, 1.31–5.28]; P <0.01), but not in patients admitted in the 3 to 6 hours window (n=193, odds ratio, 1.37 [95% CI, 0.72–2.60]; P =0.2). Conclusions— DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

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