Prediction of Outcome and Endovascular Treatment Benefit: Validation and Update of the MR PREDICTS Decision Tool
Authors: Venema Esmee , Roozenbeek Bob , Mulder Maxim J.H.L. , Brown Scott , Majoie Charles B.L.M. , Steyerberg Ewout W. , Demchuk Andrew M. , Muir Keith W. , Dávalos Antoni , Mitchell Peter J. , Bracard Serge , Berkhemer Olvert A. , Lycklama à Nijeholt Geert J. , van Oostenbrugge Robert J. , Roos Yvo B.W.E.M. , van Zwam Wim H. , van der Lugt Aad , Hill Michael D. , White Philip , Campbell Bruce C.V. , Guillemin Francis , Saver Jeffrey L. , Jovin Tudor G. , Goyal Mayank , Dippel Diederik W.J. , Lingsma Hester F. , der Lugt Aad van , Boiten Jelis , Vos Jan Albert , Jansen Ivo G.H. , Goldhoorn Robert- Jan B. , Compagne Kars C.J. , Kappelhof Manon , Brouwer Josje , den Hartog Sanne J. , Hinsenveld Wouter H. , van Es Adriaan C.G.M. , Emmer Bart J. , Coutinho Jonathan M. , Schonewille Wouter J. , Vos Jan Albert , Wermer Marieke J.H. , van Walderveen Marianne A.A. , Staals Julie , Hofmeijer Jeannette , Martens Jasper M. , Boiten Jelis , de Bruijn Sebastiaan F. , van Dijk Lukas C. , van der Worp H. Bart , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , Vries J. de , de Kort Paul L.M. , van Tuijl Julia , Peluso Jo P. , Fransen Puck , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Uyttenboogaart Maarten , Eschgi Omid , Bokkers Reinoud P.H. , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Yo Lonneke S.F. , den Hertog Heleen M. , Bulut Tomas , Brouwers Paul J.A.M. , van Walderveen Marianne A.A. , Sprengers Marieke E.S. , Jenniskens Sjoerd F.M. , van den Berg René , Yoo Albert J. , Beenen Ludo F.M. , Postma Alida A. , Roosendaal Stefan D. , van der Kallen Bas F.W. , van den Wijngaard Ido R. , van Es Adriaan C.G.M. , Emmer Bart J. , Martens Jasper M. , Yo Lonneke S.F. , Vos Jan Albert , Bot Joost , van Doormaal Pieter-Jan , Meijer Anton , Ghariq Elyas , Bokkers Reinoud P.H. , van Proosdij Marc P. , Krietemeijer G. Menno , Peluso Jo P. , Boogaarts Hieronymus D. , Lo Rob , Gerrits Dick , Dinkelaar Wouter , Appelman Auke P.A. , Hammer Bas , Pegge Sjoert , van der Hoorn Anouk , Vinke Saman , Boiten Jelis , Vos Jan Albert , Schonewille Wouter J. , Hofmeijer Jeannette , Martens Jasper M. , van der Worp H. Bart , Lo Rob H. , Hofmeijer Jeannette , Flach H. Zwenneke , Ghannouti Naziha el , Sterrenberg Martin , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , Simons Michelle , Vossers Marjolein , Meris Joke de , Vermeulen Tamara , Geerlings Annet , Vemde Gina van , Simons Tiny , Messchendorp Gert , Nicolaij Nynke , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert Maureen , Verheesen Sabrina , Jeurrissen D. , Bos Erna , Drabbe Yvonne , Sandiman Michelle , Aaldering Nicoline , Zweedijk Berber , Vervoort Jocova , Ponjee Eva , Romviel Sharon , Kanselaar Karin , Barning Denn , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R.M. , Muijres Daan , de Jong Anouk , Boers Anna M.M. , Huguet J. , Groot P.F.C. , Mens Marieke A. , van Kranendonk Katinka R. , Treurniet Kilian M. , Tolhuisen Manon L. , Alves Heitor , Weterings Annick J. , Kirkels Eleonora L.F. , Voogd Eva J.H.F. , Schupp Lieve M. , Collette Sabine L. , Groot Adrien E.D. , LeCouffe Natalie E. , Konduri Praneeta R. , Prasetya Haryadi , Arrarte- Terreros Nerea , Ramos Lucas A. 
Published: July 2021

Background and Purpose:
Benefit of early endovascular treatment (EVT) for ischemic stroke varies considerably among patients. The MR PREDICTS decision tool, derived from MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), predicts outcome and treatment benefit based on baseline characteristics. Our aim was to externally validate and update MR PREDICTS with data from international trials and daily clinical practice.

Methods:

We used individual patient data from 6 randomized controlled trials within the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration to validate the original model. Then, we updated the model and performed a second validation with data from the observational MR CLEAN Registry. Primary outcome was functional independence (defined as modified Rankin Scale score 0–2) 3 months after stroke. Treatment benefit was defined as the difference between the probability of functional independence with and without EVT. Discriminative performance was evaluated using a concordance
(C
) statistic.

Results:

We included 1242 patients from HERMES (633 assigned to EVT, 609 assigned to control) and 3156 patients from the MR CLEAN Registry (all of whom underwent EVT within 6.5 hours). The
C
-statistic for functional independence was 0.74 (95% CI, 0.72–0.77) in HERMES and, after model updating, 0.80 (0.78–0.82) in the Registry. Median predicted treatment benefit of routinely treated patients (Registry) was 10.3% (interquartile range, 5.8%–14.4%). Patients with low (<1%) predicted treatment benefit (n=135/3156 [4.3%]) had low rates of functional independence, irrespective of reperfusion status, suggesting potential absence of treatment benefit. The updated model was made available online for clinicians and researchers at
www.mrpredicts.com
.

Conclusions:
Because of the substantial treatment effect and small potential harm of EVT, most patients arriving within 6 hours at an endovascular-capable center should be treated regardless of their clinical characteristics. MR PREDICTS can be used to support clinical judgement when there is uncertainty about the treatment indication, when resources are limited, or before a patient is to be transferred to an endovascular-capable center.