Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone
Authors: Pierre Seners, Wagih Ben Hassen, Bertrand Lapergue, Caroline Arquizan, Mirjam R. Heldner, Hilde Henon, Claire Perrin, Davide Strambo, Jean-Philippe Cottier, Denis Sablot, Isabelle Girard Buttaz, Ruben Tamazyan, Cécile Preterre, Pierre Agius, Nadia Laksiri, Laura Mechtouff, Yannick Béjot, Duc-Long Duong, François Mounier-Vehier, Gioia Mione, Charlotte Rosso, Ludovic Lucas, Jérémie Papassin, Andreea Aignatoaie, Aude Triquenot, Emmanuel Carrera, Philippe Niclot, Alexandre Obadia, Aïcha Lyoubi, Pierre Garnier, Nicolae Crainic, Valérie Wolff, Clément Tracol, Frédéric Philippeau, Chantal Lamy, Sébastien Soize, Jean-Claude Baron, Guillaume Turc, Sonia Alamowitch, Charles Arteaga, Omar Bennani, Yves Berthezene, Marion Boulanger, Claire Boutet, Serge Bracard, Nicolas Bricout, Hervé Brunel, Serkan Cakmak, Mohamed Chbicheb, Frédéric Clarençon, Vincent Costalat, Audrey Courselle-Arnoux, Séverine Debiais, Mathilde Delpech, Christian Denier, Hubert Desal, Olivier Detante, Gauthier Duloquin, Laurie Fraticelli, Sébastien Gazzola, Jan Gralla, Valer Grigoras, Benoit Guillon, Matthieu Krug, Steven Hajdu, Simon Jung, Frédéric Klapczynski, Didier Leys, François Lun, Arnaud Malbranque, Sébastien Marcel, Patrik Michel, Jean-Louis Mas, Mylène Masson, Norbert Nighoghossian, Michael Obadia, Catherine Oppenheim, Canan Ozsancak, Fernando Pico, Michel Piotin, Christine Pires, Sébastien Richard, Yves Samson, Isabelle Serre, Igor Sibon, Philippe Smadja, Laurent Spelle, Laurent Suissa, Serge Timsit, Emmanuel Touzé, Amélie Tuffal, Anne-Evelyne Vallet, Marion Yger, Stéphane Vannier, Mathieu Zuber
Journal: JAMA Neurology (2021)

<h3>Importance</h3> 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<sub>i</sub>) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. <h3>Objective</h3> To develop and validate an easily applicable predictive score of END<sub>i</sub>following IVT in patients with minor stroke and LVO. <h3>Design, Setting, and Participants</h3> 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<sub>i</sub>. 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. <h3>Main Outcomes and Measures</h3> END<sub>i</sub>, 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. <h3>Results</h3> 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<sub>i</sub>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<sub>i</sub>. 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<sub>i</sub>(C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (END<sub>i</sub>rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, END<sub>i</sub>probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. <h3>Conclusions and Relevance</h3> The substantial END<sub>i</sub>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<sub>i</sub>risk prediction that may assist decision-making was derived and externally validated.