Minor stroke with LVO: who will have early deterioration after IV thrombolysis?

  • Seners P & al.
  • JAMA Neurol
  • 11 Jan 2021

  • curated by Susan London
  • Clinical Essentials
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Takeaway

  • Among patients with acute minor stroke and large vessel occlusion (LVO), a score based on occlusion features accurately predicts early neurological deterioration of presumed ischemic origin (ENDi) after intravenous (IV) thrombolysis.

Why this matters

  • Reliable risk prediction may support selection of patients for immediate transfer for additional thrombectomy.

Key results

  • 12.1% of patients in the derivation cohort experienced ENDi.
  • ENDi conferred poorer 3-month outcomes, even after rescue thrombectomy.
  • Independent predictors of ENDi:
    • More proximal occlusion site (P<.001>
    • Longer thrombus (P=.002).
  • 4-point score based on these factors had good discriminative power for ENDi, per C statistics:
    • 0.76 in the derivation cohort.
    • 0.78 in the validation cohort.
  • Probability of ENDi by score:
    • 0: ~3%.
    • 1: 7%.
    • 2: 20%. 
    • 3-4: 35%.

Study design

  • Retrospective cohort study, France:
    • Derivation cohort: 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤5) and LVO who underwent IV thrombolysis alone at 45 centers.
    • Validation cohort: 347 similar patients at 9 other centers.
  • Main outcome: ENDi (≥4-point deterioration on NIHSS score within 24 hours, without parenchymal hemorrhage or other identified cause).
  • Funding: None disclosed.

Limitations

  • Patients treated with bridging therapy were excluded.
  • Lack of information on clinical fluctuations before admission, on hospital arrival.