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Original Investigation
January 11, 2021

Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

Author Affiliations
  • 1Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
  • 2Radiology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
  • 3Neurology Department, Foch University Hospital, Suresnes, France
  • 4Neurology Department, CHRU Gui de Chauliac, Montpellier, France
  • 5Neurology Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
  • 6Neurology Department, CHU Lille, Université de Lille, INSERM U1171, Lille, France
  • 7Stroke Center, Neurology Service, CHU Vaudois, Lausanne University, Lausanne, Switzerland
  • 8Neurology Department, Bretonneau Hospital, Tours, France
  • 9Neurology Department, Perpignan Hospital, Perpignan, France
  • 10Neurology Department, Valenciennes Hospital, Valenciennes, France
  • 11Neurology Department, Saint Joseph Hospital, Paris, France
  • 12Neurology Department, Nantes University Hospital, Nantes, France
  • 13Neurology Department, St Nazaire Hospital, Saint-Nazaire, France
  • 14Neurology Department, La Timone University Hospital, Marseille, France
  • 15Department of Stroke Medicine, Hospices Civils de Lyon, Lyon, France
  • 16Neurology Department, Dijon University Hospital, Dijon, France
  • 17Neurology Department, Versailles University Hospital, Versailles, France
  • 18Neurology Department, Lens Hospital, Lens, France
  • 19Neurology Department, Nancy University Hospital, Nancy, France
  • 20Sorbonne Université, Institut du Cerveau et de la Moelle épinière, ICM, INSERM U 1127, CNRS UMR 7225, AP-HP, Urgences Cérébro-Vasculaires, ICM Infrastructure Stroke Network, Hôpital Pitié-Salpêtrière, Paris, France
  • 21Stroke Unit, Bordeaux University Hospital, Bordeaux, France
  • 22Stroke Unit, Grenoble University Hospital, Grenoble, France
  • 23Neurology Department, Centre Hospitalier Metropole-Savoie, Chambery, France
  • 24Neurology Department, Centre Hospitalier Régional d’Orléans, Orléans, France
  • 25Neurology Department, CHU Rouen, Rouen, France
  • 26Neurology Department, Geneve University Hospital, Geneve, Switzerland
  • 27Neurology Department, René Dubos Hospital, Pontoise, France
  • 28Neurology Department, Fondation Adolphe de Rothschild, Paris, France
  • 29Neurology Department, Delafontaine Hospital, Saint-Denis, France
  • 30Stroke Unit, Saint-Etienne University Hospital, Saint-Etienne, France
  • 31Neurology Department, Brest University Hospital, Brest, France
  • 32Neurology Department, Strasbourg University Hospital, Strasbourg, France
  • 33Neurology Department, Rennes University Hospital, Rennes, France
  • 34Neurology Department, Fleyriat Hospital, Bourg-en-Bresse, France
  • 35Neurology Department, Amiens University Hospital, Amiens, France
  • 36Neuroradiology Department, Reims University Hospital, Reims, France
JAMA Neurol. 2021;78(3):321-328. doi:10.1001/jamaneurol.2020.4557
Key Points

Question  Is early neurological deterioration of ischemic origin (ENDi) predictable in patients with minor stroke and large vessel occlusion (LVO) treated with intravenous thrombolysis (IVT)?

Findings  In this cohort of 729 patients with minor stroke (National Institutes of Health Stroke Scale score of 5 or less) and LVO intended for IVT alone, an easily applicable score based on occlusion site and thrombus length—2 independent predictors of ENDi—showed good discriminative power for ENDi risk prediction and was successfully validated in an independent cohort of 347 patients.

Meaning  ENDi can be reliably predicted in patients with IVT-treated minor strokes and LVO, which may help to select the best candidates for direct transfer for additional thrombectomy.


Importance  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 (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy.

Objective  To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO.

Design, Setting, and Participants  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 ENDi. 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.

Main Outcomes and Measures  ENDi, 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.

Results  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%). ENDi 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 ENDi. A 4-point score derived from these variables—1 point for thrombus length and 3 points for occlusion site—showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively.

Conclusions and Relevance  The substantial ENDi 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 ENDi risk prediction that may assist decision-making was derived and externally validated.

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