| Background and PurposeEarly judgment of long-term prognosis plays a crucial role in making medical decision on acute anterior circulation large vessel occlusion stroke(LVOS)patients after endovascular treatment(EVT).The ameliorative short-term outcome is reflected in the early neurological improvement in around 24 hours,3 days,or 5-7 days.Commonly accepted,the long-term outcome is represented as the modified Rankin Scale(mRS)at 90 days.Prior researches have outlined that early neurological improvement in 24 hours independently associated with favorable long-term outcome of acute ischemic stroke(AIS)treated with IVT or EVT could be used as an early prognostic indicator of 90-day outcome.However,it is insufficient and less rigorous that early neurological improvement in 24 hours is evaluated alone,possibly attributed to the following facts.Some pathophysiological alterations of ischemic stroke after IVT,EVT,or both are not yet evolved enough in first 24 hours but generally developed completely in 7 days,exemplified by cerebral edema,infarct expansion,vessel re-occlusion,hemorrhagic transformation,and stroke-related complications.Therefore,it is important to assess early neurological improvement in 7 days and even comprehensive evaluation of 24-hour and 7-day early neurological improvement.To our knowledge,the association between 7-day early neurological improvement and long-term outcome remains largely unclear.For another,endovascular treatment becomes accepted as the standard for stroke patients with large vessel occlusion in the acute anterior circulation.Prior randomized controlled trials generally focus on patients with stroke(NIH Stroke Scale[NIHSS]scores?25).Little research has conducted for patients with the very severe stroke(NIHSS scores>25).Under these circumstances,this work aimed to investigate the relationship between 24-hour and 7-day relative neurological improvement(RNI)and 90-day functional outcome individually and collaboratively,followed by evaluating the effect and safety of endovascular treatment for patients with very severe neurological deficit(NIHSS scores>25)compared with severe stroke(NIHSS scores 15-25).Methods and materialsThe patients data collected in this work were derived from a multicenter registry termed Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry(ACTUAL)in China.This study has gained support from the ethic committees of all the participating centers.Research regarding relative neurological improvement:The National Institutes of Health Stroke Scale(NIHSS)scores at baseline,24 hours,and 7 days were collected.Relative Neurological Improvement(RNI)was calculated by an equation of(baseline NIHSS-24-hour/7-day NIHSS)/baseline NIHSS×100%.A modified Rankin Scale(mRS)of 0-2 at 90 days was defined as a favorable outcome.Multivariable logistic regression analysis was disseminated to evaluate the relationship between 24-hour or 7-day RNI and 90-day outcome.Receiver operator characteristic(ROC)curve analysis was performed to identify the predictive power and cutoff point of 24-hour and 7-day RNI for functional outcome.The Mann-Whitney U test was performed for continuous variables and the ?2 test for categorical variables.Containing those variables with P<0.1 in the univariable analysis and 24-hour RNI as covariables,the multivariable logistic regression analysis was used for constructing the model of 90-day mRS 0-2.and the variables with P<0.05 were selected into the final model.The above-mentioned process was repeated to ascertain the significant association between 7-day RNI and 90-day mRS 0-2.Receiver operator characteristic(ROC)curve analysis was conducted to assess the predictive power of 24-hour and 7-day RNI for 90-day mRS 0-2.The best cutoff points at maximum Youden index with sensitivity,speciticity,positive predictive value(PPV),and negative predictive value(NPV)were thus calculated.The predictive power was represented by the area under the curve(AUC).The univariable logistic regression analysis was conducted to determine the odds ratio(OR)value with 95%confidence interval(CI)of obtaining 90-day favorable outcome for both 24-hour and 7-day RNI equal or greater than versus less than individual cutoff point.Research regarding the very severe acute ischemic stroke patients:The large vessel occlusion patients treated with mechanical thrombectomy were stratified according to pretreatment NIHSS and baseline data were thus collected.Symptomatic intracranial hemorr-hage(sICH)within 72 hours,functional dependence and mortality at 90 days were selected as the indicators.Comparing the baseline characteristics between the 2 groups with very severe(NIHSS>25)and severe(NIHSS 15-25)stroke,univariate analysis for continuous variables was conducted via the Student t test or Mann-Whitney U test in accordance with their normality of distribution.?2 or Fisher exact test was selected for binary variables according to cell sample size.Binary logistic regression analysis was disseminated for analyzing independent predictors for clinical outcome and sICH.Variables included those with a P value of<0.10 on univariate analysis or clinically relevant factors entered into the final model.In this whole study,statistical analyses were conducted using the SPSS,version 22(IBM,Chicago,IL,USA),and two-tailed P values of<0.05 were considered statistically significant.Results1?Among the 698 enrolled patients,118 ones were diagnosed with LOS less than 5 days,6 ones had the occlusion of the anterior cerebral artery and 6 were absent from NIHSS scores.568 patients were finally included in this study.290 patients achieved favorable 90-day mRS(0-2),accounting for 51.1%(290/568).Significant difference was observed between 24-h RNI and some variables,including baseline SBP,baseline ASPECTS score,mTICI,sICH and mRS at 3 months(P<0.001).So was the case in the association between 7-day RNI and variables,including glucose,baseline ASPECTS score,ASITN/SIR grading,mTICI,sICH,SAP and mRS at 3 months(P<0.001).Multivariable logistic regression analysis revealed that both 24-h RNI(OR =31.441,95%CI 13.455-73.471,P<0.001)and 7-day RNI(OR = 65.404,95%CI 25.800-165.804,P<0.001)were independent favorable predictors of 90-day outcome.2?The best cutoff point of 24-hour and 7-day RNI was 28%and 42%,respectively.Compared to those with 24-hour RNI<28%and 7-day RNI<42%,the patients with 24-hour RNI?28%and 7-day RNI?42%possessed an amazing 39.595-fold(95%CI 22.388-70.026)increased probability of-achieving 90-day favorable outcome.3?Of 420 enrolled patients.350 patients were diagnosed with the very severe stroke and 70 patients with severe stroke.No significant difference was observed in terms of successful recanalization(72.9%vs 82.6%;P = 0.059).Compared to the severe stroke group,patients with the very severe stroke had low favorable clinical outcomes(11.4%vs 35.4%;P<0.001)and significantly increased mortality(61.4%vs 27.1%;P<0.001)at 90 days.Multivariate analysis revealed that NIHSS>25 w.as an independent p.redictor of poor clinical outcome(OR,3.36;95%Cl,1.53-7.38;P = 0.003)and mortality(OR,3.46;95%CI,1.97-6.08;P<0.001).Higher age(OR,1.05;95%CI,1.03-1.07;P<0.001)and hyperglycemia(OR,1.18;95%CI,1.08-1.30;P<0.001)were identified as independent predictors of poor functional outcome in NIHSS>25 cohort,while higher age(OR,1.06;95%CI,1.01-1.11;P = 0.034)and ASITN/SIR 0-1(OR,0.66;95%CI,0.45-0.99;P = 0.044)were independent predictors of mortality.Conclusion1?Both 24-hour and 7-day RNI were independent favorable predictors of 90-day outcome2?The combination of 24-hour and 7-day RNI very strongly predicts 90-day functional outcome in acute anterior circulation LVOS patients receiving EVT,and it can be used as an early accurate surrogate of long-term outcome.3?The increased risk of sICH,low rates of functional independence and high mortality were observed in patients with NIHSS score>25 when compared to patients with NIHSS score 15-25,suggesting that it is less cautiously optimistic for the LOV patients with very severe stroke after treated with thrombectomy. |
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