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. 2023 Jul 31;80(9):940-948.
doi: 10.1001/jamaneurol.2023.2392. Online ahead of print.

Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke

Vicky Chalos  1   2   3 , Esmee Venema  2   4 , Maxim J H L Mulder  1 , Bob Roozenbeek  1 , Ewout W Steyerberg  5 , Marieke J H Wermer  6 , Geert J Lycklama À Nijeholt  7 , H Bart van der Worp  8 , Mayank Goyal  9 , Bruce C V Campbell  10 , Keith W Muir  11 , Francis Guillemin  12 , Serge Bracard  13 , Philip White  14 , Antoni Dávalos  15 , Tudor G Jovin  16 , Michael D Hill  9 , Peter J Mitchell  17 , Andrew M Demchuk  9 , Jeffrey L Saver  18 , Aad van der Lugt  3 , Scott Brown  19 , Diederik W J Dippel  1 , Hester F Lingsma  2 ; HERMES CollaboratorsMR CLEAN Registry Investigators
Collaborators, Affiliations

Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke

Vicky Chalos et al. JAMA Neurol. .

Abstract

Importance: Outcome prediction after endovascular treatment (EVT) for ischemic stroke is important to patients, family members, and physicians.

Objective: To develop and validate a model based on preprocedural and postprocedural characteristics to predict functional outcome for individual patients after EVT.

Design, setting, and participants: A prediction model was developed using individual patient data from 7 randomized clinical trials, performed between December 2010 and December 2014. The model was developed within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration and external validation in data from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry of patients treated in clinical practice between March 2014 and November 2017. Participants included patients from multiple centers throughout different countries in Europe, North America, East Asia, and Oceania (derivation cohort), and multiple centers in the Netherlands (validation cohort). Included were adult patients with a history of ischemic stroke from an intracranial large vessel occlusion in the anterior circulation who underwent EVT within 12 hours of symptom onset or last seen well. Data were last analyzed in July 2022.

Main outcome(s) and measure(s): A total of 19 variables were assessed by multivariable ordinal regression to predict functional outcome (modified Rankin Scale [mRS] score) 90 days after EVT. Variables were routinely available 1 day after EVT. Akaike information criterion (AIC) was used to optimize model fit vs model complexity. Probabilities for functional independence (mRS 0-2) and survival (mRS 0-5) were derived from the ordinal model. Model performance was expressed with discrimination (C statistic) and calibration.

Results: A total of 781 patients (median [IQR] age, 67 [57-76] years; 414 men [53%]) constituted the derivation cohort, and 3260 patients (median [IQR] age, 72 [61-80] years; 1684 men [52%]) composed the validation cohort. Nine variables were included in the model: age, baseline National Institutes of Health Stroke Scale (NIHSS) score, prestroke mRS score, history of diabetes, occlusion location, collateral score, reperfusion grade, NIHSS score at 24 hours, and symptomatic intracranial hemorrhage 24 hours after EVT. External validation in the MR CLEAN Registry showed excellent discriminative ability for functional independence (C statistic, 0.91; 95% CI, 0.90-0.92) and survival (0.89; 95% CI, 0.88-0.90). The proportion of functional independence in the MR CLEAN Registry was systematically higher than predicted by the model (41% vs 34%), whereas observed and predicted survival were similar (72% vs 75%). The model was updated and implemented for clinical use.

Conclusion and relevance: The prognostic tool MR PREDICTS@24H can be applied 1 day after EVT to accurately predict functional outcome for individual patients at 90 days and to provide reliable outcome expectations and personalize follow-up and rehabilitation plans. It will need further validation and updating for contemporary patients.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Roozenbeek reported receiving personal fees from Dutch Knowledge Institute Medical Specialists outside the submitted work. Dr van der Worp reported receiving consulting fees from TargED; personal fees from Bayer; grants from European Union, Dutch Heart Foundation, and Stryker; and stock options from Philips outside the submitted work. Dr Goyal reported receiving grants from Medtronic HERMES (ESCAPE-MeVO study), Cerenovus (EVOLVE study); personal fees from Medtronic for education on acute stroke; and consulting fees from Mentice outside the submitted work. Dr Muir reported receiving grants from The Stroke Association Institutional Funding; nonfinancial support from Boehringer Ingelheim Drug Supply; advisory board and speaker fees from Boehringer Ingelheim; and consultant fees from Biogen and AbbVie outside the submitted work. Dr White reported receiving grants from Codman and Medtronic during the conduct of the study. Dr Dávalos reported receiving grants from Medtronic during the conduct of the study. Dr Jovin reported receiving advisory fees and stock options from Anaconda, Methinks, Viz.ai, Kandu, Galaxy, Route92, FreeOx Biotech; data safety monitoring board and consultant fees from Cerenovus; grants from Medtronic and Stryker; and committee fees from Contigo Medical outside the submitted work. Dr Hill reported receiving grants from Medtronic, Boehringer Ingelheim Canada, NoNO, Biogen, Medtronic, Alberta Innovates, and the Canadian Institutes for Health Research; having patents (62/086,077 and 10,916,346) licensed to Circle Inc; and being president of the Canadian Neurological Sciences Federation and board member of the Canadian Stroke Consortium (not-for-profit sector) outside the submitted work. Dr Mitchell reported research support from Stryker and Medtronic outside the submitted work. Dr Demchuk reported receiving personal fees from Medtronic and having a patent for Circle Inc outside the submitted work. Dr Saver reported receiving personal fees from Medtronic, Rapid Medical, and Roche outside the submitted work. Dr van der Lugt reported receiving grants from Stryker, Penumbra, Medtronic, Cerenovus, Philips Healthcare, Siemens Healthineers, GE HealthCare, and Thrombolytic Science outside the submitted work. Dr Brown reported receiving personal fees from University of Calgary for statistical consulting during the conduct of the study. Dr Dippel reported receiving grants from Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences & Health, Medtronic, Stryker, Cerenovus, and Thrombolytic Science outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Calibration Plots
A, Functional independence (modified Rankin Scale [mRS] score, 0-2) in the validation cohort. The overall observed proportion of patients with mRS score 0 to 2 in the validation cohort was higher than the predicted proportion using our model (41% vs 32%). The linear bar chart shows the distribution of patients with (= 1) or without (= 0) the observed outcome. B, Survival (mRS score, 0-5) in the validation cohort (n = 3260). The overall observed proportion of patients with mRS score 0 to 5 in the validation cohort was similar to the predicted proportion using our model (72% vs 75%). The linear bar chart shows the distribution of patients with (= 1) or without (= 0) the observed outcome. The shading around the flexible calibration line indicates the 95% confidence limits. MR CLEAN indicates Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands.
Figure 2.
Figure 2.. Screenshot of the Online Tool
CTA indicates computed tomography angiography; eTICI, extended thrombolysis in cerebral infarction; ICH, intracranial hemorrhage; M1, middle cerebral artery segment 1; MCA, middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale.
See this image and copyright information in PMC

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