Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy

Vivek Yedavalli¹, Hamza Salim^{1

2}, Basel Musmar³, Nimer Adeeb³, Kareem El Naamani⁴, Nils Henninger^{5

6}, Sri Hari Sundararajan⁷, Anna Luisa Kühn⁸, Jane Khalife⁹, Sherief Ghozy¹⁰, Luca Scarcia¹¹, Benjamin Yq Tan^{12

13}, Jeremy J Heit¹⁴, Robert W Regenhardt², Nicole M Cancelliere¹⁵, Joshua D Bernstock¹⁶, Aymeric Rouchaud¹⁷, Jens Fiehler¹⁸, Sunil Sheth¹⁹, Muhammed Amir Essibayi²⁰, Ajit S Puri⁸, Christian Dyzmann²¹, Marco Colasurdo²², Xavier Barreau²³, Leonardo Renieri²⁴, João Pedro Filipe²⁵, Pablo Harker²⁶, Răzvan Alexandru Radu²⁷, Thomas R Marotta¹⁵, Julian Spears¹⁵, Takahiro Ota²⁸, Ashkan Mowla²⁹, Pascal Jabbour⁴, Arundhati Biswas³⁰, Frédéric Clarençon³¹, James E Siegler⁹, Thanh N Nguyen^{32

33}, Ricardo Varela³⁴, Amanda Baker²⁰, David Altschul²⁰, Nestor R Gonzalez³⁵, Markus A Möhlenbruch³⁶, Vincent Costalat²⁷, Benjamin Gory^{37

38}, Christian Paul Stracke³⁹, Mohammad Ali Aziz-Sultan¹⁶, Constantin Hecker⁴⁰, Hamza Shaikh⁹, David S Liebeskind⁴¹, Alessandro Pedicelli⁴², Andrea M Alexandre⁴², Illario Tancredi⁴³, Tobias D Faizy⁴⁴, Erwah Kalsoum¹¹, Boris Lubicz⁴⁵, Aman B Patel², Vitor Mendes Pereira¹⁵, Adrien Guenego⁴⁵, Adam A Dmytriw^{2

15}

Affiliations

¹ Division of Neuroradiology, Department of Radiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
³ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, LA, USA.
⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁵ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁶ Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
⁷ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
⁸ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
⁹ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA.
¹⁰ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹¹ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹² Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹³ Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁴ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁵ Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada.
¹⁶ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
¹⁷ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁸ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹⁹ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²⁰ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, USA.
²³ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
²⁴ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁵ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁶ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁷ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁸ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
³⁰ Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
³¹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³² GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³³ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
³⁴ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁵ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA.
³⁶ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁷ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁸ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
³⁹ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁰ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴¹ UCLA Stroke Center and Department of Neurology Department, University of California, Los Angeles, Los Angeles, CA, USA.
⁴² UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
⁴³ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁴ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Münster, Germany.
⁴⁵ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 39075759
DOI: 10.1177/17474930241270524

Multicenter Study

Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy

Vivek Yedavalli et al. Int J Stroke. 2024 Dec.

. 2024 Dec;19(10):1123-1133.

doi: 10.1177/17474930241270524. Epub 2024 Aug 19.

Authors

Affiliations

¹ Division of Neuroradiology, Department of Radiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
³ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, LA, USA.
⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁵ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁶ Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
⁷ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
⁸ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
⁹ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA.
¹⁰ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹¹ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹² Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹³ Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁴ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁵ Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada.
¹⁶ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
¹⁷ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁸ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹⁹ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²⁰ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, USA.
²³ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
²⁴ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁵ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁶ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁷ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁸ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
³⁰ Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
³¹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³² GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³³ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
³⁴ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁵ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA.
³⁶ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁷ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁸ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
³⁹ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁰ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴¹ UCLA Stroke Center and Department of Neurology Department, University of California, Los Angeles, Los Angeles, CA, USA.
⁴² UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
⁴³ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁴ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Münster, Germany.
⁴⁵ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 39075759
DOI: 10.1177/17474930241270524

Abstract

Background: Acute ischemic stroke (AIS) from primary medium vessel occlusions (MeVO) is a prevalent condition associated with substantial morbidity and mortality. Despite the common use of mechanical thrombectomy (MT) in AIS, predictors of poor outcomes in MeVO remain poorly characterized.

Methods: In this prospectively collected, retrospectively reviewed, multicenter, multinational study, data from the MAD-MT (Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy) registry were analyzed. The study included 1568 patients from 37 academic centers across North America, Asia, and Europe, treated with MT, with or without intravenous tissue plasminogen activator (IVtPA), between September 2017 and July 2021.

Results: Among the 1568 patients, 347 (22.2%) experienced very poor outcomes (modified Rankin score (mRS), 5-6). Key predictors of poor outcomes were advanced age (odds ratio (OR): 1.03; 95% confidence interval (CI): 1.02 to 1.04; p < 0.001), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (OR: 1.07; 95% CI: 1.05 to 1.10; p < 0.001), pre-operative glucose levels (OR: 1.01; 95% CI: 1.00 to 1.02; p < 0.001), and a baseline mRS of 4 (OR: 2.69; 95% CI: 1.25 to 5.82; p = 0.011). The multivariable model demonstrated good predictive accuracy with an area under the receiver-operating characteristic (ROC) curve of 0.76.

Conclusions: This study demonstrates that advanced age, higher NIHSS scores, elevated pre-stroke mRS, and pre-operative glucose levels significantly predict very poor outcomes in AIS-MeVO patients who received MT. These findings highlight the importance of a comprehensive risk assessment in primary MeVO patients for personalized treatment strategies. However, they also suggest a need for cautious patient selection for endovascular thrombectomy. Further prospective studies are needed to confirm these findings and explore targeted therapeutic interventions.

Keywords: Acute stroke therapy; acute; cerebral infarction; ischemic stroke; neurology; radiology; reperfusion.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading), and Artedrone (Board); all not directly related to the present work. Dr Henninger received support from CDMRP/DoD W81XWH-19-PRARP-RPA and NINDS NS131756, during the conduct of the study. Dr Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, and Rapid Medical. Dr Yeo reports Advisory work for AstraZeneca, substantial support from NMRC Singapore, and is a medical advisor for See-mode, Cortiro, and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson, and Phenox (paid lectures), all not directly related to the present work. Dr Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc, and Arsenal Medical; he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular, and Stryker Neurovascular; and he holds stocks in InNeuroCo, Agile, Perfuze, Galaxy, and NTI. Dr Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr Jabbour is a consultant for Medtronic, Microvention, and Cerus.

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Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy

Affiliations

Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy

Authors

Affiliations

Abstract

Conflict of interest statement

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Medical