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Published on: February 22, 2020
Predictors of functional dependence despite successful revascularization in large-vessel occlusion strokes
Zhong-Song Shi1, David S Liebeskind2, Bin Xiang2
1From the Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (Z.S.S.); Departments of Neurology and Radiology, UCLA Stroke Center (D.S.L., G.R.D.); Prospect Analytical Inc, San Jose, CA (B.X.); Department of Clinical Research, Stryker Neurovascular, Fremont, CA (S.G.G.); Department of Radiology, Kaiser Permanente Medical Center, Los Angeles, CA (L.F.); Department of Neurology, Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (G.W.A.); OhioHealth Neuroscience Institute, Riverside Methodist Hospital, Columbus (R.B.); Department of Neurology, Erlanger Health System, Chattanooga, TN (T.D.); Wellstar Neurosurgery, Wellstar Health System, Marietta, GA (R.G.); Department of Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany (O.J.); Department of Neurology, UPMC Stroke Center, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Neurology/Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria (M.K.); Department of Neurology, Oregon Health and Science University, Portland (H.L.L.); Angioradiology and Interventional Neuroradiology Unit, Radiology Department, Imaging Diagnostic Center, Clinic University Hospital, Barcelona, Spain (J.M.); Departments of Neurology, Neurosurgery and Radiology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurology, The University of Kansas Hospital (M.R.); Department of Neurology, University of California, San Francisco (W.S.S.); and Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.W.). zhongsongshi@gmail.com.
Background And Purpose:
High revascularization rates in large-vessel occlusion strokes treated by mechanical thrombectomy are not always associated with good clinical outcomes. We evaluated predictors of functional dependence despite successful revascularization among patients with acute ischemic stroke treated with thrombectomy.
Methods:
We analyzed the pooled data from the Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke (TREVO), and TREVO 2 trials. Successful revascularization was defined as thrombolysis in cerebral infarction score 2b or 3. Functional dependence was defined as a score of 3 to 6 on the modified Rankin Scale at 3 months. We assessed relationship of demographic, clinical, angiographic characteristics, and hemorrhage with functional dependence despite successful revascularization.
Results:
Two hundred and twenty-eight patients with successful revascularization had clinical outcome follow-up. The rates of functional dependence with endovascular success were 48.6% for Trevo thrombectomy and 58.0% for Merci thrombectomy. Age (odds ratio, 1.04; 95% confidence interval, 1.02-1.06 per 1-year increase), National Institutes of Health Stroke Scale score (odds ratio, 1.08; 95% confidence interval, 1.02-1.15 per 1-point increase), and symptom onset to endovascular treatment time (odds ratio, 1.11; 95% confidence interval, 1.01-1.22 per 30-minute delay) were predictors of functional dependence despite successful revascularization. Symptom onset to reperfusion time beyond 5 hours was associated with functional dependence. All subjects with symptomatic intracranial hemorrhage had functional dependence.
Conclusions:
One half of patients with successful mechanical thrombectomy do not have good outcomes. Age, severe neurological deficits, and delayed endovascular treatment were associated with functional dependence despite successful revascularization. Our data support efforts to minimize delays to endovascular therapy in patients with acute ischemic stroke to improve outcomes.
Clinical Trial Registration Url:
http://www.clinicaltrials.gov. Unique identifier: NCT00318071, NCT01088672, and NCT01270867.
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