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Updated: Sep 19, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Sequential NIHSS-NLR monitoring after endovascular thrombectomy: malignant cerebral oedema and inflammatory futility
Hesham A Alyamani1, Anter M A Nasser2, Qin Huang1
1Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
Introduction:
Successful reperfusion after endovascular thrombectomy (EVT) does not guarantee recovery. Malignant cerebral oedema (MCE) complicates approximately one in eight patients, and static pre-procedural models do not capture evolving post-reperfusion risk. We evaluated a two-phase sequential clinical-inflammatory monitoring framework.
Methods:
We conducted a retrospective consecutive-patient cohort study at Xiangya Hospital (2021-2025) including 306 successfully reperfused EVT patients. Phase 1 combined the 24-h NIHSS trajectory with neutrophil-to-lymphocyte ratio (NLR) direction for clinically ascertained MCE risk. Ridge-penalised logistic models were internally validated using Harrell bootstrap correction. Exploratory Phase 2 combined 72-h NLR with CT-perfusion anatomy for futile recanalisation (90-day mRS ≥3).
Results:
MCE occurred in 39 patients (12.7%), all co-occurring with early neurological deterioration. NIHSS worsening was the dominant predictor (aOR 6.95, 95% CI 3.63-14.46; E-value 13.4; corrected AUC 0.791). NLR direction provided minimal incremental discrimination (DeltaAUC +0.008, 95% CI -0.007 to +0.020) but separated complication profiles: concurrent NIHSS worsening and NLR rise identified an oedema-enriched subgroup (MCE 26.9%; NNM 3.7), whereas non-rising NLR among worsening patients identified a haemorrhage-enriched subgroup (sICH 37.7%). At 72 h, favourable anatomy with elevated NLR defined a candidate inflammatory futility phenotype with lower functional independence (57.3% vs 84.2%; corrected AUC 0.631, upper bound by construction).
Discussion:
Because MCE ascertainment was clinically triggered and adjudication was unblinded to NIHSS trajectory, Phase 1 identifies a clinical-inflammatory risk pattern rather than an independent radiological predictor. NLR direction functions primarily as a complication-profile stratifier. Prospective multicentre validation with blinded radiological adjudication is required before clinical or trial-design application.
