Course of Early Neurologic Symptom Severity after Endovascular Treatment of Anterior Circulation Large Vessel Occlusion Stroke: Association with Baseline Multiparametric CT Imaging and Clinical Parameters.

Hanna Zimmermann,Thomas Geyer,Daniel Puhr-Westerheide,Matthias Philipp Fabritius,Clemens Küpper,Lars Kellert,Stefan Maurus,Konstantinos Dimitriadis,Thomas Liebig,Moriz Herzberg,Wolfgang G Kunz,Sergio Grosu,Jens Ricke,Paul Reidler,Steffen Tiedt,Teresa A Wölfer,Adrian Curta

doi:10.3390/diagnostics11071272

Abstract

Background: Neurologic symptom severity and deterioration at 24 hours (h) predict long-term outcomes in patients with acute large vessel occlusion (LVO) stroke of the anterior circulation. We aimed to examine the association of baseline multiparametric CT imaging and clinical factors with the course of neurologic symptom severity in the first 24 h after endovascular treatment (EVT). Methods: Patients with LVO stroke of the anterior circulation were selected from a prospectively acquired consecutive cohort of patients who underwent multiparametric CT, including non-contrast CT, CT angiography and CT perfusion before EVT. The symptom severity was assessed on admission and after 24 h using the 42-point National Institutes of Health Stroke Scale (NIHSS). Clinical and imaging data were compared between patients with and without early neurological deterioration (END). END was defined as an increase in ≥4 points, and a significant clinical improvement as a decrease in ≥4 points, compared to NIHSS on admission. Multivariate regression analyses were used to determine independent associations of imaging and clinical parameters with NIHSS score increase or decrease in the first 24 h. Results: A total of 211 patients were included, of whom 38 (18.0%) had an END. END was significantly associated with occlusion of the internal carotid artery (odds ratio (OR), 4.25; 95% CI, 1.90–9.47) and the carotid T (OR, 6.34; 95% CI, 2.56–15.71), clot burden score (OR, 0.79; 95% CI, 0.68–0.92) and total ischemic volume (OR, 1.01; 95% CI, 1.00–1.01). In a comprehensive multivariate analysis model including periprocedural parameters and complications after EVT, carotid T occlusion remained independently associated with END, next to reperfusion status and intracranial hemorrhage. Favorable reperfusion status and small ischemic core volume were associated with clinical improvement after 24 h. Conclusions: The use of imaging parameters as a surrogate for early NIHSS progression in an acute LVO stroke after EVT reached limited performance with only carotid T occlusion as an independent predictor of END. Reperfusion status and early complications in terms of intracranial hemorrhage are critical factors that influence patient outcome in the acute stroke phase after EVT.

Highlights

The National Institutes of Health Stroke Scale (NIHSS) represents the reference standard for the functional assessment of symptom severity in the setting of acute ischemic stroke [1,2,3]
This study presents a comprehensive investigation of multiparametric CT imaging and clinical factors on neurological symptom severity progression in the first 24 h in anterior circulation large vessel occlusion (LVO) stroke
Girot et al, who focused on unexplained END (unEND), mainly found nonmodifiable factors such as premorbid disability, age and diabetes mellitus as predictors for neurologic deterioration; baseline imaging parameters were not included in the analysis and only cases with favorable reperfusion status and no early complications were considered as early neurological deterioration (END), which limits the comparability with our results [5]

Summary

Introduction

The National Institutes of Health Stroke Scale (NIHSS) represents the reference standard for the functional assessment of symptom severity in the setting of acute ischemic stroke [1,2,3]. As the most commonly performed imaging modality in acute stroke setting, multiparametric CT provides the opportunity to comprehensively assess the cerebrovascular status, including tissue perfusion, topography, collateral flow, or initial edema formation These parameters can be directly translated to morphological correlates of stroke, for example penumbra and core volume, as well as the temporal course of infarct growth [14,15,16,17,18]. It has been shown that multiparametric CT-based total ischemic volume and clot burden influence the baseline NIHSS in acute large vessel occlusion (LVO) stroke and, might serve as surrogate parameters for stroke symptom severity [19]. Conclusions: The use of imaging parameters as a surrogate for early NIHSS progression in an acute LVO stroke after EVT reached limited performance with only carotid T occlusion as an independent predictor of END.

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