Totaled Health Risks In Vascular Events Research Articles

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy.

The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) and Totaled Health Risks in Vascular Events (THRIVE) predict functional outcomes after anterior circulation endovascular thrombectomy (EVT). We evaluated the performance of CLEOS and THRIVE in patients presenting with an acute basilar artery occlusion (BAO) treated with EVT. We conducted a retrospective analysis of a health system's stroke registry. Patients presenting with an acute BAO treated with EVT and evaluated with pre-thrombectomy CT perfusion (CTP) from January 2017 to December 2021 were included. CLEOS=(5×age)+(10×National Institutes of Health Stroke Scale [NIHSS])+Glucose-(150×CTP cerebral blood volume index) and THRIVE (0-9 points)=age 60-79years, 1 point; age≥80years, 2 points; NIHSS 11-20, 2 points; NIHSS≥21, 4 points; hypertension, diabetes mellitus, atrial fibrillation, 1 point each. Multivariable logistic regression was performed for the ability of CLEOS and THRIVE to predict the primary outcome, modified Rankin Scale score 3-6. Fifty-seven patients had mean age 66.6 (±14.9) years and median NIHSS 15.5 (5-24). In the multivariable regression analysis, increased CLEOS was associated with significantly higher odds of a poor functional outcome (odds ratio [OR]=1.0011, 95% confidence interval [CI]: 1.0003-1.0019, p=.008), whereas THRIVE was not (OR=1.0326, 95% CI: 0.9478-1.1250, p=.466). CLEOS>503 best predicted poor outcomes. A higher CLEOS score was associated with elevated odds of a poor 90-day functional outcome in our cohort of acute BAO patients treated with EVT.

Multi-Mode Imaging Scale for Endovascular Therapy in Patients with Acute Ischemic Stroke (META).

Background: With the guidance of multi-mode imaging, the time window for endovascular thrombectomy (EVT) has been expanded to 24 h. However, poor clinical outcomes are still not uncommon. We aimed to develop a multi-mode imaging scale for endovascular therapy in patients with acute ischemic stroke (META) to predict the neurological outcome in patients receiving endovascular thrombectomy (EVT). Methods: We included consecutive acute ischemic stroke patients with occlusion of middle cerebral artery and/or internal carotid artery who underwent EVT. Poor outcome was defined as modified Rankin Scale (mRS) score of 3–6 at 3 months. A five-point META score was constructed based on clot burden score, multi-segment clot, the Alberta Stroke Program early computed tomography score of cerebral blood volume (CBV-ASPECTS), and collateral status. We evaluated the META score performance using area under the curve (AUC) calculations. Results: A total of 259 patients were included. A higher META score was independently correlated with poor outcomes at 3 months (odds ratio, 1.690, 95% CI, 1.340 to 2.132, p < 0.001) after adjusting for age, hypertension, baseline National Institutes of Health Stroke Scale (NIHSS) score, and baseline blood glucose. Patients with a META score ≥ 2 were less likely to benefit from EVT (mRS 3–6: 60.8% vs. 29.2%, p < 0.001). The META score predicted poor outcomes with an AUC of 0.714, higher than the Pittsburgh Response to Endovascular therapy (PRE) score, the totaled health risks in vascular events (THRIVE) score (AUC: 0.566, 0.706), and the single imaging marker in the scale. Conclusions: The novel META score could refine the predictive accuracy of prognosis after EVT, which might provide a promising avenue for future automatic imaging analysis to help decision making.

Cohort study of THRIVE predicting adverse outcomes in acute ischemic stroke of the anterior circulation and posterior circulation after 3 months and 1 year of follow-up

Purpose: To evaluate the difference of Totaled Health Risks In Vascular Events (THRIVE) in predicting adverse outcomes in acute ischemic stroke (AIS) of the anterior circulation and posterior circulation at 3-month and 1-year follow-up. Methods: A total of 858 patients with AIS were followed up for 3 months and 1 year, and their data prospectively collected. The occurrence of death or moderate to severe disability (modified Rankin Scale ≥ 3 points) was regarded as the endpoint. MedCalc software was used to create the THRIVE receiver operating characteristic curve. The area under the curve (AUC) was calculated to compare the THRIVE scale in predicting adverse outcomes in AIS of the anterior and posterior circulation and compare the differences. Results: At 3-month follow-up, the AUC of THRIVE was 0.685 (95% CI 0.644–0.724) for AIS of the anterior circulation and 0.709 (95% CI 0.647–0.765) for AIS of the posterior circulation. The area difference between them was 0.0235 (95% CI −0.0728–0.120, P = 0.6330[>0.05]). The AUC of THRIVE for AIS in the anterior circulation at 1 year was 0.701 (95% CI 0.660–0.740), and that for AIS in the posterior circulation at 1 year was 0.747 (95% CI 0.687–0.800). The area difference between them was 0.0458 (95% CI −0.0489–0.140, P = 0.3436 [>0.05]). The difference was not statistically significant. Conclusion: THRIVE can well predict the short-term and long-term adverse prognosis of AIS in the anterior and posterior circulation and has the same predictive effect.

Predicting 6-Month Unfavorable Outcome of Acute Ischemic Stroke Using Machine Learning.

Background and Purpose: Accurate prediction of functional outcome after stroke would provide evidence for reasonable post-stroke management. This study aimed to develop a machine learning-based prediction model for 6-month unfavorable functional outcome in Chinese acute ischemic stroke (AIS) patient.Methods: We collected AIS patients at National Advanced Stroke Center of Nanjing First Hospital (China) between September 2016 and March 2019. The unfavorable outcome was defined as modified Rankin Scale score (mRS) 3–6 at 6-month. We developed five machine-learning models (logistic regression, support vector machine, random forest classifier, extreme gradient boosting, and fully-connected deep neural network) and assessed the discriminative performance by the area under the receiver-operating characteristic curve. We also compared them to the Houston Intra-arterial Recanalization Therapy (HIAT) score, the Totaled Health Risks in Vascular Events (THRIVE) score, and the NADE nomogram.Results: A total of 1,735 patients were included into this study, and 541 (31.2%) of them had unfavorable outcomes. Incorporating age, National Institutes of Health Stroke Scale score at admission, premorbid mRS, fasting blood glucose, and creatinine, there were similar predictive performance between our machine-learning models, while they are significantly better than HIAT score, THRIVE score, and NADE nomogram.Conclusions: Compared with the HIAT score, the THRIVE score, and the NADE nomogram, the RFC model can improve the prediction of 6-month outcome in Chinese AIS patients.

Predictive value of the THRIVE score for outcome in patients with acute basilar artery occlusion treated with thrombectomy.

Background and purposeA higher Totaled Health Risks in Vascular Events (THRIVE) score has been shown to predict poor functional outcome in patients with acute ischemic stroke (AIS) and anterior circulation large vessel occlusions undergoing thrombectomy treatment. We attempted to evaluate the value of the THRIVE score in predicting the outcome of thrombectomy treatment in AIS patients with basilar artery occlusion (BAO).MethodsA total of 68 AIS patients with BAO who underwent thrombectomy treatment from May 2014 to August 2018 were included in the present study. Multivariable logistic regression was performed to determine the predictive value of the THRIVE score for poor functional outcome (defined as modified Rankin Scale score ≥ 3), all‐cause mortality, and hemorrhage transformation (HT) at 3 months.ResultsA total of 42 (61.8%) participants experienced poor functional outcomes, 25 (36.8%) patients died from all causes, and 21 (30.9%) patients had HT during the 3‐month follow‐up. Multivariable logistic regression showed that a higher THRIVE score was significantly associated with poor functional outcome (odds ratio [OR] 5.86, 95% confidence interval [CI], 2.28–14.91, p < .001) as well as all‐cause mortality (OR 2.40, 95% CI, 1.32–4.34, p = .004) but not HT (p = .607). The C‐statistic of the THRIVE score was significantly larger than that of the NIHSS score for predicting poor functional outcome (AUC = 0.913; cutoff > 5; sensitivity, 88.5%; specificity, 83.3%, p = .007) and all‐cause mortality (AUC = 0.768; cutoff > 5; sensitivity, 92.0%; specificity, 65.1%, p = .018).ConclusionsA high THRIVE score was independently associated with an increased risk of poor functional outcome and all‐cause mortality in AIS patients with BAO who underwent thrombectomy treatment. Moreover, the THRIVE score appeared to be a better predictor of clinical outcome than the NIHSS score.

Predictors of functional outcome in patients with stroke thrombolysis in a tertiary hospital in Malaysia.

Intravenous (IV) thrombolysis with alteplase (rt-PA) is effective in ischaemic stroke. The primary objective was to evaluate predictors of functional outcome in acute ischaemic stroke (AIS) patients treated with IV rt-PA. The secondary objective was to assess the outcome with the modified Rankin scale (mRS). We also examined the predictive value of the Totaled Health Risks in Vascular Events (THRIVE) score. AIS patients treated with IV rt-PA from February 2012 to August 2016 were recruited. Demographic data, National Institutes of Health Stroke Scale (NIHSS) scores, timing and neuroradiological findings were recorded. Patients received a dose of 0.9 mg/kg IV rt-PA within 4.5 hours of symptom onset. mRS score was evaluated at discharge and three months, and good and poor clinical outcomes were defined as scores of 0-2 and 3-6, respectively. Baseline THRIVE scores were assessed. 36 patients received IV rt-PA. 20 (55.6%) patients had an mRS score of 0-2 at three months. Based on THRIVE score, 86.1% had a good or moderately good prognosis. On univariate analysis, poor outcome was associated with NIHSS score before rt-PA (p = 0.03), THRIVE score (p = 0.02), stroke subtype (p = 0.049) and diabetes mellitus (DM; p = 0.06). Multiple logistic regression showed that outcome was significantly associated with NIHSS score before rt-PA (p = 0.032) and DM (p = 0.010). Our newly developed Malaysian IV rt-PA service is safe, with similar outcomes to the published literature. Functional outcome after thrombolysis was associated with baseline NIHSS score and DM.

Pretreatment Blood Pressure is a Simple Predictor of Hemorrhagic Infarction after Intravenous Recombinant Tissue Plasminogen Activator (rt-PA) Therapy

BackgroundHemorrhagic infarction (HI) is among the most severe complications that can occur following the administration of intravenous recombinant tissue plasminogen activator (rt-PA). In the present study, we aimed to determine the optimal cut-off points of blood pressure (BP) for HI after rt-PA treatment, and to compare our findings with those for other prediction models. MethodsWe analyzed data from 109 consecutive patients with stroke treated at our hospital between 2009 and 2016. HI was confirmed via computed tomography or magnetic resonance imaging. Patients were classified into a symptomatic HI group, an asymptomatic HI group, and a non-HI group. BP was measured on admission and before rt-PA treatment. Glucose Race Age Sex Pressure Stroke Severity (GRASPS) and Totaled Health Risks in Vascular Events (THRIVE) scores were also calculated. Receiver operating characteristic (ROC) analysis was used to determine factors associated with symptomatic and asymptomatic HI. ResultsAmong the 109 total patients, 25 patients developed symptomatic HI, while 22 patients developed asymptomatic HI. ROC analysis for predicting symptomatic and asymptomatic HI revealed that the area under the curve for pretreatment systolic BP (SBP) was .88 (95% confidence interval[CI]: .83-.94), while those for GRASPS and THRIVE scores were .75 (95% CI: .66-.85) and .69 (95% CI: .59-.79), respectively. We identified an optimal cut-off point of 160 mm Hg (sensitivity: 82.3%; specificity: 76.6%; diagnostic accuracy: 80.0%; positive predictive value: 76.6%; negative predictive value: 82.5%). ConclusionsPre-treatment SBP may be a simple predictor of symptomatic and asymptomatic HI in patients with stroke undergoing rt-PA treatment.

STUDY ON THRIVE SCORE IN THE PROGNOSIS OF ISCHEMIC STROKE

Background and Purpose: Stroke is the second cause of mortality and the leading cause of disability. Using the clinical scale to predict the outcome of the patient play an important role in clinical practice. The Totaled Health Risks in Vascular Events (THRIVE) score has shown broad utility, allowing prediction of clinical outcome and death. Methods: A cross-sectional study conducting on 102 patients with acute ischemic stroke using THRIVE score. The outcome of patient was assessed by mRankin in the day of 30 after stroke. Statistic analysis using SPSS 15.0. Results: There was 60.4% patient in the group with THRIVE score 0 – 2 points having a good outcome (mRS 0 - 2), patient group with THRIVE score 6 - 9 having a high rate of bad outcome and mortality. Having a positive correlation between THRIVE score on admission and mRankin score at the day 30 after stroke with r = 0.712. THRIVE score strongly predicts clinical outcome with ROC-AUC was 0.814 (95% CI 0.735 - 0.893, p&lt;0.001), Se 69%, Sp 84% and the cut-off was 2. THRIVE score strongly predicts mortality with ROC-AUC was 0.856 (95% CI 0.756 - 0.956, p&lt;0.01), Se 86%, Sp 77% and the cut-off was 3. Analysis of prognostic factors by multivariate regression models showed that THRIVE score was only independent prognostic factor for the outcome of post stroke patients. Conclusions: The THRIVE score is a simple-to-use tool to predict clinical outcome, mortality in patients with ischemic stroke. Despite its simplicity, the THRIVE score performs better than several other outcome prediction tools. Key words: Ischemic stroke, THRIVE, prognosis, outcome, mortality

THRIVE score predicts clinical and radiological outcome after endovascular therapy or thrombolysis in patients with anterior circulation stroke in everyday clinical practice.

Based on the data of several trials the Totaled Health Risks in Vascular Events (THRIVE) score has been shown to predict outcome after either intravenous thrombolysis (IVT) or endovascular therapy (ET) in acute stroke patients. It is unknown whether the THRIVE score can also predict outcome in everyday clinical practice. Using our prospectively obtained stroke database the utility of the THRIVE score to predict clinical and radiological outcome in everyday clinical practice was analysed. The relationships between THRIVE and good outcome (modified Rankin Scale≤2 at discharge), poor outcome (modified Rankin Scale 5-6), in-hospital death, symptomatic intracranial haemorrhage (SICH) as well as infarct size were examined in patients with distal intracranial carotid artery, M1 and M2 occlusions after either IVT or ET. From January 2008 to October 2016 a total of 546 patients were treated with IVT and 492 patients received ET with stent retrievers (with or without IVT). In both treatment groups the THRIVE score predicted clinical outcome (Mantel-Haenszel chi-squared tests for trend P<0.001 for good outcome, P<0.001 for poor outcome and P<0.001 for in-hospital death). In the ET group the THRIVE score remained an independent predictor of outcome after controlling for recanalization. The THRIVE score was associated with the infarct size after IVT or ET, whereas it did not predict SICH rates in either treatment group. In everyday clinical practice the THRIVE score strongly predicts clinical outcome and the extent of ischaemia after ET or IVT in patients with anterior circulation large vessel occlusions.

External Validation of the Totaled Health Risks in Vascular Events Score to Predict Functional Outcome and Mortality in Patients Entered into the China National Stroke Registry

THRIVE (Totaled Health Risks in Vascular Events) score is a tool used to predict the functional outcome and mortality in patients with ischemic stroke at 3 months. This project aims to explore its prognostic value at 3, 6, and 12 months in Chinese stroke patients. We applied the THRIVE score in 11,064 patients with acute ischemic stroke who were entered into the China National Stroke Registry. We applied the THRIVE score and examined its performance on mortality and poor functional outcome (modified Rankin Scale score between 3 and 6). Model discrimination was measured by c-statistic. Calibration was assessed by comparing predicted and observed probability of poor outcome or mortality by using Pearson correlation coefficient. Among the 11,064 patients with ischemic stroke, the mortality rates at discharge, and at 3, 6, and 12 months were 3.6%, 7.9%, 10.5%, and 12.7%, respectively; the corresponding c-statistics were .83(95% confidence interval [CI], .80-.86), .79(95% CI, .77-.81), .80(95% CI, .78-.81), and .79(95% CI, .78-.80), respectively. For the poor functional outcome at discharge, and at 3, 6, and 12 months, the c-statistics were .74(95% CI, .73-.75), .76(95% CI, .75-.77), .76(95% CI, .75-.77), and .77(95% CI, .76-.78), respectively. The observed and expected probability of poor functional outcome and mortality based on the THRIVE score correlated (Pearson correlation coefficient ranged from .90 to .99) highly. The THRIVE score is a reliable tool to predict the mortality and to fairly predict the functional outcome at discharge, and at 3, 6, and 12 months in Chinese patients after acute ischemic stroke.

The Totaled Health Risks in Vascular Events (THRIVE) Score Predicts Ischemic Stroke Outcomes

The Totaled Health Risks in Vascular Events (THRIVE) Score Predicts Ischemic Stroke Outcomes

Improved ischemic stroke outcome prediction using model estimation of outcome probability: the THRIVE-c calculation.

The Totaled Health Risks in Vascular Events (THRIVE) score is a previously validated ischemic stroke outcome prediction tool. Although simplified scoring systems like the THRIVE score facilitate ease-of-use, when computers or devices are available at the point of care, a more accurate and patient-specific estimation of outcome probability should be possible by computing the logistic equation with patient-specific continuous variables. We used data from 12 207 subjects from the Virtual International Stroke Trials Archive and the Safe Implementation of Thrombolysis in Stroke - Monitoring Study to develop and validate the performance of a model-derived estimation of outcome probability, the THRIVE-c calculation. Models were built with logistic regression using the underlying predictors from the THRIVE score: age, National Institutes of Health Stroke Scale score, and the Chronic Disease Scale (presence of hypertension, diabetes mellitus, or atrial fibrillation). Receiver operator characteristics analysis was used to assess model performance and compare the THRIVE-c model to the traditional THRIVE score, using a two-tailed Chi-squared test. The THRIVE-c model performed similarly in the randomly chosen development cohort (n = 6194, area under the curve = 0·786, 95% confidence interval 0·774-0·798) and validation cohort (n = 6013, area under the curve = 0·784, 95% confidence interval 0·772-0·796) (P = 0·79). Similar performance was also seen in two separate external validation cohorts. The THRIVE-c model (area under the curve = 0·785, 95% confidence interval 0·777-0·793) had superior performance when compared with the traditional THRIVE score (area under the curve = 0·746, 95% confidence interval 0·737-0·755) (P < 0·001). By computing the logistic equation with patient-specific continuous variables in the THRIVE-c calculation, outcomes at the individual patient level are more accurately estimated. Given the widespread availability of computers and devices at the point of care, such calculations can be easily performed with a simple user interface.

Totaled health risks in vascular events score predicts clinical outcome and symptomatic intracranial hemorrhage in chinese patients after thrombolysis.

The performance of the Totaled Health Risks in Vascular Events (THRIVE) score in predicting clinical outcomes in Chinese patients with acute ischemic stroke post intravenous thrombolysis is unknown. Data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) study was used to compare the THRIVE score with other scores used to predict clinical outcomes and symptomatic intracranial hemorrhage after intravenous thrombolysis. Among the 1128 patients with acute ischemic stroke who were included in this study, areas under the curve of the THRIVE score for symptomatic intracranial hemorrhage, 3-month poor functional outcomes, and death rate were 0.69, 0.71, and 0.78, respectively. The increased THRIVE score was related to the higher risk of developing symptomatic intracranial hemorrhage, poor functional outcomes, or death in patients with acute ischemic stroke at 3 months after thrombolysis. The THRIVE score predicted reliably the risks of developing symptomatic intracranial hemorrhage, poor functional outcome, or death after intravenous thrombolysis therapy in Chinese patients with acute ischemic stroke.

Abstract T P10: Therapeutic Time Window for Endovascular Therapy of Acute Ischemic Stroke Depends on THRIVE Score: A Retrospective Single-center Study

Background and purpose: The outcome after endovascular therapy in acute ischemic stroke is associated with onset-to-reperfusion time (ORT). The Totaled Health Risks in Vascular Events (THRIVE) score is also an important pre-thrapeutic predictor of outcome. We hypothesized that the therapeutic time window is narrower in patients with the higher THRIVE score. Methods: We retrospectively studied consecutive 109 ischemic stroke patients with successful reperfusion after endovascular therapy between October 2005 and March 2014 at a single institute (Kobe City Medical Center General Hospital). Inclusion criteria was as follows: National Institutes of Health Stroke Scale (NIHSS) score ≥8, stroke symptom duration ≤8 h, premorbid modified Rankin Scale (mRS) score ≤2, and thrombolysis myocardial infarction score 2-3. We analyzed the relationships of ORT, THRIVE score, and THRIVE+ORT score with good outcome (mRS ≤2 at 3 months). The THRIVE+ORT score was defined as the sum of the THRIVE score and ORT (h). Results: Median ORT was 5.5 h (IQR; 4.4-7.1 h), median THRIVE score was 5 (IQR; 4-6), and median THRIVE+ORT score was 10.8 (IQR; 9.2-12.5). Good outcome rates for patients with ORT ≤4 h, &gt;4 and ≤6 h, &gt;6 and ≤8 h, and &gt;8h were 50.0%, 45.8%, 37.0%, and 21.4%, respectively (p=0.3), those with THRIVE score ≤3, &gt;3 and ≤5, &gt;5 and ≤7, and &gt;7 were 57.1%, 51.4%, 28.3%, and 20.0%, respectively (p9 and ≤11, &gt;11 and ≤13, and &gt;13 were 64.0%, 44.1%, 34.4%, and 16.7%, respectively (p&lt;0.05). Multivariate logistic regression analysis revealed that THRIVE+ORT score was an independent predictor of good outcome after adjusted for THRIVE score (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.082-1.728) or after adjusted for ORT (OR, 1.517: 95% CI, 1.160-1.983). Conclusion: Our study showed that THRIVE+ORT score was associated with outcome that was independent from THRIVE score or ORT. This is the first report to suggest that patients with the higher THRIVE score require the shorter ORT for good outcome.

Abstract W P16: Comparing Outcome Prediction Scoring Systems in the Interventional Management of Stroke (IMS) III Trial: No Clear Winner

Introduction: Several prognostic scores have been developed to predict patient outcome after ischemic stroke. We aimed to compare eight scores in the IMS -III dataset. Hypothesis: Prediction of good and poor outcome using different scores is possible in IMS-III. Methods: We retrospectively calculated area under the curve (AUC), sensitivity, and specificity for poor (mRS 4-6) and good (mRS 0-2) 90-day outcome in all IMS-III participants with complete data. The scoring systems analyzed were: Houston Intra-arterial Therapy 2 (HIAT2), Ischemic Stroke Predictive Risk Score (iScore), Totaled Health Risks in Vascular Events (THRIVE), DRAGON, Hemorrhage after Thrombolysis (HAT), Alberta Stroke Programme Early CT Score (ASPECTS), Stroke-Thrombolytic Predictive Instrument (TPI), and Simple Variables Model (SVM). Those receiving IV rtPA followed by endovascular therapy (treatment) and those receiving IV rtPA only (control) were analyzed separately. Results: Among 656 IMS III subjects, 651 had complete data, including 429 treatment and 222 control subjects. Overall, all scoring systems showed good prediction abilities (AUC range 0.60 to 0.78). AUC comparisons did not clearly favor a single scoring system. Treatment group: For predicting poor outcome, the TPI score outperformed ASPECTS (AUC 0.73 vs 0.61; P &lt;0.05). For predicting good outcome, the HAT score was significantly better than ASPECTS (0.73 vs. 0.64; P &lt;0.05). Control group: For poor outcome, the TPI score was significantly better than ASPECTS and THRIVE (0.78 vs. 0.62 and 0.71, respectively; P &lt;0.05). For good outcome, TPI performed better than ASPECTS and THRIVE (0.73 vs. 0.61 and 0.67, respectively; P &lt;0.05). Conclusions: Outcome prediction using different scores in IMS III is possible. HIAT2, iSCORE, DRAGON, HAT, TPI, and SVM all performed comparably. Prognostic performances were comparable in both treatment arms.

Abstract T P26: Combining Clinical and Imaging Data to Develop a Highly Predictive Model of Outcomes in the MR RESCUE Trial

Background: Identifying patient characteristics that predict outcomes in acute ischemic stroke may assist in triaging those who are candidates for endovascular therapies. We sought to identify predictors of outcome in the overall Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) cohort and compare results to the previously validated Totaled Health Risks in Vascular Events (THRIVE) score. Methods: MR RESCUE randomized 118 acute ischemic stroke patients with multimodal imaging to embolectomy or standard care within 8 hours of onset. For this analysis, we investigated 17 baseline variables (e.g. age, predicted core volume, time to enrollment) and 8 intermediate variables (e.g. hemorrhagic transformation, day 7 recanalization, final infarct volume) with the potential to impact outcomes (day 90 mRS). The baseline variables were analyzed employing bivariate and multivariate methods (random forest and logistic regression). Two models were developed, one including only significant baseline variables, and the second also incorporating significant intermediate variables. Results: A multivariate model (Table) employing only baseline covariates achieved an overall accuracy (C statistic) of 85% in predicting poor outcome (day 90 mRS 3-6) compared to 80.5% for the THRIVE score. A second model (Table) adding significant intermediate variables achieved 89% accuracy in predicting day 90 mRS. Conclusions: In the MR RESCUE trial, advanced imaging variables, including predicted core volume and site of vessel occlusion, contributed to a highly accurate multivariable model of outcome. In the development phase, this model achieved higher accuracy than the THRIVE score. Future studies are needed to validate this model in an independent cohort.

Investigating the Utility of Previously Developed Prediction Scores in Acute Ischemic Stroke Patients in the Stroke Belt

To assess the utility of previously developed scoring systems, we compared SEDAN, named after the components of the score (baseline blood Sugar, Early infarct signs and (hyper) Dense cerebral artery sign on admission computed tomography scan, Age, and National Institutes of Health Stroke Scale on admission), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-arterial Therapy (HIAT), and HIAT-2 scoring systems among patients receiving systemic (intravenous [IV] tissue plasminogen activator [tPA]) and endovascular (intra-arterial [IA]) treatments. We retrospectively reviewed all IV tPA and IA patients presenting to our center from 2008-2011. The scores were assessed in patients who were treated with IV tPA only, IA only, and a combination of IV tPA and IA (IV-IA). We tested the ability of THRIVE to predict discharge modified Rankin scale (mRS) 3-6, HIAT and HIAT-2 discharge mRS 4-6, and SEDAN symptomatic intracerebral hemorrhage (sICH). Of the 366 patients who were included in this study, 243 had IV tPA only, 89 had IA only, and 34 had IV-IA. THRIVE was predictive of mRS 3-6 in the IV-IA (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.30-2.91) and the IV group (OR, 1.71; 95% CI, 1.43-2.04), but not in the IA group. HIAT was predictive of mRS 4-6 in the IA (OR, 3.55; 95% CI, 1.65-7.25), IV (OR, 3.47; 95% CI, 2.26-5.33), and IV-IA group (OR, 6.48; 95% CI, 1.41-29.71). HIAT-2 was predictive of mRS 4-6 in the IA (OR, 1.39; 95% CI, 1.03-1.87) and IV group (OR, 1.36; 95% CI, 1.18-1.57), but not in the IV-IA group. SEDAN was not predictive of sICH in the IA or the IV-IA group, but was predictive in the IV group (OR, 1.54; 95% CI, 1.01-2.36). Our study demonstrated that although highly predictive of outcome in the original study design treatment groups, prediction scores may not generalize to all patient samples, highlighting the importance of validating prediction scores in diverse samples.

The THRIVE score predicts symptomatic intracerebral hemorrhage after intravenous tPA administration in SITS-MOST.

The Totaled Health Risks in Vascular Events (THRIVE) score is a clinical prediction score that predicts ischemic stroke outcomes in patients receiving intravenous tissue plasminogen activator, endovascular stroke treatment, or no acute therapy. We have previously found an association between THRIVE and risk of post-tissue plasminogen activator symptomatic intracranial hemorrhage in the National Institute of Neurological Disorders and Stroke (NINDS) tissue plasminogen activator trial and risk of radiographic hemorrhage in Virtual International Stroke Trials Archive. The study aims to validate the relationship between THRIVE and symptomatic intracranial hemorrhage among tissue plasminogen activator-treated patients in the large Safe Implementation of Thrombolysis in Stroke - Monitoring Study (SITS-MOST). This is a retrospective analysis of the prospective SITS-MOST to examine the relationship between THRIVE and symptomatic intracranial hemorrhage after tissue plasminogen activator treatment. Symptomatic intracranial hemorrhage after tissue plasminogen activator was defined according to each of three standard definitions: the NINDS, European Cooperative Acute Stroke Study (ECASS), and Safe Implementation of Thrombolysis in Stroke (SITS) criteria. Multivariable logistic regression was used to confirm the relationship of THRIVE and individual THRIVE components with the risk of symptomatic intracranial hemorrhage and to examine the relationship of THRIVE, symptomatic intracranial hemorrhage, and functional outcome. The odds ratio for symptomatic intracranial hemorrhage at each increased level of THRIVE score is 1·34 (95% CI 1·27 to 1·41, P < 0·001) for symptomatic intracranial hemorrhage by NINDS criteria, 1·36 (95% CI 1·27 to 1·46, P < 0·001) for symptomatic intracranial hemorrhage by ECASS criteria, and 1·21 (95% CI 1·09 to 1·36, P < 0·001) for symptomatic intracranial hemorrhage by SITS criteria. In receiver-operator characteristics analysis, the C-statistic for THRIVE prediction of symptomatic intracranial hemorrhage was 0·65 (95% CI 0·62 to 0·67) for symptomatic intracranial hemorrhage by NINDS criteria, 0·66 (95% CI 0·63 to 0·69) for symptomatic intracranial hemorrhage by ECASS criteria, and 0·61 (95% CI 0·56 to 0·66) for symptomatic intracranial hemorrhage by SITS criteria. Each component of the THRIVE score predicts the risk of symptomatic intracranial hemorrhage, with independent impact of each component in multivariable analysis. The THRIVE score predicts the risk of symptomatic intracranial hemorrhage after intravenous tissue plasminogen activator administration. This external validation of the relationship between THRIVE and symptomatic intracranial hemorrhage in a prospective study further strengthens the role of the THRIVE score in the prediction of poststroke outcomes.

Posttreatment Variables Improve Outcome Prediction after Intra-Arterial Therapy for Acute Ischemic Stroke

Background: There are multiple clinical and radiographic factors that influence outcomes after endovascular reperfusion therapy (ERT) in acute ischemic stroke (AIS). We sought to derive and validate an outcome prediction score for AIS patients undergoing ERT based on readily available pretreatment and posttreatment factors. Methods: The derivation cohort included 511 patients with anterior circulation AIS treated with ERT at 10 centers between September 2009 and July 2011. The prospective validation cohort included 223 patients with anterior circulation AIS treated in the North American Solitaire Acute Stroke registry. Multivariable logistic regression identified predictors of good outcome (modified Rankin score ≤2 at 3 months) in the derivation cohort; model β coefficients were used to assign points and calculate a risk score. Discrimination was tested using C statistics with 95% confidence intervals (CIs) in the derivation and validation cohorts. Calibration was assessed using the Hosmer-Lemeshow test and plots of observed to expected outcomes. We assessed the net reclassification improvement for the derived score compared to the Totaled Health Risks in Vascular Events (THRIVE) score. Subgroup analysis in patients with pretreatment Alberta Stroke Program Early CT Score (ASPECTS) and posttreatment final infarct volume measurements was also performed to identify whether these radiographic predictors improved the model compared to simpler models. Results: Good outcome was noted in 186 (36.4%) and 100 patients (44.8%) in the derivation and validation cohorts, respectively. Combining readily available pretreatment and posttreatment variables, we created a score (acronym: SNARL) based on the following parameters: symptomatic hemorrhage [2 points: none, hemorrhagic infarction (HI)1-2 or parenchymal hematoma (PH) type 1; 0 points: PH2], baseline National Institutes of Health Stroke Scale score (3 points: 0-10; 1 point: 11-20; 0 points: >20), age (2 points: <60 years; 1 point: 60-79 years; 0 points: >79 years), reperfusion (3 points: Thrombolysis In Cerebral Ischemia score 2b or 3) and location of clot (1 point: M2; 0 points: M1 or internal carotid artery). The SNARL score demonstrated good discrimination in the derivation (C statistic 0.79, 95% CI 0.75-0.83) and validation cohorts (C statistic 0.74, 95% CI 0.68-0.81) and was superior to the THRIVE score (derivation cohort: C statistic 0.65, 95% CI 0.60-0.70; validation cohort: C-statistic 0.59, 95% CI 0.52-0.67; p < 0.01 in both cohorts) but was inferior to a score that included age, ASPECTS, reperfusion status and final infarct volume (C statistic 0.86, 95% CI 0.82-0.91; p = 0.04). Compared with the THRIVE score, the SNARL score resulted in a net reclassification improvement of 34.8%. Conclusions: Among AIS patients treated with ERT, pretreatment scores such as the THRIVE score provide only fair prognostic information. Inclusion of posttreatment variables such as reperfusion and symptomatic hemorrhage greatly influences outcome and results in improved outcome prediction.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles