J Stroke Search

CLOSE


J Stroke > Volume 23(1); 2021 > Article
Gwak, Kwon, Shim, Kim, and Hwang: Perfusion and Diffusion Variables Predict Early Neurological Deterioration in Minor Stroke and Large Vessel Occlusion

Abstract

Background and Purpose

Patients with acute large vessel occlusion (LVO) presenting with mild stroke symptoms are at risk of early neurological deterioration (END). This study aimed to identify the optimal imaging variables for predicting END in this population.

Methods

We retrospectively analyzed 94 patients from the prospectively maintained institutional stroke registry admitted between January 2011 and May 2019, presenting within 24 hours after onset, with a baseline National Institutes of Health Stroke Scale score ≤5 and anterior circulation LVO. Patients who underwent endovascular therapy before END were excluded. Volumes of Tmax delay (at >2, >4, >6, >8, and >10 seconds), mismatch (Tmax >4 seconds - diffusion-weighted imaging [DWI] and Tmax >6 seconds - DWI), and mild hypoperfusion lesions (Tmax 2-6 and 4-6 seconds) were measured. The association of each variable with END was examined using receiver operating characteristic curves. The variables with best predictive performance were dichotomized at the cutoff point maximizing Youden’s index and subsequently analyzed using multivariable logistic regression.

Results

END occurred in 39.4% of the participants. The optimal variables were identified as Tmax >6 seconds, Tmax >6 seconds - DWI, and Tmax 4-6 seconds with cut-off points of 53.73, 32.77, and 55.20 mL, respectively. These variables were independently associated with END (adjusted odds ratio [aOR], 12.78 [95% confidence interval (CI), 3.36 to 48.65]; aOR, 5.73 [95% CI, 2.04 to 16.08]; and aOR, 9.13 [95% CI, 2.76 to 30.17], respectively).

Conclusions

Tmax >6 seconds, Tmax >6 seconds - DWI, and Tmax 4-6 seconds could identify patients at high risk of END following minor stroke due to LVO.

Introduction

Patients presenting with mild symptoms of acute ischemic stroke are common and account for approximately half of all patients [1,2]. Despite the perception that minor stroke is a benign condition, nearly one-third of patients have persistent disability [3-5]. In particular, up to 30% of minor strokes are caused by acute large vessel occlusion (LVO) [1,6], and affected patients are at high risk of early neurological worsening and poor longterm outcomes [7,8].
Whether endovascular therapy (EVT) is beneficial in minor stroke due to LVO is uncertain, as most large clinical trials for EVT excluded patients with a National Institutes of Health Stroke Scale (NIHSS) score of 5 or less [9-15], and several retrospective studies have reported contradictory results on the effects of EVT in minor stroke [6,16-22]. Therefore, it is crucial to identify patients who are most likely to benefit from EVT in minor stroke with LVO.
Over half of minor stroke patients with LVO who were medically treated showed excellent outcomes at 3 months [6,18-22] and appear to be inappropriate for EVT. Meanwhile, patients who experience neurological worsening during best medical treatment show less favorable outcomes than those undergoing immediate EVT, even if they receive rescue EVT following clinical deterioration [6,20,21]. Thus, identifying patients who are likely to have early neurological deterioration (END) is clinically important, as immediate EVT may be considered as one of the treatment options in this patient group.
Infarct growth in the same vascular territory is the most common mechanism of END [23]. Theoretically, the transition from oligemic tissue to a functionally impaired state may lead to clinical deterioration. Based on this theory, those with a larger area of non-infarcted but hypoperfused tissue may be at greater risk of developing END. Imaging variables from perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) could be potential surrogate markers for hypoperfused brain regions. Using these variables, several studies have demonstrated that mismatch between PWI and DWI is associated with infarct growth [24] and poor outcomes, including END [25,26]. However, due to the heterogeneity of study participants in previous studies, whether these imaging variables predict END in patients with LVO presenting with mild symptoms remains unknown. We aimed to investigate the optimal imaging variables using PWI and DWI for the prediction of END in this population.

Methods

Study population

We retrospectively reviewed consecutive patients with ischemic stroke from our prospectively maintained institutional stroke registry. We identified patients who met the following inclusion criteria: (1) admission to Kyungpook National University Hospital between January 2011 and May 2019 (n=7,945); (2) arrival within 24 hours of the last known normal (n=5,465); (3) baseline NIHSS score of five or less (n=3,001); (4) pre-stroke modified Rankin Scale (mRS) of 0 or 1 (n=2,705); and (5) acute LVO in the anterior circulation (defined by occlusion of the intracranial internal carotid artery, proximal segment of the middle cerebral artery [M1 or M2 trunk], or tandem occlusion) documented on the initial computed tomography angiography or magnetic resonance angiography (n=158). Patients with LVO due to moyamoya disease were excluded (n=15). Patients were also excluded if they were treated with EVT before END (n=14) or did not undergo PWI (n=35). Finally, 94 patients were eligible for analysis (Supplementary Figure 1). The study protocol was approved by the Institutional Review Board (IRB approval number: KNUH 2020-04-001). The need for informed consent was waived due to the retrospective nature of the study and the minimal risk to study participants. All study participants were fully anonymized.

Data collection

Baseline demographics and clinical characteristics were obtained from the institutional stroke registry database or through a review of electronic medical records. The following variables were collected: age, sex, baseline NIHSS score, onset-to-door time, pre-stroke mRS, stroke mechanism classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria with some modifications [27], occluded vessel location, hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, myocardial infarction or angina, history of smoking, baseline blood pressure, type of recanalization therapy, and laboratory data including baseline leukocyte count, hemoglobin, hematocrit, platelet count, erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and glucose level.
Ischemic core lesions identified on DWI were measured using an automated software program with minimal manual editing (Olea Sphere 3.0, SP6, Olea Medical, La Ciotat, France). Dynamic susceptibility PWI was performed, and the Tmax value of the residue function generated by deconvolution was obtained. The Tmax delay volumes (Tmax >2, 4, 6, 8, and 10 seconds) were measured using the same program. The Tmax delay lesion of the optimal threshold was determined as a critical hypoperfusion lesion reflecting its association with neurological worsening. Mismatch volumes (Tmax >4 seconds - DWI volume and Tmax >6 seconds - DWI volume) and mild hypoperfusion lesions where perfusion deficits were milder than the penumbra [28,29] (Tmax 2-6 seconds and Tmax 4-6 seconds) were also recorded.
The outcome variables, including END and unfavorable functional outcome (defined as an mRS of 2 to 6) at 3 months were collected. To capture neurological worsening sensitively and exclude systemic causes, we defined END as any new neurological symptom or any neurological worsening with an increase in the total NIHSS score of 2 or more, or an increase in the motor score (5a-6b) of one or more within 72 hours of stroke onset [30-32]. It was immediately documented by the onduty neurologist or attending physician.

Statistical analysis

Data are summarized as number (%), mean±standard deviation, or median (interquartile range [IQR]). Comparisons of variables between the groups with or without END were made using Student’s t-test or the Mann-Whitney U test for continuous variables, and Pearson’s chi-square test or Fisher’s exact method for categorical variables, as appropriate. In addition, the association of END with unfavorable outcomes was tested using Pearson’s chi-square test.
The optimal threshold for the Tmax delay lesion was defined as that showing the best predictive performance for END and was determined using receiver operating characteristic (ROC) curve analysis. For the variables of mismatch volume and mild hypoperfusion lesions of each Tmax threshold, the optimal threshold was also obtained in the same way. Furthermore, these continuous variables were dichotomized at the cutoff point maximizing Youden’s index (sensitivity+specificity-1) [33]. The best thresholds of Tmax delay lesion (critical hypoperfusion lesion), mismatch volume, and mild hypoperfusion lesion were subsequently analyzed to derive predictive models using multivariable logistic regression analysis.
Univariable logistic regression analyses were performed to examine the associations of critical hypoperfusion lesions, mismatch volumes, and mild hypoperfusion lesions with clinical outcomes. All variables that were different between the two groups (defined as P<0.1) were then included in the backward stepwise multivariable logistic regression analyses to adjust for the effects of confounding variables. To avoid multicollinearity among the imaging variables, critical hypoperfusion lesions, mismatch volumes, and mild hypoperfusion lesions were tested in separate models. A two-sided P-value <0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 25.0 (IBM Co., Armonk, NY, USA).

Results

A total of 94 patients with acute LVO presenting with mild symptoms were included in this study. Among them, 37 (39.4%) patients experienced END. In all cases, the mechanism of END was progressive stroke in the same vascular territory. Baseline demographics and clinical characteristics are shown in Table 1. We found no statistical difference in the baseline characteristics between the groups with or without END, except for onset-to-door time and type of recanalization therapy. The onset-to-door time (hours) was shorter in patients with END (2.50 [IQR, 1.45 to 9.33]) than in those without END (4.28 [IQR, 1.58 to 13.67]; P=0.019). Patients who experienced END were more frequently treated with intravenous tissue-type plasminogen activator (tPA; 54.1%) than patients without END (14.0%; P<0.001). The PWI and DWI variables are presented in Table 2. Initial hypoperfusion lesion volumes with a Tmax threshold of >4, >6, >8, and >10 seconds were larger in the END group than in the non-END group. Mismatch volumes with a Tmax threshold >4 and >6 seconds and mild hypoperfusion lesion of Tmax 4-6 seconds were also larger in the END group. Patients with END were more likely to have an unfavorable outcome at 3 months than those without END (35.1% vs. 7.0%, P=0.001). Of the patients with END, 62.2% (23/37) received EVT following neurological worsening (Table 1). However, 30.4% (7/23) of these patients showed unfavorable outcomes at 3 months despite rescue EVT.
The ROC analysis of imaging variables for each threshold and their association with END identified Tmax >6 seconds, Tmax >6 seconds - DWI, and Tmax 4-6 seconds as the optimal values for further analysis (area under the curve=0.725 [95% confidence interval (CI), 0.622 to 0.829; P<0.001]; 0.753 [95% CI, 0.654 to 0.852; P<0.001]; and 0.648 [95% CI, 0.535 to 0.762; P=0.016], respectively). Based on Youden’s Index, the optimal volume of Tmax >6 seconds for predicting END was ≥53.73 mL, Tmax >6 seconds - DWI was ≥32.77 mL, and Tmax 4-6 seconds was ≥55.20 mL (Table 3).
In the univariate logistic regression analysis, patients who had a Tmax >6 seconds of ≥53.73 mL (the group with a large critical hypoperfusion lesion volume) were more likely to experience END than those with a Tmax >6 seconds of <53.73 mL (odds ratio [OR], 6.77; 95% CI, 2.44 to 18.77; P<0.001) (Table 4). In addition, patients who had a mismatch volume ≥32.77 mL (the mismatch pattern group) and mild hypoperfusion lesion of Tmax 4-6 seconds ≥55.20 mL (the group with a large mild hypoperfusion lesion volume) were more likely to experience END (OR, 5.34 [95% CI, 2.17 to 13.11; P<0.001] and 4.21 [95% CI, 1.75 to 10.15; P=0.001], respectively). Due to the multicollinearity of these variables, each imaging variable was tested in a separate multivariable logistic regression model. In model 1, adjusting for the difference in variables between the two groups, patients with large critical hypoperfusion lesion volumes were still significantly more likely to experience END (adjusted OR [aOR], 12.78; 95% CI, 3.36 to 48.65; P<0.001). Furthermore, the association between the mismatch pattern and END remained significant in model 2 (aOR, 5.73; 95% CI, 2.04 to 16.08; P=0.001). In model 3, patients with large mild hypohypoperfusion lesion volumes were independently associated with END (aOR, 9.13; 95% CI, 2.76 to 30.17; P<0.001). Those who received tPA also showed an independent association with END in all models.
Large critical hypoperfusion lesion volume, mismatch pattern, and large mild hypoperfusion lesion volume were associated with increased odds of an unfavorable outcome at 3 months (OR, 11.82 [95% CI, 3.55 to 39.29; P<0.001]; OR, 5.69 [95% CI, 1.69 to 19.13; P=0.005]; and OR, 4.44 [95% CI, 1.42 to 13.95; P=0.011], respectively) (Table 5). We also found that these variables were independently associated with an unfavorable outcome at 3 months, even after adjusting for confounding variables (aOR, 23.72 [95% CI, 4.79 to 117.47; P<0.001]; aOR, 12.47 [95% CI, 2.43 to 64.09; P=0.003]; and aOR, 5.61 [95% CI, 1.56 to 20.19; P=0.008], respectively). Other variables, including pre-stroke mRS in all three models and baseline glucose in models 2 and 3, were independent predictors of an unfavorable outcome at 3 months.

Discussion

This study shows that END occurs frequently (39.4%) in patients with minor stroke and LVO. The optimal imaging variables for predicting END were Tmax >6 seconds, Tmax >6 seconds - DWI, and Tmax 4-6 seconds, respectively. Specifically, large critical hypoperfusion lesion volume (Tmax >6 seconds ≥53.73 mL), mismatch pattern (Tmax >6 seconds - DWI ≥32.77 mL), and large mild hypoperfusion lesion volume (Tmax 4-6 seconds ≥55.20 mL) were associated with END. These imaging variables were also associated with unfavorable functional outcomes at 3 months.
Previous studies have demonstrated that a mismatch volume or ratio was associated with END [25,26]. However, these studies enrolled patients regardless of LVO, and one included a patient with relatively severe stroke with an NIHSS score of ≥6 [25]. Accordingly, optimal imaging variables predicting END in minor stroke and LVO remain unknown. Although a recent study failed to find radiological predictors of END in a similar patient population, patients with END tended to have larger Tmax >6 seconds lesion volumes [34], which is in line with our findings. The current and earlier studies suggest that critical hypoperfusion lesions on magnetic resonance imaging would reliably reflect collateral status [35,36], which is an important determinant of fluctuations of neurological status [37-39]. In addition, our results suggest that mismatch lesions and mild hypoperfusion lesions could be another predictor of END, and these lesions are at risk of progressing to the infarct core in patients with minor stroke and acute LVO. Patients treated with tPA were also independently related to END. However, the results should be interpreted with caution. As treatment strategies were determined at the discretion of the attending physicians, patients expected to have poorer outcomes may have had a higher chance of receiving tPA. Although not statistically significant, patients who received tPA had larger Tmax >6 seconds and Tmax >6 seconds - DWI volume than those who did not. Furthermore, patients treated with tPA had shorter onset-to-door times and thus received medical attention for a longer time, and thus had a higher chance of neurological worsening being detected by physicians (Supplementary Table 1) [32].
Given the association between END and perfusion status in patients with minor stroke and acute LVO, restoration of perfusion deficits might be considered as a potential treatment strategy for patients at high risk of END. Since delaying EVT until neurologic worsening appears to reduce its beneficial effect [6,20,21], immediate EVT might be considered in cases of minor stroke and LVO with a large critical hypoperfusion lesion volume, mismatch pattern, or a large mild hypoperfusion lesion volume. Further well-designed clinical trials should be conducted to prove the benefit of immediate EVT in minor stroke patients with a high risk of END.
Our study has several limitations. Due to its retrospective design, selection bias cannot be ruled out. Patients who were deemed to have neurological worsening were possibly treated with immediate EVT and excluded from this study (n=14). They had a larger mismatch volume between Tmax >6 seconds and DWI (median 51.98 mL [IQR, 25.61 to 129.21]) and Tmax >6 seconds lesion volume (62.33 mL [IQR, 10.15 to 56.67]) (Supplementary Tables 2 and 3). Despite this bias, END was frequent (39.4%) in our study cohort. Another shortcoming may be unmeasured confounders. Further, as the perfusion status of each tissue may dynamically change over time in the acute stage of stroke [40], a single PWI snapshot may not accurately reflect temporal change and may be an inaccurate predictor. In addition, follow-up neuroimaging was not available in most patients, and therefore we were not able to consider the effect of spontaneous recanalization on clinical outcomes.

Conclusions

In conclusion, our study showed that END was frequent in patients with minor stroke and acute LVO and could be predicted using perfusion/diffusion imaging variables. Tmax >6 seconds ≥53.73 mL, Tmax >6 seconds - DWI ≥32.77 mL, and Tmax 4-6 seconds ≥55.20 mL were independently associated with END and unfavorable functional outcomes at 3 months. These thresholds could be considered as reference values to select candidates for immediate EVT in minor stroke patients at a high risk of END to improve outcomes.

Supplementary materials

Supplementary materials related to this article can be found online at https://doi.org/10.5853/jos.2020.01466.
Supplementary Table 1.
Patients’ characteristics by IV tPA status
jos-2020-01466-suppl1.pdf
Supplementary Table 2.
Baseline demographics of enrolled patients and patients who underwent EVT before END
jos-2020-01466-suppl2.pdf
Supplementary Table 3.
Imaging variables of enrolled patients and patients who underwent EVT before END
jos-2020-01466-suppl3.pdf
Supplementary Figure 1.
Flowchart of patient screening and enrollment. NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; LVO, large vessel occlusion; IC-ICA, intracranial internal carotid artery; MCA, middle cerebral artery; EVT, endovascular treatment; END, early neurological deterioration; PWI, perfusion-weighted imaging.
jos-2020-01466-suppl4.pdf

Notes

Disclosure
The authors have no financial conflicts of interest.

Table 1.
Baseline characteristics of the patients
Characteristic All (n=94) END (n=37) Non-END (n=57) P
Age (yr) 66.9±13.0 67.2±11.8 66.8±13.9 0.875
Men 49 (52.1) 16 (43.2) 33 (57.9) 0.165
Baseline NIHSS 2.12±1.63 2.08±1.64 2.14±1.64 0.865
Onset-to-door time (hr) 3.23 (1.45-9.33) 2.50 (1.09-5.10) 4.28 (1.58-13.67) 0.019
Pre-stroke mRS 0.377
 0 80 (85.1) 30 (81.1) 50 (87.7)
 1 14 (14.9) 7 (18.9) 7 (12.3)
Stroke mechanism 0.448
 LAA 42 (44.7) 15 (40.5) 27 (47.4)
 CE 36 (38.3) 17 (47.2) 19 (33.3)
 Other determined 0 (0) 0 (0) 0 (0)
 Undetermined 16 (17.0) 5 (13.5) 11 (19.3)
Site of occlusion 0.553
 Intracranial ICA 7 (7.4) 4 (10.8) 3 (5.3)
 Tandem 6 (6.4) 3 (8.1) 3 (5.3)
 MCA M1 44 (46.8) 18 (48.6) 26 (45.6)
 MCA M2 trunk 37 (39.4) 12 (32.4) 25 (43.9)
Hypertension 63 (67.0) 28 (75.7) 35 (61.4) 0.150
Diabetes mellitus 25 (26.6) 12 (32.4) 13 (22.8) 0.302
Hyperlipidemia 37 (39.4) 17 (45.9) 20 (35.1) 0.292
Atrial fibrillation 26 (27.7) 11 (29.7) 15 (26.3) 0.718
MI or angina 9 (9.6) 3 (8.1) 6 (10.5) 1.000
Prior stroke 11 (11.7) 4 (10.8) 7 (12.3) 1.000
Smoking 19 (20.2) 6 (16.2) 13 (22.8) 0.437
SBP (mm Hg) 157.2±31.1 151.4±30.8 161.0±31.0 0.143
DBP (mm Hg) 86.6±17.0 86.7±15.2 86.5±18.2 0.961
Leukocyte count (n/μL) 8,075.1±2,324.8 8,358.6±2,268.8 7,891.1±2,361.9 0.343
Hemoglobin (g/dL) 13.7±1.5 13.7±1.4 13.7±1.6 0.983
Hematocrit (%) 39.9±4.1 39.8±3.6 40.0±4.5 0.835
Platelet count (n/μL) 245,053±74,857 257,730±72,276 236,825±75,978 0.187
ESR (mm/hr) 10.0 (5.0-19.0) 9.0 (5.0-19.0) 11.0 (5.5-19.0) 0.645
CRP (mg/dL) 0.25 (0.08-0.34) 0.29 (0.06-0.29) 0.24 (0.09-0.42) 0.660
Fibrinogen (mg/dL) 287.2±82.7 301.2±98.2 278.1±70.4 0.221
Baseline glucose (mg/ dL) 143.8±51.4 152.2±49.8 138.2±52.1 0.201
Type of recanalization therapy
 IV tPA 28 (29.8) 20 (54.1) 8 (14.0) <0.001
 Rescue EVT 23 (24.5) 23 (62.2) 0 (0) <0.001
Values are presented as mean±standard deviation, number (%), or median (interquartile range).
END, early neurological deterioration; NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; LAA, large artery atherosclerosis; CE, cardioembolism; ICA, internal carotid artery; MCA, middle cerebral artery; MI, myocardial infarction; SBP, systolic blood pressure; DBP, diastolic blood pressure; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; IV tPA, intravenous tissue-type plasminogen activator; EVT, endovascular therapy.
Table 2.
Perfusion- and diffusion-weighted imaging variables
Variable All (n=94) Patients with END (n=37) Patients without END (n=57) P
Initial DWI volume (mL) 1.34 (0.00-5.61) 0.56 (0.00-3.87) 1.87 (0.45-5.88) 0.054
Tmax >2 sec (mL) 217.62 (156.56-274.25) 243.66 (153.83-297.30) 202.64 (157.97-272.31) 0.091
Tmax >4 sec (mL) 84.24 (47.78-120.57) 108.33 (64.04-165.55) 65.60 (41.43-95.93) <0.001
Tmax >6 sec (mL) 28.97 (10.15-56.67) 40.93 (22.43-67.57) 21.38 (3.31-42.65) <0.001
Tmax >8 sec (mL) 12.53 (0.00-25.10) 21.34 (4.16-41.56) 7.63 (0.00-18.73) 0.001
Tmax >10 sec (mL) 3.85 (0.00-12.70) 11.08 (0.00-17.50) 0.00 (0.00-8.74) 0.005
Tmax >4 sec - DWI (mL) 75.21 (43.27-118.17) 105.70 (64.00-162.93) 63.17 (34.99-90.24) <0.001
Tmax >6 sec - DWI (mL) 24.96 (6.45-46.25) 40.93 (19.53-63.21) 16.25 (1.00-34.93) <0.001
Tmax 2-6 sec (mL) 185.54 (131.62-229.11) 198.02 (122.93-227.93) 184.90 (134.13-229.69) 0.998
Tmax 4-6 sec (mL) 47.19 (28.10-76.63) 62.08 (33.46-81.68) 42.03 (24.06-67.48) 0.004
Values are presented as median (interquartile range).
END, early neurological deterioration; DWI, diffusion-weighted imaging.
Table 3.
Receiver operating characteristic curve analysis of imaging variables of each threshold for predicting early neurological deterioration
Imaging variable AUC 95% CI Youden’s Index Sensitivity Specificity P
Tmax delay
 >2 sec 0.585 0.461-0.709 0.22 0.57 0.65 0.165
 >4 sec 0.710 0.601-0.818 0.36 0.49 0.88 0.001
 >6 sec 0.725 0.622-0.829 0.36 0.49 0.88 <0.001
 >8 sec 0.703 0.593-0.813 0.35 0.60 0.75 0.001
 >10 sec 0.665 0.548-0.781 0.34 0.57 0.77 0.007
Mismatch volume
 Tmax >4 sec - DWI 0.718 0.611-0.825 0.37 0.54 0.83 <0.001
 Tmax >6 sec - DWI 0.753 0.654-0.852 0.40 0.68 0.72 <0.001
Mild hypoperfusion lesion
 Tmax 2-6 sec 0.509 0.388-0.631 0.15 0.51 0.63 0.880
 Tmax 4-6 sec 0.648 0.535-0.762 0.34 0.62 0.72 0.016
AUC, area under the curve; CI, confidence interval; DWI, diffusion-weighted imaging.
Table 4.
Logistic regression analysis investigating the association between clinical and imaging variables and early neurological deterioration
Variable Crude OR (95% CI) P Adjusted OR (95% CI) Model 1 P Adjusted OR (95% CI) Model 2 P Adjusted OR (95% CI) Model 3 P
Tmax >6 sec* 6.77 (2.44-18.77) <0.001 12.78 (3.36-48.65) <0.001 NA NA NA NA
Tmax >6 sec - DWI 5.34 (2.17-13.11) <0.001 NA NA 5.73 (2.04-16.08) 0.001 NA NA
Tmax 4-6 sec 4.21 (1.75-10.15) 0.001 NA NA NA NA 9.13 (2.76-30.17) <0.001
Onset-to-door time (hr) 0.89 (0.81-0.97) 0.008 NA NA NA NA NA NA
IV tPA 7.21 (2.68-19.36) <0.001 7.68 (2.52-23.43) <0.001 5.97 (2.05-17.40) 0.001 14.94 (4.18-53.33) <0.001
Initial DWI volume (mL) 0.95 (0.88-1.03) 0.239 0.88 (0.78-1.001) 0.052 0.92 (0.82-1.03) 0.131 NA NA
Model 1 was adjusted for Tmax >6 seconds ≥53.73 mL, onset-to-door time, IV tPA, and initial DWI volume; Model 2 was adjusted for Tmax >6 seconds - DWI ≥32.77 mL, onset-to-door time, IV tPA, and initial DWI volume; Model 3 was adjusted for Tmax 4-6 seconds ≥55.20 mL, onset-to-door time, IV tPA, and initial DWI volume.
OR, odds ratio; CI, confidence interval; NA, not applicable; DWI, diffusion-weighted imaging; IV tPA, intravenous tissue-type plasminogen activator.
* Tmax >6 seconds volume over 53.73 mL;
Tmax >6 seconds - DWI volume over 32.77 mL;
Tmax 4-6 seconds volume over 55.20 mL.
Table 5.
Logistic regression analysis investigating the association between clinical and imaging variables and 3-month unfavorable outcome
Variable Crude OR (95% CI) P Adjusted OR (95% CI) Model 1 P Adjusted OR (95% CI) Model 2 P Adjusted OR (95% CI) Model 3 P
Tmax >6 sec* 11.82 (3.55-39.29) <0.001 23.72 (4.79-117.47) <0.001 NA NA NA NA
Tmax >6 sec - DWI 5.69 (1.69-19.13) 0.005 NA NA 12.47 (2.43-64.09) 0.003 NA NA
Tmax 4-6 sec 4.44 (1.42-13.95) 0.011 NA NA NA NA 5.61 (1.56-20.19) 0.008
Baseline glucose (/5 mg/dL) 1.05 (1.00-1.10) 0.051 NA NA 1.06 (1.002-1.12) 0.044 1.06 (1.01-1.12) 0.032
Pre-stroke mRS 4.71 (1.37-16.18) 0.014 13.78 (2.31-82.14) 0.004 14.32 (2.49-82.44) 0.003 6.67 (1.66-26.79) 0.007
Model 1 was adjusted for Tmax >6 seconds ≥53.73 mL, baseline glucose, and pre-stroke mRS; Model 2 was adjusted for Tmax >6 seconds - DWI ≥32.77 mL, baseline glucose, and pre-stroke mRS; Model 3 was adjusted for Tmax 4-6 seconds ≥55.20 mL, baseline glucose, and pre-stroke mRS.
OR, odds ratio; CI, confidence interval; NA, not applicable; DWI, diffusion-weighted imaging; mRS, modified Rankin Scale.
* Tmax >6 seconds volume over 53.73 mL;
Tmax >6 seconds - DWI volume over 32.77 mL;
Tmax 4-6 seconds volume over 55.20 mL.

References

1. Heldner MR, Zubler C, Mattle HP, Schroth G, Weck A, Mono ML, et al. National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke 2013;44:1153-1157.
crossref pmid
2. Reeves M, Khoury J, Alwell K, Moomaw C, Flaherty M, Woo D, et al. Distribution of national institutes of health stroke scale in the Cincinnati/Northern Kentucky stroke study. Stroke 2013;44:3211-3213.
crossref pmid pmc
3. Spokoyny I, Raman R, Ernstrom K, Khatri P, Meyer DM, Hemmen TM, et al. Defining mild stroke: outcomes analysis of treated and untreated mild stroke patients. J Stroke Cerebrovasc Dis 2015;24:1276-1281.
crossref pmid pmc
4. Khatri P, Conaway MR, Johnston KC; Acute Stroke Accurate Prediction Study (ASAP) Investigators. Ninety-day outcome rates of a prospective cohort of consecutive patients with mild ischemic stroke. Stroke 2012;43:560-562.
crossref pmid
5. Romano JG, Smith EE, Liang L, Gardener H, Camp S, Shuey L, et al. Outcomes in mild acute ischemic stroke treated with intravenous thrombolysis: a retrospective analysis of the Get With the Guidelines-Stroke registry. JAMA Neurol 2015;72:423-431.
crossref pmid
6. Messer MP, Schönenberger S, Möhlenbruch MA, Pfaff J, Herweh C, Ringleb PA, et al. Minor stroke syndromes in largevessel occlusions: mechanical thrombectomy or thrombolysis only? AJNR Am J Neuroradiol 2017;38:1177-1179.
crossref pmid
7. Rajajee V, Kidwell C, Starkman S, Ovbiagele B, Alger JR, Villablanca P, et al. Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology 2006;67:980-984.
crossref pmid
8. Kim JT, Park MS, Chang J, Lee JS, Choi KH, Cho KH. Proximal arterial occlusion in acute ischemic stroke with low NIHSS scores should not be considered as mild stroke. PLoS One 2013;8:e70996.
crossref pmid pmc
9. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015;372:2285-2295.
crossref pmid
10. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009-1018.
crossref pmid
11. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019-1030.
crossref pmid
12. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296-2306.
crossref pmid
13. Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 2016;15:1138-1147.
crossref pmid
14. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, OrtegaGutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018;378:708-718.
crossref pmid pmc
15. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018;378:11-21.
pmid
16. Wolman DN, Marcellus DG, Lansberg MG, Albers G, Guenego A, Marks MP, et al. Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms. Int J Stroke 2020;15:324-331.
crossref pmid
17. Dargazanli C, Arquizan C, Gory B, Consoli A, Labreuche J, Redjem H, et al. Mechanical thrombectomy for minor and mild stroke patients harboring large vessel occlusion in the anterior circulation: a multicenter cohort study. Stroke 2017;48:3274-3281.
crossref pmid
18. Sarraj A, Hassan A, Savitz SI, Grotta JC, Cai C, Parsha KN, et al. Endovascular thrombectomy for mild strokes: how low should we go? Stroke 2018;49:2398-2405.
crossref pmid pmc
19. Urra X, San Román L, Gil F, Millán M, Cánovas D, Roquer J, et al. Medical and endovascular treatment of patients with large vessel occlusion presenting with mild symptoms: an observational multicenter study. Cerebrovasc Dis 2014;38:418-424.
crossref
20. Nagel S, Bouslama M, Krause LU, Küpper C, Messer M, Petersen M, et al. Mechanical thrombectomy in patients with milder strokes and large vessel occlusions. Stroke 2018;49:2391-2397.
crossref pmid
21. Haussen DC, Bouslama M, Grossberg JA, Anderson A, Belagage S, Frankel M, et al. Too good to intervene? Thrombectomy for large vessel occlusion strokes with minimal symptoms: an intention-to-treat analysis. J Neurointerv Surg 2017;9:917-921.
crossref pmid
22. Haussen DC, Lima FO, Bouslama M, Grossberg JA, Silva GS, Lev MH, et al. Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts. J Neurointerv Surg 2018;10:325-329.
crossref pmid
23. Siegler JE, Boehme AK, Albright KC, George AJ, Monlezun DJ, Beasley TM, et al. A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke. J Stroke Cerebrovasc Dis 2013;22:e549-e556.
crossref pmid pmc
24. Gawlitza M, Gragert J, Quäschling U, Hoffmann KT. FLAIR-hyperintense vessel sign, diffusion-perfusion mismatch and infarct growth in acute ischemic stroke without vascular recanalisation therapy. J Neuroradiol 2014;41:227-233.
crossref pmid
25. Hsu CY, Cheng CY, Tsai YH, Lee JD, Yang JT, Weng HH, et al. Perfusion-diffusion mismatch predicts early neurological deterioration in anterior circulation infarction without thrombolysis. Curr Neurovasc Res 2015;12:277-282.
crossref pmid pmc
26. Asdaghi N, Hill MD, Coulter JI, Butcher KS, Modi J, Qazi A, et al. Perfusion MR predicts outcome in high-risk transient ischemic attack/minor stroke: a derivation-validation study. Stroke 2013;44:2486-2492.
crossref pmid
27. Ko Y, Lee S, Chung JW, Han MK, Park JM, Kang K, et al. MRI-based algorithm for acute ischemic stroke subtype classification. J Stroke 2014;16:161-172.
crossref pmid pmc
28. Olivot JM, Mlynash M, Thijs VN, Kemp S, Lansberg MG, Wechsler L, et al. Optimal Tmax threshold for predicting penumbral tissue in acute stroke. Stroke 2009;40:469-475.
crossref pmid
29. Takasawa M, Jones PS, Guadagno JV, Christensen S, Fryer TD, Harding S, et al. How reliable is perfusion MR in acute stroke? Validation and determination of the penumbra threshold against quantitative PET. Stroke 2008;39:870-877.
pmid
30. Saji N, Kimura K, Kawarai T, Shimizu H, Kita Y. Arterial stiffness and progressive neurological deficit in patients with acute deep subcortical infarction. Stroke 2012;43:3088-3090.
crossref pmid
31. Jeong HG, Kim BJ, Yang MH, Han MK, Bae HJ. Neuroimaging markers for early neurologic deterioration in single small subcortical infarction. Stroke 2015;46:687-691.
crossref pmid
32. Hwang YH, Seo JG, Lee HW, Park SP, Suh CK. Early neurological deterioration following intravenous recombinant tissue plasminogen activator therapy in patients with acute lacunar stroke. Cerebrovasc Dis 2008;26:355-359.
crossref pmid
33. Youden WJ. Index for rating diagnostic tests. Cancer 1950;3:32-35.
crossref pmid
34. Saleem Y, Nogueira RG, Rodrigues GM, Kim S, Sharashidze V, Frankel M, et al. Acute neurological deterioration in large vessel occlusions and mild symptoms managed medically. Stroke 2020;51:1428-1434.
crossref
35. Bang OY, Goyal M, Liebeskind DS. Collateral circulation in ischemic stroke: assessment tools and therapeutic strategies. Stroke 2015;46:3302-3309.
pmid pmc
36. Bang OY, Saver JL, Buck BH, Alger JR, Starkman S, Ovbiagele B, et al. Impact of collateral flow on tissue fate in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2008;79:625-629.
crossref pmid
37. Fanou EM, Knight J, Aviv RI, Hojjat SP, Symons SP, Zhang L, et al. Effect of collaterals on clinical presentation, baseline imaging, complications, and outcome in acute stroke. AJNR Am J Neuroradiol 2015;36:2285-2291.
crossref pmid
38. Miteff F, Levi CR, Bateman GA, Spratt N, McElduff P, Parsons MW. The independent predictive utility of computed tomography angiographic collateral status in acute ischaemic stroke. Brain 2009;132:2231-2238.
crossref pmid
39. Shuaib A, Butcher K, Mohammad AA, Saqqur M, Liebeskind DS. Collateral blood vessels in acute ischaemic stroke: a potential therapeutic target. Lancet Neurol 2011;10:909-921.
crossref pmid
40. Campbell BC, Christensen S, Tress BM, Churilov L, Desmond PM, Parsons MW, et al. Failure of collateral blood flow is associated with infarct growth in ischemic stroke. J Cereb Blood Flow Metab 2013;33:1168-1172.
crossref pmid pmc


ABOUT JoS
AUTHOR INFORMATION
ARTICLE CATEGORY

Browse all articles >

BROWSE ARTICLES
Editorial Office
Department of Neurology, Asan Medical Center,Ulsan University College of Medicine
88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
Submission, status and progress, etc ⟫ E-mail: editor@j-stroke.org
Website and system ⟫ E-mail: journal@m2community.co.kr
Publishing company ⟫ E-mail: jin@ijpnc.com
Developed in M2PI
Copyright © 2021 by Korean Stroke Society. All rights reserved.
Close layer
prev next