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Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry
  1. Italo Linfante1,2,
  2. Amy K Starosciak2,3,
  3. Gail R Walker3,
  4. Guilherme Dabus1,2,
  5. Alicia C Castonguay4,
  6. Rishi Gupta5,
  7. Chung-Huan J Sun5,
  8. Coleman Martin6,
  9. William E Holloway6,
  10. Nils Mueller-Kronast7,
  11. Joey D English8,
  12. Tim W Malisch9,
  13. Franklin A Marden9,
  14. Hormozd Bozorgchami10,
  15. Andrew Xavier11,
  16. Ansaar T Rai12,
  17. Michael T Froehler13,
  18. Aamir Badruddin14,
  19. Thanh N Nguyen15,
  20. M Asif Taqi6,
  21. Michael G Abraham17,
  22. Vallabh Janardhan18,
  23. Hashem Shaltoni19,
  24. Roberta Novakovic20,
  25. Albert J Yoo21,
  26. Alex Abou-Chebl22,
  27. Peng R Chen23,
  28. Gavin W Britz24,
  29. Ritesh Kaushal25,
  30. Ashish Nanda26,
  31. Mohammad A Issa4,
  32. Raul G Nogueira5,
  33. Osama O Zaidat4
  1. 1Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, Florida, USA
  2. 2Neuroscience Center, Baptist Hospital, Miami, Florida, USA
  3. 3Center for Research and Grants, Baptist Health South Florida, Coral Gables, Florida, USA
  4. 4Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin, USA
  5. 5Emory University School of Medicine, Atlanta, Georgia, USA
  6. 6St. Luke's Kansas City, Kansas City, Missouri, USA
  7. 7Delray Medical Center, Delray Beach, Florida, USA
  8. 8California Pacific Medical Center, San Francisco, California, USA
  9. 9Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
  10. 10Oregon Health and Sciences, Portland, Oregon, USA
  11. 11Wayne State University School of Medicine, Detroit, Michigan, USA
  12. 12West Virginia University Hospital, Morgantown, West Virginia, USA
  13. 13Vanderbilt University Medical Center, Nashville, Tennessee, USA
  14. 14Provena St. Joseph Medical Center, Joliet, Illinois, USA
  15. 15Boston Medical Center, Boston, Massachusetts, USA
  16. 16Desert Regional Medical Center, Palm Springs, California, USA
  17. 17University of Kansas Medical Center, Kansas City, Kansas, USA
  18. 18Texas Stroke Institute, Plano, Texas, USA
  19. 19Baylor College of Medicine, Houston, Texas, USA
  20. 20UT Southwestern Medical Center, Dallas, Texas, USA
  21. 21Massachusetts General Hospital, Boston, Massachusetts, USA
  22. 22Baptist Health Louisville, Louisville, Kentucky, USA
  23. 23The University of Texas Medical School at Houston, Houston, Texas, USA
  24. 24Methodist Neurological Institute, Houston, Texas, USA
  25. 25St Louis University, St Louis, Missouri, USA
  26. 26University of Missouri, Columbia, Missouri, USA
  1. Correspondence to Dr Italo Linfante, Miami Cardiac and Vascular Institute and Neuroscience Center, Baptist Hospital, Miami, FL, USA; linfante.italo{at}gmail.com

Abstract

Background Mechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70–83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40–55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.

Methods Logistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0–2 (good outcome) vs 3–6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power.

Results Of 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80).

Conclusions Age, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.

  • Intervention
  • Stroke
  • Thrombectomy
  • Angiography

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