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  • Age-adjusted infarct volume cut-off points improve stroke outcome prognostication beyond modeling with age and infarct volume

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Ischemic stroke
Original research
Age-adjusted infarct volume cut-off points improve stroke outcome prognostication beyond modeling with age and infarct volume
  1. Mehdi Bouslama1,
  2. Diogo C Haussen2,
  3. Gabriel Martins Rodrigues1,
  4. Clara M Barreira2,
  5. Seena Dehkharghani3,
  6. Michael R Frankel1,
  7. Raul G Nogueira1
  1. 1 Department of Neurology, Emory University, Atlanta, Georgia, USA
  2. 2 Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
  3. 3 Department of Radiology, NYU Langone Health, New York, New York, USA
  1. Correspondence to Dr Raul G Nogueira, Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, GA 30322, USA; rnoguei{at}emory.edu

Abstract

Background Age and infarct volume are among the most powerful predictors of outcome after large vessel occlusion acute strokes (LVOS).

Objective To study the impact of age-adjusted final infarct volume (FIV) on functional outcomes.

Methods Review of a prospectively collected thrombectomy database at a tertiary care center between September 2010 and February 2018. Consecutive patients with anterior circulation LVOS who achieved full reperfusion (modified Thrombolysis in Cerebral Infarction 3) were categorized into four age groups: (G1) <60 years, (G2) 60–69, (G3) 70–79, (G4) ≥80 years. The Youden Index was used to identify the optimal FIV cut-off point for good outcome (modified Rankin Scale score 0–2) discrimination in each group and the overall population. The predictive ability of these specific thresholds was evaluated using binary logistic regressions and compared with the non-age-adjusted cut-off point.

Results 516 patients were analyzed (G1: n=171, G2: n=130, G3: n=103, G4: n=112). Patients with poor outcome had a larger FIV in each group (p<0.01 for all). The target FIV cut-off point decreased with increased age: G1: 45.7 mL (sensitivity 56%, specificity 80%); G2: 30.4 mL (sensitivity 63%, specificity 75%); G3: 20.2 mL (sensitivity 76%, specificity 65%); G4: 16.9 mL (sensitivity 68%, specificity 70%). The non-age-adjusted cut-off point was 19.2 mL (sensitivity 70%, specificity 59%).

In multivariate analysis, adjusting for confounders including age and FIV, achieving a FIV less than the age-adjusted threshold was an independent predictor of good outcome (aOR=2.72, 95% CI 1.41 to 5.24, p<0.001). In contrast, a similar model including the non-age-adjusted target cut-off point failed to reveal an association with good outcome (aOR=1.72, 95% CI 0.93 to 3.19, p<0.085). Furthermore, the latter model had a weaker outcome predictive ability as assessed by the Akaike information criterion (409 vs 403).

Conclusions Age-adjusted infarct volume represents a strong outcome discriminator beyond age and infarct volume in isolation and might help to refine patient selection and improve outcome prognostication in stroke thrombectomy.

  • stroke
  • thrombectomy

Data availability statement

The unpublished data from this dataset are held by Grady Memorial Hospital/Emory University and MB/RGN. Requests for data sharing would have to be discussed with them directly.

https://doi.org/10.1136/neurintsurg-2020-017066

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    Data availability statement

    The unpublished data from this dataset are held by Grady Memorial Hospital/Emory University and MB/RGN. Requests for data sharing would have to be discussed with them directly.

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    Footnotes

    • Twitter @bouslamamd, @diogohaussen

    • Contributors Study design: MB, RGN. Data collection, analysis, and interpretation: MB, DCH, GMR, CMB, SD, MRF, RGN. Drafting the original manuscript: MB. Revising the work critically for important intellectual content: MB, DCH, GMR, CMB, SD, MRF, RGN. Final approval: MB, DCH, GMR, CMB, SD, MRF, RGN. Agreement to be accountable for all aspects of the work: MB, DCH, GMR, CMB, SD, MRF, RGN.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.