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Original research
Optimal thresholds to predict long-term outcome after complete endovascular recanalization in acute anterior ischemic stroke
  1. Ulf Neuberger1,
  2. Philipp Vollmuth1,
  3. Simon Nagel2,
  4. Silvia Schönenberger2,
  5. Charlotte Sabine Weyland1,
  6. Christoph Gumbinger2,
  7. Peter Arthur Ringleb2,
  8. Martin Bendszus1,
  9. Johannes Alex Rolf Pfaff1,
  10. Markus Alfred Möhlenbruch1
  1. 1 Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
  2. 2 Clinic of Neurology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
  1. Correspondence to Dr Ulf Neuberger, Department of Neuroradiology, University Hospital Heidelberg, Heidelberg 69120, Germany; ulf.neuberger{at}


Background Despite complete endovascular recanalization, a significant percentage of patients with acute anterior stroke do not achieve a good clinical outcome. We analyzed optimal thresholds of relevant parameters to discern functional independence after successful endovascular recanalization and test their predictive performance.

Methods Patients with acute anterior ischemic stroke undergoing endovascular treatment between April 2015 and November 2019 were retrospectively analyzed. Only patients with premorbid modified Rankin Scale (mRS) score <3 and complete recanalization (modified Thrombolysis In Cerebral Infarction 2c/3) were included. Optimal thresholds of the most important variables predicting functional independence (mRS 0–2 after 90 days) were calculated using receiver operating characteristic curves and their predictive performance was tested in an independent dataset using machine learning algorithms.

Results Overall, 371 patients met the inclusion criteria. Optimal thresholds for the overall most important variables to predict functional independence were (1) National Institutes of Health Stroke Scale (NIHSS) score ≤5 after 24 hours (area under the curve (AUC) 0.88 (95% CI 0.84 to 0.92)); (2) Alberta Stroke Program Early CT Score (ASPECTS) ≥7 on follow-up CT (AUC 0.72 (95% CI 0.68 to 0.77)); and (3) change in NIHSS score ≥8 after 24 hours (AUC 0.70 (95% CI 0.65 to 0.74)). The performance of these thresholds to predict a good outcome using machine learning in the independent dataset was evaluated for (1) NIHSS score ≤5 after 24 hours (AUC 0.76 (95% CI 0.71 to 0.81)); (2) follow-up ASPECTS ≥7 (AUC 0.64 (95% CI 0.58 to 0.70)); (3) change in NIHSS score ≥8 after 24 hours (AUC 0.61 (95% CI 0.55 to 0.67)); and (4) the combination of all three parameters (AUC 0.84 (95% CI 0.80 to 0.88)).

Conclusions After complete recanalization in acute anterior circulation ischemic stroke, a good long-term outcome could be accurately predicted reaching NIHSS score ≤5 after 24 hours.

  • thrombectomy
  • stroke
  • statistics

Data availability statement

Data are available upon reasonable request from the corresponding author.

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Data availability statement

Data are available upon reasonable request from the corresponding author.

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  • Contributors UN, MB and MM conceived and designed the research. UN, PK, SN, SS, CSW, CG, JARP and MM acquired and analyzed the data. UN performed the statistical analysis and prepared the first draft of the report. All authors made critical revisions of the manuscript for important intellectual content and approved the final version.

  • Funding UN was funded by the Physician-Scientist Program from the University of Heidelberg Medical Faculty.

  • 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.