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Unexplained early neurological deterioration after endovascular treatment for acute large vessel occlusion: incidence, predictors, and clinical impact: Data from ANGEL-ACT registry
  1. Dapeng Sun1,
  2. Xu Tong1,
  3. Xiaochuan Huo1,
  4. Baixue Jia1,
  5. Raynald1,
  6. Anxin Wang2,
  7. Gaoting Ma1,
  8. Ning Ma1,
  9. Feng Gao1,
  10. Dapeng Mo1,
  11. Ligang Song1,
  12. Xuan Sun1,
  13. Lian Liu1,
  14. Yiming Deng1,
  15. Xiaoqing Li1,
  16. Bo Wang1,
  17. Gang Luo1,
  18. Yongjun Wang2,
  19. Zhongrong Miao1
  20. On behalf of the ANGEL-ACT study group
  1. 1Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
  2. 2China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
  1. Correspondence to Dr Zhongrong Miao, Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing 100070, China; zhongrongm{at}


Background Early neurological deterioration (END) may occur in some patients with acute large vessel occlusion (LVO) undergoing endovascular treatment (EVT). Despite several clear causes of END, such as symptomatic intracranial hemorrhage, failure of recanalization, and intraprocedure complications, a particular END, termed unexplained END (ENDunexplained), exists. We aimed to investigate the incidence, independent predictors, and clinical impact of ENDunexplained after EVT in patients with acute LVO.

Methods Subjects were selected from the ANGEL-ACT registry. ENDunexplained was defined as ≥4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score between baseline and 24 hours after EVT, without the causes listed above. Logistic regression analyses were performed to determine the independent predictors of ENDunexplained, as well as the association between ENDunexplained and 90-day outcomes assessed by modified Rankin Scale (mRS) score.

Results Among the 1557 enrolled patients, the incidence of ENDunexplained was 4.3% (67/1557). Admission NIHSS ≤8 (OR=6.88, 95% CI 3.86 to 12.26, p<0.001), general anesthesia (OR=3.15, 95% CI 1.81 to 5.48, p<0.001), admission neutrophil to lymphocyte ratio >5 (OR=2.82, 95% CI 1.61 to 4.94, p<0.001), and number of EVT attempts >3 (OR=2.11, 95% CI 1.14 to 3.89, p=0.018) were associated independently with a high risk of ENDunexplained. Furthermore, patients with ENDunexplained were associated with a shift toward worse 90-day outcomes (mRS 5 vs 3, common OR=5.24, 95% CI 3.22 to 8.52, p<0.001).

Conclusions ENDunexplained associated with poor 90day outcomes occurred in 4.3% of patients with acute LVO undergoing EVT. Several independent predictors of ENDunexplained were identified in this study, which should be considered in daily practice to improve acute LVO management.

Clinical trial Registration http://wwwclinicaltrialsgov NCT03370939.

  • stroke
  • thrombectomy

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors Study concept and design, data acquisition, statistical analyses, interpretation of the data, and drafting the manuscript: DS. Major role in data acquisition, interpretation of the data, and critical revision of the manuscript for intellectual content: XT. Critical revision of the manuscript for intellectual content: XH, BJ, R, AW, GM, NM, FG, DM, LS, XS, LL, YD, XL, BW, GL, and YW. Study concept and design, interpretation of the data, critical revision of the manuscript for intellectual content: ZM.

  • Funding The study was funded by the National Key Research and Development Program of China, grant No 2016YFC1301500.

  • 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.

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