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Original research
Similar admission NIHSS may represent larger tissue-at-risk in patients with right-sided versus left-sided large vessel occlusion
  1. Adrian Mak1,2,
  2. Charles Matouk3,
  3. Emily W Avery1,
  4. Jonas Behland1,2,
  5. Dietmar Frey2,4,
  6. Vince Istvan Madai2,5,6,
  7. Peter Vajkoczy4,
  8. Ajay Malhotra1,
  9. Anthony Abou Karam1,
  10. Pina Sanelli7,
  11. Guido J Falcone8,
  12. Nils H Petersen8,
  13. Lauren Sansing8,
  14. Kevin N Sheth8,
  15. Seyedmehdi Payabvash1
  1. 1Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
  2. 2CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
  3. 3Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  4. 4Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
  5. 5School of Computing and Digital Technology, Birmingham City University, Birmingham, UK
  6. 6QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
  7. 7Radiology, Feinstein Institute for Medical Research, Manhasset, New York, USA
  8. 8Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Dr Seyedmehdi Payabvash, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA; sam.payabvash{at}yale.edu

Abstract

Background We investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS) score.

Methods We retrospectively identified patients with anterior LVO who received endovascular thrombectomy and follow-up MRI. Applying voxel-wise general linear models and multivariate analysis, we assessed the effects of occlusion side, admission NIHSS, and post-thrombectomy reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI) on final infarct distribution and volume as well as discharge modified Rankin Scale (mRS) score.

Results We included 469 patients, 254 with left-sided and 215 with right-sided LVO. Admission NIHSS was higher in those with left-sided LVO (median (IQR) 16 (10–22)) than in those with right-sided LVO (14 (8–16), p>0.001). In voxel-wise analysis, worse post-thrombectomy reperfusion, lower admission NIHSS score, and poor discharge outcome were associated with right-hemispheric infarct lesions. In multivariate analysis, right-sided LVO was an independent predictor of larger final infarct volume (p=0.003). There was a significant three-way interaction between admission stroke severity (based on NIHSS), LVO side, and mTICI with regard to final infarct volume (p=0.041). Specifically, in patients with moderate stroke (NIHSS 6–15), incomplete reperfusion (mTICI 0–2b) was associated with larger final infarct volume (p<0.001) and worse discharge outcome (p=0.02) in right-sided compared with left-sided LVO.

Conclusions When adjusted for admission NIHSS, worse post-thrombectomy reperfusion is associated with larger infarct volume and worse discharge outcome in right-sided versus left-sided LVO. This may represent larger tissue-at-risk in patients with right-sided LVO when applying admission NIHSS as a clinical biomarker for penumbra.

  • thrombectomy
  • brain
  • MRI

Data availability statement

Data are available upon reasonable request. All supporting anonymized data are available on reasonable request to the corresponding author and after clearance by corresponding ethics committee.

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Data availability statement

Data are available upon reasonable request. All supporting anonymized data are available on reasonable request to the corresponding author and after clearance by corresponding ethics committee.

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Footnotes

  • Twitter @AnotherMak, @AjayMalhotraRad

  • Presented at 56th Annual Conference of the German Society of Neuroradiology - neuroRAD 2021

  • Contributors AM: Study design and implementation, data collection, data analysis and interpretation, drafting the article, final approval of the version to be published. CM, EWA, JB, AAK: Data collection, interpretation of study results, critical revision of the article and final approval of the version to be published. DF, VIM, PV, AM, PS, GJF, NHP, LS, KNS: Interpretation of study results, critical revision of the article and final approval of the version to be published. SP: Study design and implementation, data collection, data analysis and interpretation, drafting the article, final approval of the version to be published, project supervision and guarantor for overall content.

  • Funding DF has received funding by the German Federal Ministry of Education and Research through a Go-Bio grant for the research group PREDICTioN2020 (lead: DF) and from the European Commission (PRECISE4Q Grant No. 777 107, coordinator: DF). PS is supported by the National Institutes of Health (R56NS114275, P01AI073693). GJF is supported by the National Institutes of Health (K76AG059992, R03NS112859 and P30AG021342), the American Heart Association (18IDDG34280056), the Yale Pepper Scholar Award and the Neurocritical Care Society Research Fellowship. NHP is supported by the National Institutes of Health (K23NS110980). LS is supported by the National Institutes of Health (R01NS095993, R01NS097728). KNS is supported by the National Institutes of Health (U24NS107215, U24NS107136, U01NS106513, R01NR018335), the American Heart Association (17CSA33550004), and grants from Novartis, Biogen, Bard, Hyperfine and Astrocyte. SP has received grant support from National Institutes of Health (K23NS118056), Doris Duke Charitable Foundation (2020097) and Foundation of the American Society of Neuroradiology (1861150721). VIM has received funding by the German Federal Ministry of Education and Research through a Go-Bio grant for the research group PREDICTioN2020 (lead: DF) and from the European Commission (PRECISE4Q Grant No. 777 107, coordinator: DF).

  • Competing interests DF reports holding an equity interest in ai4medicine with no connection to the presented work. He also reports a pending patent for A clinical decision support system for stroke treatment (EP21159801.6). VIM reports receiving personal fees from ai4medicine outside the presented work. There is no connection, commercial exploitation, transfer or association between the projects of ai4medicine and the presented work. He also reports a pending patent for A clinical decision support system for stroke treatment (EP21159801.6). PS received research funding from Siemens Healthineers and the Neiman Health Policy Institute. KNS reports equity interests in Alva Health and serves on the advisory board for NControl.

  • 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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