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.
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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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.
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