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Original research
Risk factors of unexplained early neurological deterioration after treatment for ischemic stroke due to large vessel occlusion: a post hoc analysis of the HERMES study
  1. Romain Bourcier1,
  2. Mayank Goyal2,
  3. Keith W Muir3,
  4. Hubert Desal4,
  5. Diederik W J Dippel5,
  6. Charles B L M Majoie6,
  7. Wim H van Zwam7,
  8. Tudor G Jovin8,
  9. Peter J Mitchell9,
  10. Andrew M Demchuk10,11,
  11. Robert J van Oostenbrugge12,
  12. Scott B Brown13,
  13. Bruce Campbell14,
  14. Philip White15,16,
  15. Michael D Hill10,17,
  16. Jeffrey L Saver18,19,
  17. Christian Weimar20,
  18. Reza Jahan21,
  19. Francis Guillemin22,
  20. Serge Bracard23,
  21. Olivier Naggara24
  22. HERMES Trialists Collaboration
  1. 1Neuroradiology, Université de Nantes, Nantes, Pays de la Loire, France
  2. 2Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
  3. 3Centre for Stroke & Brain Imaging University of Glasgow, University of Glasgow, Glasgow, UK
  4. 4Neuroradiology, University Hospital of Nantes, Nantes, France
  5. 5Neurology, Erasmus Mc University Medical Center, Rotterdam, The Netherlands
  6. 6Radiology and Nuclear Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, North Holland, The Netherlands
  7. 7Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
  8. 8Neurology, Cooper University Hospital, Camden, New Jersey, USA
  9. 9Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  10. 10Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  11. 11Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
  12. 12Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands
  13. 13Altair Biostatistics, Mooresville, New York, USA
  14. 14Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Melbourne, Austria
  15. 15Institute for Ageing & Health, Newcastle University, Newcastle upon Tyne, UK
  16. 16Neuroradiology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
  17. 17Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
  18. 18Neurology, UCLA, Los Angeles, California, USA
  19. 19Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
  20. 20Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Duisburg, Nordrhein-Westfalen, Germany
  21. 21Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
  22. 22CIC 1433 Epidémiologie clinique, University of Lorraine and University Hospital of Nancy, Nancy, France
  23. 23Neuroradiology, University of Lorraine and University Hospital of Nancy, Nancy, France
  24. 24Department of Neuroradiology, Saint Anne Hospital Centre, Paris, Île-de-France, France
  1. Correspondence to Dr Romain Bourcier, Neuroradiology, Université de Nantes, Nantes 44000, Pays de la Loire, France; romain.bourcier{at}


Background Early neurological deterioration (END) after endovascular treatment (EVT) in patients with anterior circulation acute ischemic stroke (AIS) is associated with poor outcome. END may remain unexplained by parenchymal hemorrhage (UnEND). We aim to analyze the risk factors of UnEND in the medical management (MM) and EVT arms of the HERMES study.

Methods We conducted a post-hoc analysis of anterior AIS patients who underwent EVT for proximal anterior occlusions. Risk factors of UnEND, defined as a worsening of ≥4 points between baseline National Institutes of Health Stroke Scale (NIHSS) and NIHSS at 24 hours without hemorrhage, were compared between both arms using mixed logistic regression models adjusted for baseline characteristics. An interaction analysis between the EVT and MM arms for risk factors of UnEND was conducted.

Results Among 1723 patients assessable for UnEND, 160 patients experienced an UnEND (9.3%), including 9.1% (78/854) in the EVT arm and 9.4% (82/869) in the MM arm. There was no significant difference in the incidence of UnEND between the two study arms. In the EVT population, independent risk factors of UnEND were lower baseline NIHSS, higher baseline glucose, and lower collateral grade. In the MM population, the only independent predictor of UnEND was higher baseline glucose. However, we did not demonstrate an interaction between EVT and MM for baseline factors as risk factors of UnEND. UnEND was, similarly in both treatment groups, a significant predictor of unfavorable outcome in both the EVT (p<0.001) and MM (p<0.001) arms.

Conclusions UnEND is not an uncommon event, with a similar rate which ever treatment arm is considered. In the clinical scenario of AIS due to large vessel occlusion, no patient-related factor seems to increase the risk for UnEND when treated by EVT compared with MM.

  • stroke
  • thrombectomy
  • thrombolysis

Data availability statement

Data are available upon reasonable request. Please contact us.

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Data availability statement

Data are available upon reasonable request. Please contact us.

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  • Contributors All coauthors significantly contributed to the study reporting, conception and design; RB, MG, KWM, HD, DWJD, CBLMM, WhvZ, TGJ, PJM, AMD, RJvO, SBB, BC, PW, MDH, JLS, FG, CW, RJ, FG, SB, ON. Acquisition: RB, MG, KWM, HD, DWJD, CBLMM, WhvZ, TGJ, PJM, AMD, RJvO, SBB, BC, PW, MDH, JLS, FG, CW, RJ, FG, SB. Data or analysis: RB, MG, SBB, FG. Interpretation of data: RB, MG, SBB, FG, ON. Drafting the manuscript: RB, MG, KWM, DWJD, CBLMM, WhvZ, PJM, RJvO, SBB, BC, PW, MDH, JLS, FG, CW, FG, ON. RB is the guarantor of full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The HERMES Collaboration was funded by a grant from Medtronic LLC to the University of Calgary.

  • Competing interests PW is member of the editorial board of the Journal of Neurointerventional Surgery.

  • 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.