Background Chronological heterogeneity in neurological improvement after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is commonly observed in clinical practice. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence in patients who do not improve early, is essential for prognostication and rehabilitation. We aim to determine the incidence of early functional independence (EFI) and delayed functional independence (DFI), identify associated predictors after EVT, and develop the Delayed Functional Independence After Neurothrombectomy (DEFIANT) score.
Methods Demographic, clinical, radiological, treatment, and procedural information were analyzed from the Trevo Registry (patients undergoing EVT due to anterior LVO using the Trevo stent retriever). Incidence and predictors of EFI (modified Rankin Scale (mRS) score 0–2 at discharge) and DFI (mRS score 0–2 at 90 days in non-EFI patients) were analyzed.
Results A total of 1623 patients met study criteria. EFI was observed in 45% (730) of patients. Among surviving non-EFI patients (884), DFI was observed in 35% (308). Younger age (p=0.003), lower discharge National Institutes of Health Stroke Scale (NIHSS) score (p<0.0001), and absence of any hemorrhage (p=0.021) were independent predictors of DFI. After age 60, the probability of DFI declines significantly with 5 year age increments (approximately 7% decline for every 5 years; p(DFI)= 1.3559–0.0699, p for slope=0.001). The DEFIANT score is available online (https://bit.ly/3KZRVq5).
Conclusion Approximately 45% of patients experience EFI. About one-third of non-early improvers experience DFI. Younger age, lower discharge NIHSS score, and absence of any hemorrhage were independent predictors of DFI among non-early improvers.
Data availability statement
Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Contributors Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: SMD, APJ. Critically revising the article: all authors. Administrative/technical/material support: all authors. Study supervision: APJ. The guarantor accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish: APJ
Funding The Trevo Retriever Registry was sponsored and funded by Stryker Neurovascular. Clinicaltrials.gov NCT02040259.
Competing interests RG is a Principal Investigator for ASSIST Registry, Stryker Neurovascular, Modest Compensation; Principal Investigator for Tiger Retriever Study, Rapid Medical, Modest Compensation Principal Investigator for Recclaim trial, Zoll Medical, No compensation; Consultant Cerenovous, Modest Compensation. BWB is the SNIS Foundation Chair and sits on the editorial board of JNIS. BWB reports receiving consulting fees and fees for serving on a speakers’ bureau from Penumbra and consulting fees from Medtronic, Route 92 Medical, Viz.ai, 880 Medical, Marblehead Medical, Rapid Medical, Metactive, and holding U.S. Patent 9526863 on devices and methods for perfusion therapy, licensed to Neuronal Protection System. AK is a consultant for Stryker Neurovascular. Dr Nogueira reports potential conflicts with Stryker Neurovascular (DAWN Trial Principal Investigator–no compensation, TREVO Registry Steering Committee–no compensation, Trevo-2 Trial Principal Investigator–modest; Consultant–modest), Medtronic (SWIFT Trial Steering Committee–modest; SWIFT-Prime Trial Steering Committee–no compensation; STAR Trial Angiographic Core Lab–significant), Penumbra (3D Separator Trial Executive Committee–no compensation), Cerenovus/ Neuravi (ENDOLOW Trial Principal Investigator, EXCELLENT Registry Principal Investigator, ARISE-2 trial Steering Committee–no compensation, Physician Advisory Board, modest), Phenox (Physician Advisory Board, modest), Anaconda (Physician Advisory Board, modest), Genentech (Physician Advisory Board–modest), Biogen (Physician Advisory Board–modest), Prolong Pharmaceuticals (Physician Advisory Board–modest), Allm Inc (Physician Advisory Board–no compensation), IschemaView (Speaker, modest), Brainomix (Research Software Use–no compensation), Sensome (Research Device Use–no compensation), Viz-AI (Physician Advisory Board, stock options), Philips (Research Software Use–no compensation, Speaker–modest), and Corindus Vascular Robotics (Physician Advisory Board, stock options). DSL is a consultant as an imaging core lab for Cerenovus, Genentech, Medtronic, Rapid Medical, Stryker, Vesalio. EV reports being a co-Principal Investigator for the Trevo Registry.
Provenance and peer review Not commissioned; externally peer reviewed.
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