Predictors of functional dependence despite successful revascularization in large-vessel occlusion strokes

Zhong-Song Shi; David S Liebeskind; Bin Xiang; Sijian Grace Ge; Lei Feng; Gregory W Albers; Ronald Budzik; Thomas Devlin; Rishi Gupta; Olav Jansen; Tudor G Jovin; Monika Killer-Oberpfalzer; Helmi L Lutsep; Juan Macho; Raul G Nogueira; Marilyn Rymer; Wade S Smith; Nils Wahlgren; Gary R Duckwiler; Multi MERCI, TREVO, and TREVO 2 Investigators

doi:10.1161/STROKEAHA.114.005603

Predictors of functional dependence despite successful revascularization in large-vessel occlusion strokes

Stroke. 2014 Jul;45(7):1977-84. doi: 10.1161/STROKEAHA.114.005603. Epub 2014 May 29.

Authors

Zhong-Song Shi¹, David S Liebeskind², Bin Xiang², Sijian Grace Ge², Lei Feng², Gregory W Albers², Ronald Budzik², Thomas Devlin², Rishi Gupta², Olav Jansen², Tudor G Jovin², Monika Killer-Oberpfalzer², Helmi L Lutsep², Juan Macho², Raul G Nogueira², Marilyn Rymer², Wade S Smith², Nils Wahlgren², Gary R Duckwiler²; Multi MERCI, TREVO, and TREVO 2 Investigators

Affiliations

¹ From the Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (Z.S.S.); Departments of Neurology and Radiology, UCLA Stroke Center (D.S.L., G.R.D.); Prospect Analytical Inc, San Jose, CA (B.X.); Department of Clinical Research, Stryker Neurovascular, Fremont, CA (S.G.G.); Department of Radiology, Kaiser Permanente Medical Center, Los Angeles, CA (L.F.); Department of Neurology, Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (G.W.A.); OhioHealth Neuroscience Institute, Riverside Methodist Hospital, Columbus (R.B.); Department of Neurology, Erlanger Health System, Chattanooga, TN (T.D.); Wellstar Neurosurgery, Wellstar Health System, Marietta, GA (R.G.); Department of Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany (O.J.); Department of Neurology, UPMC Stroke Center, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Neurology/Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria (M.K.); Department of Neurology, Oregon Health and Science University, Portland (H.L.L.); Angioradiology and Interventional Neuroradiology Unit, Radiology Department, Imaging Diagnostic Center, Clinic University Hospital, Barcelona, Spain (J.M.); Departments of Neurology, Neurosurgery and Radiology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurology, The University of Kansas Hospital (M.R.); Department of Neurology, University of California, San Francisco (W.S.S.); and Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.W.). [email protected].
² From the Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (Z.S.S.); Departments of Neurology and Radiology, UCLA Stroke Center (D.S.L., G.R.D.); Prospect Analytical Inc, San Jose, CA (B.X.); Department of Clinical Research, Stryker Neurovascular, Fremont, CA (S.G.G.); Department of Radiology, Kaiser Permanente Medical Center, Los Angeles, CA (L.F.); Department of Neurology, Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (G.W.A.); OhioHealth Neuroscience Institute, Riverside Methodist Hospital, Columbus (R.B.); Department of Neurology, Erlanger Health System, Chattanooga, TN (T.D.); Wellstar Neurosurgery, Wellstar Health System, Marietta, GA (R.G.); Department of Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany (O.J.); Department of Neurology, UPMC Stroke Center, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Neurology/Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria (M.K.); Department of Neurology, Oregon Health and Science University, Portland (H.L.L.); Angioradiology and Interventional Neuroradiology Unit, Radiology Department, Imaging Diagnostic Center, Clinic University Hospital, Barcelona, Spain (J.M.); Departments of Neurology, Neurosurgery and Radiology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurology, The University of Kansas Hospital (M.R.); Department of Neurology, University of California, San Francisco (W.S.S.); and Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.W.).

Abstract

Background and purpose: High revascularization rates in large-vessel occlusion strokes treated by mechanical thrombectomy are not always associated with good clinical outcomes. We evaluated predictors of functional dependence despite successful revascularization among patients with acute ischemic stroke treated with thrombectomy.

Methods: We analyzed the pooled data from the Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke (TREVO), and TREVO 2 trials. Successful revascularization was defined as thrombolysis in cerebral infarction score 2b or 3. Functional dependence was defined as a score of 3 to 6 on the modified Rankin Scale at 3 months. We assessed relationship of demographic, clinical, angiographic characteristics, and hemorrhage with functional dependence despite successful revascularization.

Results: Two hundred and twenty-eight patients with successful revascularization had clinical outcome follow-up. The rates of functional dependence with endovascular success were 48.6% for Trevo thrombectomy and 58.0% for Merci thrombectomy. Age (odds ratio, 1.04; 95% confidence interval, 1.02-1.06 per 1-year increase), National Institutes of Health Stroke Scale score (odds ratio, 1.08; 95% confidence interval, 1.02-1.15 per 1-point increase), and symptom onset to endovascular treatment time (odds ratio, 1.11; 95% confidence interval, 1.01-1.22 per 30-minute delay) were predictors of functional dependence despite successful revascularization. Symptom onset to reperfusion time beyond 5 hours was associated with functional dependence. All subjects with symptomatic intracranial hemorrhage had functional dependence.

Conclusions: One half of patients with successful mechanical thrombectomy do not have good outcomes. Age, severe neurological deficits, and delayed endovascular treatment were associated with functional dependence despite successful revascularization. Our data support efforts to minimize delays to endovascular therapy in patients with acute ischemic stroke to improve outcomes.

Clinical trial registration url: http://www.clinicaltrials.gov. Unique identifier: NCT00318071, NCT01088672, and NCT01270867.

Keywords: stroke.

MeSH terms

Aged
Aged, 80 and over
Brain Infarction / epidemiology
Brain Infarction / physiopathology
Brain Ischemia / drug therapy
Brain Ischemia / epidemiology*
Brain Ischemia / physiopathology
Cerebral Revascularization* / standards
Cerebral Revascularization* / statistics & numerical data
Clinical Trials as Topic
Female
Humans
Male
Middle Aged
Multicenter Studies as Topic
Predictive Value of Tests
Recovery of Function / physiology*
Severity of Illness Index
Stroke / drug therapy
Stroke / epidemiology*
Stroke / physiopathology
Thrombectomy* / standards
Thrombectomy* / statistics & numerical data
Thrombolytic Therapy* / standards
Thrombolytic Therapy* / statistics & numerical data

Associated data

ClinicalTrials.gov/NCT00318071
ClinicalTrials.gov/NCT01088672
ClinicalTrials.gov/NCT01270867

Grants and funding

K24 NS072272/NS/NINDS NIH HHS/United States