Why this study was conducted? |
A few randomized clinical trials have shown that patients with large cerebral infarction had better functional outcomes with EVT than with medical care. |
We hypothesize that there is a correlation between NIHSS score and prognosis of patients with large core infarction. |
What was learned from this study? |
Patients with a higher baseline NIHSS score are less likely to have a favorable outcome, especially in those with NIHSS scores greater than 20. |
Age and sex indirectly affect favorable outcomes through their association with baseline NIHSS score. |
Introduction
Methods
Study Design and Patient Populations
Data Collection
Outcome Measurement
Statistical Analysis
Results
Patient Characteristics
Characteristic | All (n = 490) | Low NIHSS group (n = 152) | Medium NIHSS group (n = 174) | High NIHSS group (n = 164) | χ2/H | P value |
---|---|---|---|---|---|---|
Age, median (IQR), years | 69 (59–78) | 67.00 (57.25–76.00) | 67 (57–77) | 73 (64–79) | H = 11.574 | 0.003 |
≥ 65 | 250/490 (51.0) | 70/152 (46.1) | 79/174 (45.4) | 101/164 (61.6) | χ2 = 6.970 | 0.031 |
Sex, frequency, (%) | ||||||
Female | 209/490 (42.7) | 59/152 (38.8) | 66/174 (37.9) | 84/164 (51.2) | χ2 = 7.421 | 0.024 |
Male | 281/490 (57.3) | 93/152 (61.2) | 108/174 (62.1) | 80/164 (48.8) | ||
SBP, median (IQR), mmHg | 146.00 (128.00–164.00) | 145.00 (128.00–160.50) | 144.00 (125.00–160.00) | 149.00 (130.00–170.00) | H = 6.246 | 0.044 |
DBP, median (IQR), mmHg | 86.00 (75.00–96.00) | 86.00 (77.00–93.00) | 85.00 (73.00–97.25) | 88.00 (78.00–100.00) | H = 4.734 | 0.094 |
Baseline ASPECTS, median (IQR) | 4 (2–5) | 4 (3–4) | 4 (2–5) | 3 (2–5) | H = 14.518 | < 0.001 |
Medical history, frequency (%) | ||||||
Smoking, current or past | 151/490 (30.8) | 51/152 (33.6) | 55/174 (31.6) | 45/164 (27.4) | χ2 = 1.463 | 0.481 |
Hypertension | 297/490 (60.6) | 98/152 (64.5) | 95/174 (54,6) | 104/64 (63.4) | χ2 = 4.125 | 0.127 |
Hyperlipidemia | 106/490 (21.6) | 43/152 (28.3) | 37/174 (21.3) | 26/164 (15.9) | χ2 = 7.218 | 0.027 |
Diabetes | 73/490 (14.9) | 22/152 (14.5) | 24/174 (13.8) | 27/164 (16.5) | χ2 = 0.506 | 0.776 |
Atrial fibrillation | 221/490 (45.1) | 62/152 (40.8) | 72/174 (41.4) | 87/164 (53.0) | χ2 = 6.298 | 0.043 |
Occlusion site, frequency (%) | ||||||
ICA | 206/490 (42.0) | 51/152 (33.6) | 71/174 (40.8) | 84/164 (51.2) | χ2 = 10.581 | 0.032 |
M1 | 233/490 (47.2) | 84/152 (55.3) | 85/174 (48.9) | 64/164 (39.0) | ||
M2 | 51/490 (10.4) | 17/152 (11.2) | 18/174 (10.3) | 16/164 (9.8) | ||
Toast, frequency (%) | ||||||
Large artery atherosclerosis | 146/490 (29.8) | 54/152 (35.5) | 54/174 (31.0) | 38/164 (23.2) | χ2 = 14.684 | 0.023 |
Cardioembolism | 277/490 (56.5) | 71/152 (46.7) | 97/174 (55.7) | 109/164 (66.5) | ||
Other causes | 20/490 (4.1) | 8/152 (5.3) | 9/174 (5.2) | 3/164 (1.8) | ||
Unknown | 47/490 (9.6) | 19/152 (12.5) | 14/174 (8.0) | 14/164 (8.5) | ||
Intravenous thrombolysis (IVT), frequency (%) | 122/490 (24.9) | 35/152 (23.0) | 51/174 (29.3) | 36/164 (22.0) | χ2 = 2.858 | 0.240 |
ASITN/SIR collateral grade | ||||||
0–1 | 239/490 (48.8) | 57/152 (37.5) | 75/174 (43.1) | 107/164 (65.2) | χ2 = 31.401 | < 0.001 |
2 | 169/490 (34.5) | 64/152 (42.1) | 66/174 (37.9) | 39/164 (23.8) | ||
3–4 | 82/490 (16.7) | 31/152 (20.4) | 33/174 (19.0) | 18/164 (11.0) | ||
Procedure variables | ||||||
Onset to imaging, min, median (IQR) | 292.50 (157.75–459.00) | 320.50 (173.75–533.75) | 326.50 (161.00–486.25) | 226.00 (142.25–399.75) | H = 8.073 | 0.018 |
Onset to puncture, min, median (IQR) | 362 (240–547) | 380.00 (258.50–625.00) | 393.00 (248.00–553.50) | 324.00 (225.00–490.00) | H = 8.850 | 0.012 |
Onset to recanalization, min, median (IQR) | 449.50 (326.00–657.25) | 472.00 (342.50–750.00) | 468.00 (347.00–692.25) | 420.00 (300.00–580.00) | H = 8.982 | 0.011 |
First choice of EVTa | ||||||
Stent thrombectomy | 87/487 (17.8) | 36/151 (23.7) | 26/172 (14.9) | 25/164 (15.2) | χ2 = 20.587 | 0.422 |
Balloon | 25/487 (5.1) | 8/151 (5.3) | 11/172 (6.3) | 6/164 (3.7) | ||
Stenting | 3/487 (0.6) | 1/151 (0.7) | 1/172 (0.6) | 1/164 (0.6) | ||
Intra-arterial thrombolysis | 2/487 (0.4) | 2/151 (1.3) | 0 | 0 | ||
Intra-arterial tirofiban | 5/487 (1.0) | 2/151 (1.3) | 1/172 (0.6) | 2/164 (1.2) | ||
Mechanical fragmentation | 3/487 (0.6) | 2/151 (1.3) | 0 | 1/164 (0.6) | ||
Aspiration | 251/487 (51.2) | 71/151 (46.7) | 93/172 (53.4) | 87/164 (53) | ||
Swim | 109/487 (22.2) | 29/151 (19.1) | 40/172 (23.0) | 40/164 (24.4) | ||
Spontaneous reperfusion | 1/487 (0.2) | 0 | 0 | 1/164 (0.6) | ||
Mechanical fragmentation and intra-arterial thrombolysis | 1/487 (0.2) | 0 | 0 | 1/164 (0.6) |
Baseline NIHSS as a Continuous Variable and Outcomes
Characteristic | Unadjusted | Model 1 | Model 2 | Model 3 | ||||
---|---|---|---|---|---|---|---|---|
Unadjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | |
Primary outcome | ||||||||
mRS0–3 | 0.85 (0.81–0.89)a | < 0.001 | 0.86 (0.81–0.91)a | < 0.001 | 0.86 (0.81–0.91)a | < 0.001 | 0.85 (0.80–0.90)a | < 0.001 |
Secondary outcome | ||||||||
mRS at 90 days | 1.17 (1.12–1.21)b | < 0.001 | 1.14 (1.09–1.18)b | < 0.001 | 1.13 (1.08–1.18)b | < 0.001 | 1.13 (1.09–1.18)b | < 0.001 |
mRS0–2 | 0.88 (0.83–0.93)a | < 0.001 | 0.88 (0.83–0.94)a | < 0.001 | 0.88 (0.83–0.94)a | < 0.001 | 0.88 (0.82–0.94)a | < 0.001 |
mRS0–4 | 0.83 (0.80–0.87)a | < 0.001 | 0.85 (0.81–0.90)a | < 0.001 | 0.85 (0.80–0.90)a | < 0.001 | 0.85 (0.80–0.90)a | < 0.001 |
Successful recanalization | 0.11 (0.92–1.01)a | 0.106 | 0.96 (0.91–1.01)a | 0.139 | 0.96 (0.91–1.02)a | 0.19 | 0.96 (0.91–1.02)a | 0.23 |
Adverse events | ||||||||
sICH | 1.04 (0.99–1.09)a | 0.08 | 1.03 (0.98–1.09)a | 0.29 | 1.02 (0.97–1.09)a | 0.43 | 1.02 (0.97–1.09)a | 0.43 |
AICH | 1.03 (0.99–1.07) | 0.14 | 1.02 (0.98–1.06)a | 0.43 | 1.02 (0.97–1.06)a | 0.47 | 1.02 (0.98–1.06)a | 0.45 |
Mortality at 90 days | 1.17 (1.12–1.22)a | < 0.001 | 1.14 (1.09–1.19)a | < 0.001 | 1.13 (1.08–1.19)a | < 0.001 | 1.13 (1.07–1.19)a | < 0.001 |
Baseline NIHSS as a Categorical Variable and Outcomes
Characteristic | Frequencies | χ2 | P value | Unadjusted | Model 1 | Model 2 | Model 3 | ||||
---|---|---|---|---|---|---|---|---|---|---|---|
Unadjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | ||||
Primary outcome | |||||||||||
mRS0–3 | 37.54 | < 0.001 | |||||||||
NIHSS 10–14 | 81/152 (53.3) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 67/127 (38.5) | 0.55 (0.35–0.85)a | 0.008 | 0.53 (0.32–0.90)a | 0.04 | 0.53 (0.32–0.90)a | 0.02 | 0.52 (0.31–0.88)a | 0.02 | ||
NIHSS ≥ 20 | 33/164 (20.1) | 0.22 (0.13–0.36)a | < 0.001 | 0.29 (0.16–0.52)a | < 0.001 | 0.29 (0.16–0.52)a | < 0.001 | 0.29 (0.16–0.52)a | < 0.001 | ||
Secondary outcome | |||||||||||
mRS at 90 days | 61.76 | < 0.001 | |||||||||
NIHSS 10–14 | Reference | NA | Reference | NA | Reference | NA | Reference | NA | |||
NIHSS 15–19 | 0.60 (0.41–0.88)b | 0.009 | 0.63 (0.41–0.95)b | 0.07 | 0.63 (0.41–0.95)b | 0.03 | 0.62 (0.40–0.94)b | 0.02 | |||
NIHSS ≥ 20 | 0.23 (0.15–0.35)b | < 0.001 | 0.34 (0.21–0.54)b | < 0.001 | 0.34 (0.21–0.54)b | < 0.001 | 0.33 (0.21–0.53)b | < 0.001 | |||
mRS0–2 | 20.41 | < 0.001 | |||||||||
NIHSS 10–14 | 44/152 (28.9) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 45/174 (25.9) | 0.86 (0.53–1.40)a | 0.53 | 0.88 (0.51–1.54)a | 0.89 | 0.88 (0.51–1.54)a | 0.66 | 0.89 (0.51–1.56)a | 0.692 | ||
NIHSS ≥ 20 | 16/164 (9.8) | 0.27 (0.14–0.50)a | < 0.001 | 0.32 (0.16–0.64)a | < 0.001 | 0.32 (0.16–0.64)a | 0.001 | 0.32 (0.16–0.64)a | 0.001 | ||
mRS0–4 | 54.25 | < 0.001 | |||||||||
NIHSS 10–14 | 107/152 (70.4) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 93/174 (53.4) | 0.48 (0.31–0.76)a | 0.002 | 0.43 (0.25–0.75)a | 0.01 | 0.43 (0.25–0.75)a | 0.003 | 0.43 (0.25–0.74)a | 0.002 | ||
NIHSS ≥ 20 | 48/164 (29.3) | 0.17 (0.11–0.28)a | < 0.001 | 0.23 (0.13–0.41)a | < 0.001 | 0.23 (0.13–0.41)a | < 0.001 | 0.23 (0.13–0.41)a | < 0.001 | ||
Successful recanalization | 7.68 | 0.02 | |||||||||
NIHSS 10–14 | 138/152 (90.8) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 153/174 (87.9) | 0.74 (0.36–1.51)a | 0.41 | 0.72 (0.33–1.56)a | 0.54 | 0.72 (0.33–1.56)a | 0.40 | 0.71 (0.33–1.55)a | 0.39 | ||
NIHSS ≥ 20 | 132/164 (80.5) | 0.42 (0.21–0.82)a | 0.01 | 0.41 (0.19–0.90)a | 0.02 | 0.41 (0.19–0.90)a | 0.03 | 0.41 (0.19–0.90)a | 0.03 | ||
Safety outcome | |||||||||||
sICH | 9.76 | 0.008 | |||||||||
NIHSS 10–14 | 19/152 (12.5) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 14/174 (8.0) | 0.61 (0.30–1.27)a | 0.19 | 0.62 (0.27–1.42)a | 0.10 | 0.62 (0.27–1.42)a | 0.26 | 0.63 (0.27–1.43)a | 0.27 | ||
NIHSS ≥ 20 | 32/164 (19.5) | 1.70 (0.92–3.14)a | 0.09 | 1.36 (0.64–2.89)a | 0.35 | 1.36 (0.64–2.89)a | 0.42 | 1.36 (0.64–2.90)a | 0.42 | ||
AICH | 3.58 | 0.17 | |||||||||
NIHSS 10–14 | 55/152 (36.2) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 56/174 (32.2) | 0.84 (0.53–1.32)a | 0.45 | 0.80 (0.49–1.32)a | 0.34 | 0.80 (0.49–1.32)a | 0.38 | 0.81 (0.50–1.33)a | 0.41 | ||
NIHSS ≥ 20 | 69/164 (42.1) | 1.28 (0.81–2.02)a | 0.28 | 1.10 (0.66–1.83)a | 0.60 | 1.10 (0.66–1.83)a | 0.71 | 1.10 (0.66–1.84)a | 0.70 | ||
Mortality at 90 days | 43.91 | < 0.001 | |||||||||
NIHSS 10–14 | 36/152 (23.7) | Reference | NA | Reference | NA | Reference | NA | Reference | NA | ||
NIHSS 15–19 | 70/174 (40.2) | 2.17 (1.34–3.51)a | 0.002 | 2.16 (1.24–3.79)a | 0.02 | 2.16 (1.24–3.79)a | 0.007 | 2.19 (1.25–3.84)a | 0.006 | ||
NIHSS ≥ 20 | 99/164 (60.4) | 4.91 (3.01–7.99)a | < 0.001 | 3.28 (1.86–5.80)a | < 0.001 | 3.28 (1.86–5.81)a | < 0.001 | 3.29 (1.86–5.80)a | < 0.001 |