Skip to main content
SpringerLink
Log in

NIHSS 24 h After Mechanical Thrombectomy Predicts 90-Day Functional Outcome

  • Original Article
  • Published:
Clinical Neuroradiology Aims and scope Submit manuscript

Abstract

Background

Mechanical thrombectomy (MT) for large vessel occlusion (LVO) ischemic stroke is a safe and effective treatment modality. The National Institute of Health Stroke Scale (NIHSS) 24 h after MT (24 h-NIHSS) was shown to serve as the strongest surrogate for 90-day functional outcome. Here, we seek to externally validate 24 h-NIHSS as predictor for 90-day functional outcome and explore additional variables in this context.

Methods

Patients treated for anterior LVO between February 2016 and August 2020 with premorbid mRS < 3 were included. Receiver operating characteristics were used to compare different NIHSS-related surrogates, such as baseline (B) NIHSS, 24 h-NIHSS, Δ‑NIHSS and percent (%) change NIHSS to predict favorable function outcome (mRS 0–2). Additional analysis was performed to assess predictors associated with poor outcome despite reaching the best predictor threshold.

Results

A total of 337 eligible cases were identified. The 24 h-NIHSS outperformed B‑NIHSS, Δ‑NIHSS, and %‑NIHSS in terms of 90-day mRS 0–2 prediction. A 24-NIHSS ≤ 8 was identified as the optimal binary threshold. Multivariable analysis demonstrated that 24-NIHSS ≤ 8 and younger patient age were independently associated with mRS 0–2. Despite achieving 24 h-NIHSS ≤ 8, 23/143 (16.1%) cases experienced poor outcome (mRS 4–6). Older age, higher baseline NIHSS, coexisting chronic kidney disease, and longer hospital stay were independent predictors for poor outcome despite achieving 24 h-NIHSS ≤ 8.

Conclusion

An NIHSS of 8 or less 24 h after MT was validated to serve as an independent, strong surrogate for favorable functional outcome; however, cofactors such as older age, higher baseline NIHSS and coexisting comorbidities appear to mitigate this clinical adjunct.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. Erratum in: N Engl J Med. 2015;372:394.

  2. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.

    Article  CAS  Google Scholar 

  3. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.

    Article  CAS  Google Scholar 

  4. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.

    Article  CAS  Google Scholar 

  5. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–95.

    Article  CAS  Google Scholar 

  6. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31.

    Article  Google Scholar 

  7. Heit JJ, Mlynash M, Kemp SM, Lansberg MG, Christensen S, Marks MP, Ortega-Gutierrez S, Albers GW. Rapid Neurologic Improvement Predicts Favorable Outcome 90 Days After Thrombectomy in the DEFUSE 3 Study. Stroke. 2019;50:1172–7.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Soize S, Fabre G, Gawlitza M, Serre I, Bakchine S, Manceau PF, Pierot L. Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome? J Neurointerv Surg. 2019;11:450–4.

    Article  Google Scholar 

  9. Meyer L, Broocks G, Bechstein M, Flottmann F, Leischner H, Brekenfeld C, Schön G, Deb-Chatterji M, Alegiani A, Thomalla G, Fiehler J, Kniep H, Hanning U; German Stroke Registry – Endovascular Treatment (GSR – ET). Early clinical surrogates for outcome prediction after stroke thrombectomy in daily clinical practice. J Neurol Neurosurg Psychiatry. 2020;91:1055–9.

    Article  Google Scholar 

  10. Wirtz MM, Hendrix P, Goren O, Beckett LA, Dicristina HR, Schirmer CM, Dalal S, Weiner G, Foreman PM, Zand R, Griessenauer CJ. Predictor of 90-day functional outcome after mechanical thrombectomy for large vessel occlusion stroke: NIHSS score of 10 or less at 24 hours. J Neurosurg. 2019. https://doi.org/10.3171/2019.10.JNS191991.

    Article  PubMed  Google Scholar 

  11. Mistry EA, Yeatts S, de Havenon A, Mehta T, Arora N, De Los Rios La Rosa F, Starosciak AK, Siegler JE 3rd, Mistry AM, Yaghi S, Khatri P. Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change. Stroke. 2021;52:2547–53.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kharitonova T, Mikulik R, Roine RO, Soinne L, Ahmed N, Wahlgren N; Safe Implementation of Thrombolysis in Stroke Investigators. Association of early National Institutes of Health Stroke Scale improvement with vessel recanalization and functional outcome after intravenous thrombolysis in ischemic stroke. Stroke. 2011;42:1638–43.

    Article  PubMed  Google Scholar 

  13. Cherng YG, Lin CS, Shih CC, Hsu YH, Yeh CC, Hu CJ, Chen TL, Liao CC. Stroke risk and outcomes in patients with chronic kidney disease or end-stage renal disease: Two nationwide studies. PLoS One. 2018;13:e0191155.

    Article  Google Scholar 

Download references

Funding

PH received salary support from Geisinger and Medtronic.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Geisinger, Danville, PA, USA

    Philipp Hendrix, Itay Melamed, Oded Goren, Clemens M. Schirmer & Christoph J. Griessenauer

  2. Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany

    Philipp Hendrix

  3. Geisinger Commonwealth School of Medicine, Scranton, PA, USA

    Malie Collins, Noah Lieberman & Vaibhav Sharma

  4. Department of Neurology, Geisinger, Danville, PA, USA

    Ramin Zand

  5. Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria

    Clemens M. Schirmer & Christoph J. Griessenauer

  6. Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria

    Christoph J. Griessenauer

Authors
  1. Philipp Hendrix
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Itay Melamed
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Malie Collins
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Noah Lieberman
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vaibhav Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Oded Goren
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ramin Zand
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Clemens M. Schirmer
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Christoph J. Griessenauer
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design: PH, CJG; Acquisition of data: PH, IM, MC, NL, VS, CJG; Analysis and interpretation of data: PH, CJG; Drafting the article: PH, CJG; Critically revising the article: All authors; Reviewed submitted version of manuscript: All authors; Approved the final version of the manuscript on behalf of all authors: CJG; Administrative/technical/material support: CMS, CJG; Study supervision: CJG

Corresponding author

Correspondence to Christoph J. Griessenauer.

Ethics declarations

Conflict of interest

The authors P. Hendrix, I. Melamed, M. Collins, N. Lieberman, V. Sharma, O. Goren, R. Zand, C.M. Schirmer and C.J. Griessenauer have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Outside the presented work: OG received consulting fees from Stryker; CMS received research funding from Penumbra and has ownership in NTI; CG received research funding from Medtronic and Penumbra, and consulting fees from Stryker and MicroVention.

Ethical standards

This retrospective study was performed after consultation with the institutional ethics committee and in accordance with national legal requirements. IRB approval for this retrospective analysis was obtained.

Additional information

Availability of data and material

Any data sharing requires the execution of a data sharing agreement between the requestor and Geisinger. For such requests, research contracts at Geisinger and Geisinger’s Institutional Review Board have to be contacted. Please direct requests to irb@geisinger.edu. Once appropriate data use agreements are executed, others will be able to access the data in the same manner. There are no special privileges others will not be able to get access to after appropriate data use agreements are executed.

Consent to participate

Waived for retrospective analysis

Code availability

Not applicable.

Consent for publication

Not applicable.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hendrix, P., Melamed, I., Collins, M. et al. NIHSS 24 h After Mechanical Thrombectomy Predicts 90-Day Functional Outcome. Clin Neuroradiol 32, 401–406 (2022). https://doi.org/10.1007/s00062-021-01068-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00062-021-01068-4

Keywords

Search

Navigation