Early Neurological Deterioration After Intravenous Thrombolysis: Still No End in Sight in the Quest for Understanding END

Analysis of Safety and Efficacy of the Early Initiation of Antithrombotic Secondary Prevention in Patients Treated with Intravenous Thrombolysis for Acute Ischemic Stroke

Background and Objectives: Current guidelines and the alteplase product insert recommend that antithrombotic therapy be avoided within 24 h of intravenous thrombolytic therapy with rt-PA in acute ischemic stroke. Therefore, the rate of stroke recurrence is unclear in terms of early neurological deterioration, which we could prevent with the early administration of antithrombotic therapy. We do not know the effect of early antithrombotic therapy after intravenous thrombolysis with rt-PA in acute stroke on the outcome in patients after 90 days either. Design: Prospective monocentric observational cohort study. Methods: Data were collected from consecutive patients treated with alteplase for acute ischemic stroke between January 2015 and January 2023. We examined functional outcome at 90 days, including the risk of symptomatic intracranial hemorrhage and mortality rate as safety indicators and stroke recurrence events in both early and standard antithrombotic therapy at 24 h after intravenous thrombolysis. Results: A total of 489 patients were included, of which 278 (56.9%) were men. Of these, 407 (83.2%) patients received early antithrombotic therapy. No symptomatic intracranial hemorrhage occurred in any participants. There was a significantly higher number of patients with an excellent outcome (mRS 0-1) in early antithrombotic treatment (211 (53.1%) versus 28 (34.6%) in standard antithrombotic treatment (p = 0.002, OR 0.47, 95% CI: 0.28-0.76). Conclusions: Early antithrombotic treatment after intravenous therapy in patients with acute ischemic stroke revealed no safety concerns compared with standard antithrombotic therapy and resulted in a significantly higher proportion of patients with an excellent functional outcome.

Prediction of early neurological deterioration in acute ischemic stroke patients treated with intravenous thrombolysis

A proportion of acute ischemic stroke (AIS) patients suffer from early neurological deterioration (END) within 24 hours following intravenous thrombolysis (IVT), which greatly increases the risk of poor prognosis of these patients. Therefore, we aimed to explore the predictors of early neurological deterioration of ischemic origin (ENDi) in AIS patients after IVT and develop a nomogram prediction model. This study collected 244 AIS patients with post-thrombolysis ENDi as the derivation cohort and 155 patients as the validation cohort. To establish a nomogram prediction model, risk factors were identified by multivariate logistic regression analysis. The results showed that neutrophil to lymphocyte ratio (NLR) (OR 2.616, 95% CI 1.640-4.175, P < 0.001), mean platelet volume (MPV) (OR 3.334, 95% CI 1.351-8.299, P = 0.009), body mass index (BMI) (OR 1.979, 95% CI 1.285-3.048, P = 0.002) and atrial fibrillation (AF) (OR 8.012, 95% CI 1.341-47.873, P = 0.023) were significantly associated with ENDi. The area under the curve of the prediction model constructed from the above four factors was 0.981 (95% CI 0.961-1.000) and the calibration curve was close to the ideal diagonal line. Therefore, this nomogram prediction model exhibited good discrimination and calibration power and might be a reliable and easy-to-use tool to predict post-thrombolysis ENDi in AIS patients.

CNS-LAND score: predicting early neurological deterioration after intravenous thrombolysis based on systemic responses and injury

Importance

Early neurological deterioration (END) is a critical complication in acute ischemic stroke (AIS) patients receiving intravenous thrombolysis (IVT), with a need for reliable prediction tools to guide clinical interventions.

Objective

This study aimed to develop and validate a rating scale, utilizing clinical variables and multisystem laboratory evaluation, to predict END after IVT.

Design setting and participants

The Clinical Trial of Revascularization Treatment for Acute Ischemic Stroke (TRAIS) cohort enrolled consecutive AIS patients from 14 stroke centers in China (Jan 2018 to Jun 2022).

Outcomes

END defined as NIHSS score increase >4 points or death within 24 h of stroke onset.

Results

1,213 patients (751 in the derivation cohort, 462 in the validation cohort) were included. The CNS-LAND score, a 9-point scale comprising seven variables (CK-MB, NIHSS score, systolic blood pressure, LDH, ALT, neutrophil, and D-dimer), demonstrated excellent differentiation of END (derivation cohort C statistic: 0.862; 95% CI: 0.796-0.928) and successful external validation (validation cohort C statistic: 0.851; 95% CI: 0.814-0.882). Risk stratification showed END risks of 2.1% vs. 29.5% (derivation cohort) and 2.6% vs. 31.2% (validation cohort) for scores 0-3 and 4-9, respectively.

Conclusion

CNS-LAND score is a reliable predictor of END risk in AIS patients receiving IVT.

Prognostic Values Serum Cav-1 and NGB Levels in Early Neurological Deterioration After Intravenous Thrombolysis in Patients with Acute Ischemic Stroke

Early neurological deterioration after intravenous thrombolysis (IAT) leads to increased mortality and morbidity in patients with acute ischemic stroke (AIS). This study investigated the correlation between serum Cav-1 and NGB levels and END after IAT and explored their predictive values for poor prognosis of AIS. Totally 210 patients with AIS who underwent IAT within 4.5 h of onset were included and assigned into END group (n = 90) and Non-END group (n = 120). ELISA was used to detect serum Cav-1 and NGB levels before IAT in AIS patients. The prognosis of END patients after 3 months of treatment was evaluated using the modified Rankin Scale. Logistic multifactorial regression was used to analyze independent risk factors for END and poor prognosis after IAT. ROC curve was used to analyze the predictive effect of Cav-1 and NGB on END and poor prognosis after IAT. The area under the ROC curve was analyzed by MedCalc comparison. Compared with the Non-END group, serum Cav-1 was lower and NGB was higher in the END group. Cav-1 and NGB were independent risk factors for END after IAT. Cav-1 + NGB better predicted END after IAT than Cav-1 or NGB alone. Cav-1 and NGB were independent risk factors for END poor prognosis after IAT. Cav-1 combined with NGB better predicted poor prognosis of END after IAT than Cav-1 or NGB alone. Serum Cav-1 combined with NGB may assist in predicting the risk of END occurrence and poor prognosis after IAT in patients with AIS.

Construction of a prediction model for risk of early neurological deterioration following intravenous thrombolysis in patients with acute ischemic stroke

BACKGROUND

The etiology of early neurological deterioration (END) occurring after intravenous thrombolysis is unclear.

OBJECTIVE

To investigate the factors associated with END following intravenous thrombolysis in patients with acute ischemic stroke, and to construct a prediction model.

METHODS

We selected a total of 321 patients with acute ischemic stroke, who were divided into two groups: the END group (n= 91) and the non-END group (n= 230). They were compared for their demographics, onset-to-needle time (ONT), door-to-needle time (DNT), related score results, and other data. The risk factors of the END group were identified using logistic regression analysis, and we constructed a nomogram model using the R software. A calibration curve was used to evaluate the calibration of the nomogram, and we assessed its clinical applicability using decision curve analysis (DCA).

RESULTS

In our multivariate logistic regression analysis, we found that four indexes, namely, complication with atrial fibrillation, post-thrombolysis National Institutes of Health Stroke Scale (NIHSS) score, pre-thrombolysis systolic blood pressure (SBP), and serum albumin level, were independent risk factors for END following intravenous thrombolysis in the patients (P< 0.05). We constructed an individualized nomogram prediction model using the above four predictors. The AUC value of the nomogram model was 0.785 (95% CI: 0.727-0.845) after internal validation, and the mean absolute error (MAE) in the calibration curve was 0.011, which indicated that the nomogram model had good prediction value. The decision curve analysis indicated that the nomogram model was clinically relevant.

CONCLUSION

The model was found to have excellent value in clinical application and prediction of END. This will be beneficial for healthcare providers to develop individualized prevention measures for END in advance, and thus reduce the incidence of END following intravenous thrombolysis.

Impact of Stress Hyperglycemia on Early Neurological Deterioration in Acute Ischemic Stroke Patients Treated With Intravenous Thrombolysis

Background and Purpose

It has been widely reported that stress hyperglycemia contributes to poor prognosis in patients experiencing acute ischemic stroke (AIS). However, its predictive value for early neurological deterioration (END) after intravenous administration of recombinant tissue-type plasminogen activator (IV-rtPA) in AIS patients is still unclear. The aim of this study was to evaluate the impact of stress hyperglycemia on the risk of END after IV-rtPA.

Methods

A total of 798 consecutive patients treated with IV-rtPA were included in this study. The stress hyperglycemia ratio (SHR) was calculated as fasting plasma glucose level at admission (mg/dl)/glycosylated hemoglobin (HbAlc) (%). END was defined as a National Institutes of Health Stroke Scale Score (NIHSS) ≥ 4 points 24 h after IV-rtPA, and poor functional outcome at discharge was defined as a modified Rankin Scale (mRS) score of 3–6 at discharge. Patients with a prior history of diabetes or HbAlc ≥ 6.5% were considered to have diabetes mellitus. Patients were grouped according to SHR values. Multivariate logistical regression was used to evaluate the risk of END for patients within specific SHR categories.

Results

In total, 139 (17.4%) patients had END. After adjusting for confounders, the highest tertile group had higher risks of END and poor functional outcome at discharge than those of patients in the lowest tertile group (OR, 1.95; 95% CI, 1.21–3.15; p = 0.006) (OR, 1.85; 95% CI, 1.163–2.941; p = 0.009), and the predictive value of high SHR for END was also significant in patients with diabetes mellitus (OR, 3.05; 95% CI, 1.29–7.21; p = 0.011). However, a significant association of high SHR and poor functional outcome was only found in patients without diabetes (OR, 1.85; 95% CI, 1.002–3.399; p = 0.045).

Conclusion

A higher SHR predicted that patients with severe stress hyperglycemia had higher risks of END and poor functional outcome at discharge after IV-rtPA.