Functional ability, infarct discrepancies tied to differences in pretreatment factors

Discrepancies between functional outcome and postendovascular therapy infarct volume correlated with differences in pretreatment factors and post-treatment complications, according to study results published in JAMA Network Open.

“Several explanations have been proposed for discrepant outcomes, including errors in measuring [follow-up infarct volume (FIV)] or ascertaining outcome (pseudodiscrepancy); pretreatment factors, such as age, comorbidities, functional eloquence and selective neuronal loss vs. pan-necrosis of involved regions; or post-treatment factors, such as differences in postacute care or complications, including hemorrhage or pneumonia,” Aravind Ganesh, MD, DPhil, of the department of clinical neurosciences at the University of Calgary in Canada, and colleagues wrote.

In the current cohort study, the investigators aimed to validate exploratory findings from a prior trial, specifically examining pretreatment, treatment-linked and post-treatment factors correlated with discrepancies between FIV and functional outcome at 90 days. They conducted a post hoc analysis of the Safety and

Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial. They included 1,091 participants (median age, 70.8 years; 49.7% women) of ESCAPE-NA1 who had available 90-day modified Rankin Scale (mRS) scores and parenchymal imaging conducted at 24-hour to 48-hour post-treatment follow-up. Exposures included small FIV and large FIV on 24-hour computed tomography/MRI. The researchers compared baseline factors, outcomes, treatments and poststroke serious adverse events between discrepant patients, which included those with 90-day mRS score of 3 despite small FIV or those with mRS scores of 2 despite large FIV, and nondiscrepant cases.

Results showed an mRS score of three or more among 42 of 287 patients (14.6%) with FIV of 7 mL or less. Of 275 patients with FIV of 92 mL or greater, 65 (23.6%) had an mRS score of 2 or less. Prespecified models of pretreatment factors, including age, cancer and vascular risk factors, linked to low FIV and higher mRS score did comparably to models chosen via stepwise regression. Serious adverse events, including infarct in new territory, recurrent stroke, pneumonia and congestive heart failure, correlated with low FIV and higher mRS scores. Stepwise models pinpointed 24-hour hemoglobin as treatment-related/post-treatment factor. The researchers noted an association between younger age and high FIV and lower mRS score, with stepwise models showing absence of diabetes and higher baseline hemoglobin as other pretreatment factors. Absence of serious adverse events, particularly stroke progression, symptomatic intracerebral hemorrhage and pneumonia, were linked to high FIV and lower mRS score 2. Stepwise models showed 24-hour hemoglobin level, glucose and diastolic blood pressure as post-treatment factors linked to discrepant cases.

“In this study, discrepancies between functional ability and infarct volume were associated with differences in pretreatment factors, such as age; comorbidities, such as cancer or vascular risk factors; and poststroke complications related to the evolution of the index stroke, secondary prevention and quality of periprocedural and stroke unit care,” Ganesh and colleagues wrote. “Besides prevention of such complications, optimization of BP, glucose levels and potentially hemoglobin levels constitute important modifiable treatment-related post-treatment factors for further study.”