Predictors of Unexplained Early Neurological Deterioration After Endovascular Treatment for Acute Ischemic Stroke

Jean-Baptiste Girot, MSc; Sébastien Richard, MD, PhD; Florent Gariel, MD; Igor Sibon, MD, PhD; Julien Labreuche, BST; Maéva Kyheng, BST; Benjamin Gory, MD, PhD; Cyril Dargazanli, MD, PhD; Benjamin Maier, MD; Arturo Consoli, MD; Benjamin Daumas-Duport, MD; Bertrand Lapergue, MD, PhD; Romain Bourcier, MD, PhD


Stroke. 2020;51(10):2943-2950. 

In This Article

Abstract and Introduction


Background and Purpose: Although the efficacy of endovascular treatment (EVT) in patients with anterior circulation ischemic stroke (AIS) is well documented, early neurological deterioration after EVT remains a serious issue associated with poor outcome. Besides obvious causes, such as lack of reperfusion, procedural complications, or parenchymal hemorrhage, early neurological deterioration may remain unexplained (UnEND). Our aim was to investigate predictors of UnEND after EVT in patients with AIS.

Methods: Patients who underwent EVT for AIS, with an initial National Institutes of Health Stroke Scale score >5, Alberta Stroke Program Early CT Score ≥6, and included in a multicenter prospective observational registry were analyzed. Predictors of UnEND, defined as ≥4-point increase in the National Institutes of Health Stroke Scale score between baseline and day 1 after EVT, were determined via center-adjusted analyses.

Results: Among the 1925 included in the analysis, 128 UnEND (6.6%) were recorded. In multivariate analysis, predictors of UnEND were diabetes mellitus (odds ratio [OR], 2.17 [95% CI, 1.32–3.56]), prestroke modified Rankin Scale score ≥2 (OR, 2.22 [95% CI, 1.09–4.55]), general anesthesia (OR, 2.55 [95% CI, 1.51–4.30]), admission systolic blood pressure (OR, 1.10 [95% CI, 1.01–1.20]), age (OR, 1.38 [95% CI, 1.14–1.67]), number of passes (OR, 1.16 [95% CI, 1.04–1.28]), direct admission or not to a comprehensive stroke center (OR, 0.49 [95% CI, 0.30–0.81]), and initial National Institutes of Health Stroke Scale score (OR, 0.65 [95% CI, 0.52–0.81]).

Conclusions: Severely impaired AIS patients with nonmodifiable factors are more likely to develop UnEND. Some modifiable predictors of UnEND such as the number of EVT passes could be the object of improvement in AIS management.


In the natural history of patients presenting cerebral ischemia due to anterior circulation ischemic stroke (AIS), an immediate necrosis area surrounded by oligemia and penumbra is observed with sudden neurological deficit. An increase in ≥4 points of the National Institutes of Health Stroke Scale (NIHSS) between pretreatment and day one is commonly considered as an early neurological deterioration (END).[1,2] These END cases have been reported to occur in 10% to 40% of patients after intravenous thrombolysis alone[3–5] and may occur due to infarction extension, edema, or hemorrhagic transformation.[6,7]

Trials have demonstrated that endovascular treatment (EVT) represents a key therapy to improve clinical outcome, especially since the results of the DAWN (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trials showed a gain beyond the usual therapeutic time windows.[8,9] Thus, EVT is widely utilized, and the incidence of END following EVT remains unknown. Furthermore, reperfusion failure, periprocedural complications, hemorrhagic transformations, or malignant edema are therapeutic failures or complications clearly related to worse outcomes that distinguish explained END from unexplained END (UnEND). Indeed, identifying predictors of UnEND would help to investigate future prevention strategies or to determine a population for whom EVT may be considered, at the least, futile or even deleterious. Moreover, this would allow the modification of some parameters inherent to EVT to avoid UnEND.

From the large prospective multicenter Endovascular Treatment in Ischemic Stroke (ETIS) registry, we aim to identify factors associated with UnEND, defined as END not related to reperfusion failure, periprocedural complications, hemorrhagic transformations, or malignant edema, in a population of stroke patients presenting AIS treated with EVT.