Differential Effect of Endovascular Treatment in Medium or Distal Vessel Occlusion: A Distal Secondary Analysis
Christoph Kurmann, Urs Fischer, Nikki Rommers, Alex Brehm, Vera Aebischer, Fabiano Cavalcante, Bruce C.V. Campbell, Jan Gralla, Marios Nikos Psychogios, Johannes Kaesmacher, Victor Schulze-Zachau, Kristine-Ann Blackham, Ioannis Tsogkas, Benjamin Wagner, Ioannis Farah, Davide Strambo, Alexander Salerno, Guillaume Thevoz, Francesco Puccinelli, Bruno Bartolini, Guillaume Saliou, David Julian Seiffge, Sara Pilgram-Pastor, Janis Rauch, Eike Immo Piechowiak, Elias Auer, Grzegorz Marek Karwacki, Guillaume Marie, Pia Niederau, Lehel-Barna Lakatos, Marton David Gyurko, Eilsabeth Dirren, Maria Messe, Gianmarco Bernava, Jeremy Hofmeister, Pasquale Mordasini, Jürgen Den Hollander, Gian Marco De Marchis, Jochen Vehoff, Luca Remonda, Timo Kahles, Stephanie Pflugi, Jawid Madjidyar, Tilman Schubert, Christoph Globas, Marco Pileggi, Giovanni Bianco, Christian Commodaro, Johannes C. Gerber, Christian Hartmann, Martin Arndt, Lars-Peder Pallesen, Annahita Sedghi, Casjupea Knispel, Rimpal Patoliya, Bastian Cheng, Eckhard Schlemm, Maximillian Schell, Christian Thaler, Fabian Flottmann, Tobias Boeckh-Behrens, Dennis Hedderich, Christian Maegerlein, Martin Renz, Johanna Härtl, Wolfram Schwindt, Mohamed Elsharkawy, Tobias Faizy, Christoph Riegler, Noah Ayadi, Tatjana Wittenberg, Ida Rangus, Andreea Gottschalk, Fabio Capilli, Carmen-Alexandra Vieriu, Philipp Erdmann, Maria Alexandrou, Christian Roth, Friedericke Austein, Kristina Szabo, Hendrik Lesch, Eva Neumaier-Probst, Sherif Mohamed, Rüdiger Lange, Benedikt Kügelgen, Florian Eff, Martin Schlösser, Jan-Hendrik Schäfer, Franziska Lieschke, Johanna Herget, Patrick Samp, Maximilian Rauch, Hani Ridwan, Charlotte S. Weyland, Arno Reich, João Pinho, Daniel Pielenz, Elmar Lobsien, Elke Leinisch, Ala Jamous, Christian H. Riedel, Michael Bartl, Manuel Requena, Marta Olive-Gadea, Alvaro Gracia-Tornel, Marc Rodrigo-Gispert, Alejandro Tomassello, Miguel Schüller, Jorge Galván, Mercedes de Lera, Ana Isabel Calleja Sanz, Alicia Sierra-Gómez, Laura Albert Lacal, Estefania Garcia Molina, Ainara Sanz Monllor, Gonzalo De Paco, Jose Díaz-Pérez, Isabel Rodríguez, Martí Boix, Marina Martínez, Daniel Santana, Rosa García-Sort, Mariano Werner, Guillem Dolz, Alejandro Rodriguez-Vazquez, Antonio Doncel-Moriano, Tomàs Xuclà, Juan Alvarez-Cienfuegos, Yolanda Silva, Isabel Vielba, Carlos Pérez-García, Angela H. Schmolling, Carlos Gómez-Escalonilla, Nicolas Cavez, Olivier Vander Elst, Sophie Pitersky, Koenraad Nieboer, Martijn Verdam, Fenne Vandervorst, Anissa Ourtani, Sylvie Antoine, Lawrence Bonne, Jelle Demeestere, Lieselotte Vandewalle, Louise Maes, Anke Wouters, Veerle De Herdt, Peter Vanlangenhove, Fréderick Van Gool, Anne Sophie Desloovere, Alexander Vanhoorne, Olivier Cornet, Carla Ciobanu, François Delvoye, Joost Kager, Jesse Marrannes, Sofie Deblauwe, Ellis S. van Etten, Charles Majoie, Miou Koopman, Maud Eurlings, Anne van der Meij, Magretha M Q Robbe, Robrecht R Knapen, Christiaan van der Leij, Nadinja Bouwmans, Sterre Dassen, Geert Lycklama a Nijeholt, Bas van der Kallen, Hajo Hund, Tamara Dofferhoff-Vermeulen, Paul Cernohorsky, Sarah Vermeer, Michelle Simons, Diederik W.J. Dippel, Aad van der Lugt, Martin Sterrenberg, Sjoerd F.M. Jenniskens, Frederick J.A. Meijer, Erno Peltola, Tatu Kokkonen, Liisa Tomppo, Nicolas Martinez-Majander, Laura Mannismäki, Jori Ruuskanen, Julia Åivo, Matias Sinisalo, Arianna Rustici, Salvatore Isceri, Matteo Paolucci, Mauro Gentile, Francesco Capasso, Enrico Fainardi, Anna Poggesi, Benedetta Piccardi, Chiara Comelli, Andrea Naldi, Ludovico Ciolli, Gianluigi Guarnieri, Massimo Muto, Giuseppe Leone, Teresa Ullberg, Åke Holmberg, Wilma Hörnell, Levan Makalanda, Ken Wong, Jo Lansley, Eddie Kinsella-Perks, Mariana Baptista, Mário Alcatrão, Ana Paiva Nunes, Issa Metanis, Tamer Joubeh, Hamza Jubran, Yoel Schwartzmann, Steven Hajdu, Patrik Michel, Marcel Arnold, Alexander von Hessling, Manuel Bolognese, Paolo Machi, Emmanuel Carrera, Georg Kägi, Claudia Hader, Philipp Gruber, Krassen Nedeltchev, Zsolt Kulcsar, Andreas Luft, Carlo Cereda, Alessandro Cianfoni, Daniel Kaiser, Volker Pütz, Victoria Hellstern, Ali Khanafer, Götz Thomalla, Jens Fiehler, Jan Kirschke, Silke Wunderlich, Jens Minnerup, Paul Stracke, Christian Nolte, Justus Kleine, Rüdiger Hilker-Roggendorf, Christian Loehr, Panagiotis Papanagiotou, Andreas Kastrup, Angelika Alonso, Christoph Groden, Markus Holtmannspoetter, Jan Liman, Fee Keil, Natalia Kurka, Martin Wiesmann, Jörg B. Schulz, Joachim Klisch, Donald Lobsien, Till Illies, Bernd Eckert, Marielle Ernst, Ilko Maier, Marc Ribo, Federica Rizzo, Juan F. Arenillas, Mario Martinez-Galdamez, Guillermo Parrilla, Ana Morales Ortiz, Carlos Hernan Castaño Duque, Natàlia Pérez de la Ossa, Sergio Amaro, Jordi Blasco, Mikel Terceno, Saima Bashir, Manuel Moreu Gamazo, Patricia Simal, Flavio Bellante, Illario Tancredi, Frans Van den Bergh, Sylvie De Raedt, Robin Lemmens, Jo P. Peluso, Luc Defreyne, Dimitri Hemelsoet, Olivier Francois, Peter Vanacker, Philippe Desfontaines, Denis Brisbois, Geert Vanhooren, Johan Ghekiere, Adriaan van Es, Nyika Kruyt, Jonathan Coutinho, Bart Emmer, Julie Staals, Wim van Zwam, Ido van den Wijngaard, Elyas Ghariq, Jeannette Hofmeijer, Jasper Martens, Bob Roozenbeek, Pieter Jan van Doormaal, Anil Man, Tuladhar Hieronymus, Damianus Boogaarts, Maarten Uyttenboogaart, Reinoud Bokkers, Daniel Strbian, Silja Räty, Pauli Ylikotila, Riitta Rautio, Andrea Zini, Luigi Simonetti, Leonardo Renieri, Nicola Limbucci, Andrea Boghi, Davide Castellano, Mario Muto, Flavio Giordano, Irina Dragancea, Johan Wasselius, Pervinder Bhogal, Isabel Fragata, Diana Aguiar Sousa, Ronen R. Leker, Jose E. CohenBACKGROUND:
Patients with medium or distal vessel occlusion stroke are heterogeneous. Randomized trials show no net benefit of endovascular treatment (EVT) over best medical treatment (BMT) alone, which may mask heterogeneity of treatment effect. We used an externally developed machine learning model to predict excellent early neurological outcome (EENO) with BMT alone and examined whether the effect of EVT differed across predicted risk.
METHODS:
A Tabular Prior-Data Fitted Network (TabPFN) model was trained to predict EENO (24-hour National Institutes of Health Stroke Scale [NIHSS] score of 0–2) in patients with medium or distal vessel occlusion treated with BMT alone in a local Bernese Stroke Registry. This model was applied to patients from the DISTAL randomized trial (55 centers and 11 countries), who were randomized to EVT plus BMT or BMT alone. We tested for interaction between predicted EENO and treatment allocation on the primary outcome (90-day modified Rankin Scale shift), repeating this using admission NIHSS alone.
RESULTS:
In the development cohort (n=257, 42% female, and mean age 70.4±14.8 years), 54% achieved EENO. In the DISTAL cohort (270 BMT alone, 269 EVT plus BMT, 44% female, and mean age 74.9±12.0 years), the model showed moderate external discrimination (area under the receiver operating characteristic curve 0.73). A significant interaction was found between predicted EENO and treatment effect (
CONCLUSIONS:
EVT was harmful in patients with medium or distal vessel occlusion predicted to achieve EENO with BMT alone, and an NIHSS-alone model performed comparably to the multivariable model.
REGISTRATION:
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