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Peer-reviewedCC BY-NC-NDStroke (Hoboken, N.J.)

Clinical Improvement, No Improvement, and Worsening at 24 Hours Following Reperfusion in Patients With Stroke due to Large-Vessel Occlusion

  • Umberto Pensato1,2
  • Thalia S Field3
  • Brian van Adel4
  • Ruchir Shah5
  • Jason W Tarpley6
  • Hana Choe7
  • Nima Kashani8
  • Mohammed Almekhlafi9
  • Raul G Nogueira10
  • Ryan A McTaggart11
  • Alexandre Y Poppe12
  • Jeremy L Rempel13
12 more authors
  • Manish Joshi14
  • Dar Dowlatshahi15
  • Richard H Swartz16
  • Eric Sauvageau17
  • Volker Puetz18
  • Bruce C V Campbell19
  • René Chapot20
  • Michael Tymianski21
  • Andrew M Demchuk9,14
  • Mayank Goyal14
  • Michael D Hill9,14
  • Johanna M Ospel14
21 affiliations
  1. 1Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy (U.P.).
  2. 2Department of Biomedical Sciences, Humanitas University, Milan, Italy (U.P.).
  3. 3Vancouver Stroke Program, Division of Neurology, University of British Columbia, Canada (T.S.F.).
  4. 4Departments of Radiology and Neurosurgery, McMaster University, Hamilton, ON, Canada (B.v.A.).
  5. 5Department of Neurology, Erlanger Hospital, Chattanooga, TN (R.S.).
  6. 6Department of Neurology, Pacific Neuroscience Institute, Santa Monica, CA (J.W.T.).
  7. 7Department of Neurology, Community Neurosciences Institute, Fresno, CA (H.C.).
  8. 8Department of Radiology (N.K.), University of Manitoba, Winnipeg, Canada.
  9. 9Department of Clinical Neurosciences (M.A., A.M.D., M.D.H.), University of Calgary, Alberta, Canada.
  10. 10Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, PA (R.G.N.).
  11. 11Department of Neurology (R.A.M.), University of Manitoba, Winnipeg, Canada.
  12. 12Department of Neurology, CHUM-Centre hospitalier de l'Université de Montréal, QC, Canada (A.Y.P.).
  13. 13Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada (J.L.R.).
  14. 14Department of Radiology, Cumming School of Medicine (M.J., A.M.D., M.G., M.D.H., J.M.O.), University of Calgary, Alberta, Canada.
  15. 15Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, ON, Canada (D.D.).
  16. 16Department of Neurosurgery, Institute of Medical Science (R.H.S.), University of Toronto, Canada.
  17. 17Department of Neurosurgery, Lyerly Neurosurgery, Baptist Medical Center Jacksonville, FL (E.S.).
  18. 18Faculty of Medicine and University Hospital Carl Gustav Carus, Department of Neurology, Technische Universität Dresden, Germany (V.P.).
  19. 19Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.).
  20. 20Department of Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany (R.C.).
  21. 21Krembil Research Institute, University Health Network (M.T.), University of Toronto, Canada.
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Abstract

Background

Restoring blood flow to ischemic tissue is the cornerstone of acute stroke therapy and is usually beneficial. However, when reperfusion is achieved for severely injured tissue, it is often futile and may occasionally cause harm. We aim to determine the prevalence and variables associated with clinical no improvement or acute worsening at 24 hours despite reperfusion in patients with large-vessel occlusion stroke treated with endovascular thrombectomy.Methods

Data are from ESCAPE-NA1 (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke), a randomized trial of nerinetide in patients with acute large-vessel occlusion stroke undergoing endovascular thrombectomy. Patients with unsuccessful recanalization (expanded Thrombolysis in Cerebral Infarction <2b), infarcts in new vascular territories, vessel perforation, or remote parenchymal hemorrhage were excluded. Clinical outcomes after reperfusion were classified by 24-hour National Institutes of Health Stroke Scale changes compared with baseline: improvement (≥4-point improvement), no improvement (±3-point from baseline), and worsening (≥4-point worsening). Baseline variables associated with worsening were identified using logistic regression. In the computed tomography perfusion subgroup, prevalence of parenchymal hemorrhage (any parenchymal hematoma) and infarct progression (final infarct volume exceeding the initial hypoperfused region) were evaluated.Results

A total of 833 patients were included (median age, 70.9 years [interquartile range, 60.7-79.4]; 51.4% men). After reperfusion, 669 (80.3%) patients improved, 135 (16.2%) showed no improvement, and 29 (3.5%) worsened. Independent predictors of worsening were longer onset-to-reperfusion time (adjusted odds ratio, 1.02 [95% CI, 1.00-1.04] per 10-minute increase) and greater degree of sedation (adjusted odds ratio, 1.78 [95% CI, 1.29-2.46] per category of none, conscious sedation, and general anesthesia). In the computed tomography perfusion subgroup (n=414), among patients with worsening after reperfusion, parenchymal hemorrhage was seen in 5 patients (31.3%) and infarct progression in 4 patients (25%).Conclusions

Clinical worsening in the acute period (ie, early neurological deterioration) despite reperfusion and the absence of procedure-related complications was rare in this selected large-vessel occlusion stroke cohort (3.5%). Factors associated with worsening after reperfusion were a longer time from symptom onset-to-reperfusion and a higher degree of sedation.

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Cite

BibTeXRIS
BibTeX
@article{pensato2026clinical,
  title = {{Clinical Improvement, No Improvement, and Worsening at 24 Hours Following Reperfusion in Patients With Stroke due to Large-Vessel Occlusion}},
  author = {Umberto Pensato and Thalia S Field and Brian van Adel and Ruchir Shah and Jason W Tarpley and Hana Choe and Nima Kashani and Mohammed Almekhlafi and Raul G Nogueira and Ryan A McTaggart and Alexandre Y Poppe and Jeremy L Rempel and Manish Joshi and Dar Dowlatshahi and Richard H Swartz and Eric Sauvageau and Volker Puetz and Bruce C V Campbell and René Chapot and Michael Tymianski and Andrew M Demchuk and Mayank Goyal and Michael D Hill and Johanna M Ospel},
  journal = {Stroke (Hoboken, N.J.)},
  year = {2026},
  month = sep,
  doi = {10.1161/svin.126.002411},
  url = {https://europepmc.org/article/PMC/PMC13727238},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Clinical Improvement, No Improvement, and Worsening at 24 Hours Following Reperfusion in Patients With Stroke due to Large-Vessel Occlusion
AU  - Umberto Pensato
AU  - Thalia S Field
AU  - Brian van Adel
AU  - Ruchir Shah
AU  - Jason W Tarpley
AU  - Hana Choe
AU  - Nima Kashani
AU  - Mohammed Almekhlafi
AU  - Raul G Nogueira
AU  - Ryan A McTaggart
AU  - Alexandre Y Poppe
AU  - Jeremy L Rempel
AU  - Manish Joshi
AU  - Dar Dowlatshahi
AU  - Richard H Swartz
AU  - Eric Sauvageau
AU  - Volker Puetz
AU  - Bruce C V Campbell
AU  - René Chapot
AU  - Michael Tymianski
AU  - Andrew M Demchuk
AU  - Mayank Goyal
AU  - Michael D Hill
AU  - Johanna M Ospel
PY  - 2026
DA  - 2026/09/24
JO  - Stroke (Hoboken, N.J.)
DO  - 10.1161/svin.126.002411
UR  - https://europepmc.org/article/PMC/PMC13727238
AB  - Background  Restoring blood flow to ischemic tissue is the cornerstone of acute stroke therapy and is usually beneficial. However, when reperfusion is achieved for severely injured tissue, it is often futile and may occasionally cause harm. We aim to determine the prevalence and variables associated with clinical no improvement or acute worsening at 24 hours despite reperfusion in patients with large-vessel occlusion stroke treated with endovascular thrombectomy.Methods  Data are from ESCAPE-NA1 (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke), a randomized trial of nerinetide in patients with acute large-vessel occlusion stroke undergoing endovascular thrombectomy. Patients with unsuccessful recanalization (expanded Thrombolysis in Cerebral Infarction <2b), infarcts in new vascular territories, vessel perforation, or remote parenchymal hemorrhage were excluded. Clinical outcomes after reperfusion were classified by 24-hour National Institutes of Health Stroke Scale changes compared with baseline: improvement (≥4-point improvement), no improvement (±3-point from baseline), and worsening (≥4-point worsening). Baseline variables associated with worsening were identified using logistic regression. In the computed tomography perfusion subgroup, prevalence of parenchymal hemorrhage (any parenchymal hematoma) and infarct progression (final infarct volume exceeding the initial hypoperfused region) were evaluated.Results  A total of 833 patients were included (median age, 70.9 years [interquartile range, 60.7-79.4]; 51.4% men). After reperfusion, 669 (80.3%) patients improved, 135 (16.2%) showed no improvement, and 29 (3.5%) worsened. Independent predictors of worsening were longer onset-to-reperfusion time (adjusted odds ratio, 1.02 [95% CI, 1.00-1.04] per 10-minute increase) and greater degree of sedation (adjusted odds ratio, 1.78 [95% CI, 1.29-2.46] per category of none, conscious sedation, and general anesthesia). In the computed tomography perfusion subgroup (n=414), among patients with worsening after reperfusion, parenchymal hemorrhage was seen in 5 patients (31.3%) and infarct progression in 4 patients (25%).Conclusions  Clinical worsening in the acute period (ie, early neurological deterioration) despite reperfusion and the absence of procedure-related complications was rare in this selected large-vessel occlusion stroke cohort (3.5%). Factors associated with worsening after reperfusion were a longer time from symptom onset-to-reperfusion and a higher degree of sedation.
SN  - 2694-5746
ER  -