Comparison of pragmatic post-thrombectomy prognostic scores not based on advanced imaging in a large national stroke registry

Abstract

Background:

Nearly half of the patients who received endovascular thrombectomy (EVT) for large vessel occlusion experience poor functional outcomes. Reliable tools for early post-procedural prognostication are needed. We aimed to assess and compare the performance of existing, pragmatic post-EVT prognostic scores in a large national multicenter cohort.

Methods:

We conducted a systematic literature search to identify pragmatic post-thrombectomy prognostic scores predicting 90-day functional outcomes. Models relying on advanced imaging, small derivation samples, or machine learning were excluded. We analyzed data from the IRETAS registry—a prospective, multicenter Italian cohort of stroke patients treated with EVT. Inclusion criteria were pre-stroke modified Rankin Scale (mRS) ⩽ 2 and available 90-day mRS. The primary outcome was good functional outcome (mRS ⩽ 2). Prognostic performance was assessed using c-statistics in the samples where each individual score was measurable. Scores were compared using DeLong tests in the subset of patients for whom all scores were measurable.

Results:

Three scores were identified: HERMES-24, BET, and SNARL. Among 22,768 patients in the registry, 18,408 (89.1%) had a measurable HERMES-24 score, 13,593 (59.7%) had a measurable BET score, and 19,007 (83.5%) had a measurable SNARL score. Median age was 75 years (IQR 65–82), and 11,528 (50.6%) were female. In the subset in which each test was measurable, HERMES-24 showed the best performance for predicting mRS ⩽ 2 (c-statistic = 0.889), followed by BET (c-statistic = 0.794) and SNARL (c-statistic = 0.762) (p < 0.001). In the subset of 12,233 patients for whom all three prognostic scores were calculable, a head-to-head comparison confirmed the superior performance of the HERMES-24 model: HERMES-24 score versus BET score (c-statistic difference = 0.098 [95% CI = 0.092–0.105]; p < 0.001) and HERMES-24 score versus SNARL score (c-statistic difference = 0.124 [95% CI = 0.116–0.132]; p < 0.001).

Conclusions:

In this large, multicenter, national cohort, the post-EVT HERMES-24 score—which accounts only for age and 24-h NIHSS—demonstrated the highest prognostic performance among existing, pragmatic post-EVT scores. Its simplicity and robust performance support its routine adoption in clinical practice.

Graphical abstract

Keywords

Endovascular thrombectomy acute ischemic stroke prognostic score outcome prediction HERMES-24 real-world cohort

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References

Goyal

Menon

van Zwam

, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387: 1723–1731.

Tsivgoulis

Katsanos

Sandset

, et al. Thrombolysis for acute ischaemic stroke: current status and future perspectives. Lancet Neurol 2023; 22: 418–429.

Meinel

Lerch

Fischer

, et al. Multivariable prediction model for futile recanalization therapies in patients with acute ischemic stroke. Neurology 2022; 99: e1009–e1018.

Chalos

Venema

Mulder

MJHL

, et al. Development and validation of a postprocedural model to predict outcome after endovascular treatment for ischemic stroke. JAMA Neurol 2023; 80: 940–948.

Venema

Roozenbeek

Mulder

MJHL

, et al. Prediction of outcome and endovascular treatment benefit: validation and update of the MR PREDICTS decision tool. Stroke 2021; 52: 2764–2772.

Sajobi

Menon

Wang

, et al. Early trajectory of stroke severity predicts long-term functional outcomes in ischemic stroke subjects. Stroke 2017; 48: 105–110.

Wirtz

Hendrix

Goren

, et al. Predictor of 90-day functional outcome after mechanical thrombectomy for large vessel occlusion stroke: NIHSS score of 10 or less at 24 hours. J Neurosurg 2021; 134: 115–121.

Raza

Rangaraju

Prognostic scores for large vessel occlusion strokes. Neurology 2021; 97: S79–S90.

You

Wang

, et al. Twenty-four-hour post-thrombolysis NIHSS score as the strongest prognostic predictor after acute ischemic stroke: ENCHANTED study. J Am Heart Assoc 2024; 13: 36109.

10.

Mistry

Yeatts

de Havenon

, et al. Predicting 90-day outcome after thrombectomy: baseline-adjusted 24-hour NIHSS is more powerful than NIHSS score change. Stroke 2021; 52: 2547–2553.

11.

Mangiafico

Pracucci

Saia

, et al. The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients. Neurol Sci 2015; 36: 985–993.

12.

Turc

Bhogal

Fischer

, et al. European Stroke Organisation (ESO)- European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg 2019; 11: 535–538.

13.

Hacke

Kaste

Fieschi

, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet 1998; 352: 1245–1251.

14.

Higashida

Furlan

Roberts

, et al. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 2003; 34: e109–e137.

15.

Tanaka

Brown

Goyal

, et al. HERMES-24 score derivation and validation for simple and robust outcome prediction after large vessel occlusion treatment. Stroke 2024; 55: 1982–1990.

16.

Prabhakaran

Jovin

Tayal

, et al. Posttreatment variables improve outcome prediction after intra-arterial therapy for acute ischemic stroke. Cerebrovasc Dis 2014; 37: 356–363.

17.

Javed

Qin

Mowery

Kadaba

Altschul

Haranhalli

Predicting 90-day functional dependency and death after endovascular thrombectomy for stroke: the BET score. J Stroke Cerebrovasc Dis 2022; 31: 106342.

18.

Rudilosso

Laredo

Amaro

, et al. Clinical improvement within 24 hours from mechanical thrombectomy as a predictor of long-term functional outcome in a multicenter population-based cohort of patients with ischemic stroke. J Neurointerv Surg 2021; 13: 119–123.

19.

McDonough

Ospel

Campbell

BCV

, et al. Functional outcomes of patients ⩾85 years with acute ischemic stroke following EVT: a HERMES substudy. Stroke 2022; 53: 2220–2226.

20.

Hendrix

Melamed

Collins

, et al. NIHSS 24 h after mechanical thrombectomy predicts 90-day functional outcome. Clin Neuroradiol 2022; 32: 401–406.

21.

Rinkel

Ospel

Kappelhof

, et al. Comparing early national institutes of health stroke scale versus 90-day modified Rankin Scale outcomes in acute ischemic stroke trials: a systematic review and analysis. J Am Heart Assoc 2025; 14: e040304.

22.

Yufe

Stroke prognostication using age and NIH stroke scale: span-100. Neurology 2013; 81: 603.

23.

Bres-Bullrich

Fridman

Sposato

LA.

Relative effect of stroke severity and age on outcomes of mechanical thrombectomy in acute ischemic stroke. Stroke 2021; 52: 2846–2848.

24.

Rangaraju

Liggins

JTP

Aghaebrahim

, et al. Pittsburgh outcomes after stroke thrombectomy score predicts outcomes after endovascular therapy for anterior circulation large vessel occlusions. Stroke 2014; 45: 2298–2304.

25.

Tanaka

Brown

Albers

, et al. Validation of the HERMES-24 score for outcome prediction post large vessel occlusion treatment in later time window. Neurology 2025; 105: e213796.