Baseline-characteristics
From the 2636 patients included in the GSR the 90-day MoCA had been recorded in 215 (8.1%) patients. Of these, 166 (77.2%) patients had an independent functional outcome with a 90-day mRS≤2. In this group 103 (62%) patients were treated with EVT+IVT, 63 (38%) received an EVT alone. The baseline characteristics of both groups are summarized in table 1. In most cases stroke was located in the anterior cerebral circulation (n=146, 88%); the remaining 20 (12%) patients had vertebrobasilar strokes. There was a significant shorter median symptom onset to admission time in patients with EVT+IVT compared to in the EVT-IVT group (69 min, IQR 40-171 min vs 205 IQR 73-508 min in the EVT-IVT group, p<0.001). The proportion of smokers (37.1% vs. 27.3%, p=0.19) and patients with anticoagulation (28,6% vs. 0%, p<0.001) were higher in the EVT-IVT group compared to the EVT+IVT group. Functional impairment, quantified by the National Institute of Health Stroke Scale (NIHSS) on admission was more pronounced in the EVT+IVT group (12 pts, IQR 7-16 pts, vs. 10 pts, IQR 5-15 pts, p=0.14) as well as the ASPECT score for the assessment of early infarct signs, which was also higher in the EVT+IVT group (9 pts, IQR 8-10 pts vs. 8 pts, IQR 7-10, p=0.01). At discharge, both groups showed mild symptoms with a median NIHSS of 2 points (p=0.24).
Table 1: Baseline Characteristics MRS ≤ 2
|
Variable
|
Bridging
|
Non-Bridging
|
p-value
|
(n = 103)
|
(n = 63)
|
Sex (n, %)
|
|
|
0.29
|
Male
|
55 (53.4)
|
39 (61.9)
|
|
Female
|
48 (46.6)
|
24 (38.1)
|
|
Age (mean ± SD)
|
67 (±14.28)
|
69 (±11.18)
|
0.29
|
Vasc. risk-factors (n, %)
|
|
|
|
Art. hypertension
|
69 (67)
|
45 (71.4)
|
0.55
|
Smoking
|
27 (27.3)
|
23 (37.1)
|
0.19
|
Diabetes
|
17 (16.5)
|
14 (22.2)
|
0.36
|
Dyslipidemia
|
39 (37.9)
|
23 (36.5)
|
0.86
|
Atrial fibrillation
|
25 (24.3)
|
21 (33.3)
|
0.21
|
Baseline medication (n, %)
|
|
|
|
Aspirin
|
28 (28.9)
|
12 (20)
|
0.22
|
Clopidogrel
|
3 (3.1)
|
2 (3.3)
|
0.93
|
Anticoagulation
|
0 (0)
|
18 (28.6)
|
<0.001
|
NIHSS at admission (median points, IQR)
|
12 (7-16)
|
10 (5-15)
|
0.14
|
Symptom-onset to admission (median time, IQR)
|
69 (40-171)
|
205 (73-508)
|
<0.001
|
ASPECTS (median points, IQR)
|
9 (8-10)
|
8 (7-10)
|
0.01
|
NIHSS at discharge (median points, IQR)
|
2 (0-4)
|
2 (1-3)
|
0.24
|
MTICI ≥2b after EVT (n, %)
|
98 (95)
|
60 (95)
|
0.65
|
Table 1: Baseline-Characteristics MRS≤2; SD: standart deviation; IQR: interquartile range
|
A subgroup of 54 (33.7%) patients had no stroke associated functional impairment corresponding to a 90-day mRS of 0 pts. The baseline characteristics of these patients are given in supplementary table 1. This subgroup showed differences in gender distribution with a lower proportion of male patients in the EVT+IVT group compared to the EVT-IVT group (38.5% vs. 66.7%, p=0.06). Again, there was a significant difference between the two groups in terms of median time between symptom onset and admission (82 min, IQR 45-236 min in the EVT+IVT group, 156 min, IQR 73-553 min in the EVT-IVT group, p<0.001). Patients with bridging therapy also had a higher NIHSS on admission compared to EVT-IVT patients (NIHSS median 11 pts, IQR 7-15 in the EVT+IVT group vs. 6 pts, IQR 4-12 in the EVT-IVT group, p=0.057), while the NIHSS was slightly higher at discharge in the EVT-IVT group (1 pt, IQR 0-2 in the EVT-IVT and 0 pts, IQR 0-2 in the EVT+IVT group, p=0.101). Again, the proportion of anticoagulated patients in the EVT-IVT group was higher (33.3% vs. 0%, p<0.001).
MoCA-Score at day 90:
For patients with a 90-day mRS≤2, there was a significant difference in the MoCA scores between the EVT+IVT and EVT-IVT group with a median MoCA score in the EVT+IVT group of 20 points (IQR 18-25 pts) vs 18 points (IQR 16-21 pts) in the EVT-IVT group (p=0.014). For patients with excellent functional outcome (mRS=0), we also found a significantly higher MoCA score in the EVT+IVT group (21 points (IQR 18-29 pts) vs 19 points (IQR 17-21 pts), p=0.018).
After the adjustment for sex, age, NIHSS at admission and at discharge, symptom-onset-to admission-time, ASPECTS, vascular-risk factors (atrial fibrillation, smoking), as well as baseline medication (aspirin and anticoagulation), a significant difference at the significance level of 5% for the 90-day MoCAs persisted for both patients with independent and excellent functional outcome (mRS≤2: B=2.39, p=0.033; mRS=0: B=4.38, p=0.021) (table 2). This difference was independent concerning reperfusion status after endovascular treatment since 95% reached mTICI≥2b in both groups (p=0.65). The linear regression model furthermore showed a significant correlation to a poorer MoCA result after 90 days in smokers (B=-1.91, p=0.038) and older age (B=-0.11, p=0.001).
Table 2: Influence of variables on the 90d MoCA value
|
Variable
|
Single linear regression
|
Multiple linear regression
|
MRS ≤ 2
|
B (95% CI)
|
p-value
|
B (95% CI)
|
p-value
|
Bridging-therapy
|
2.01 (0.4-3.62)
|
0.015
|
2.39 (0.20-4.58)
|
0.033
|
Sex
|
|
|
0.52 (-1.08-2.12)
|
0.526
|
Age
|
|
|
0.11 (0.04-0.17)
|
0.001
|
Symptom-onset to admission
|
|
|
0.00 (-0.003-0.003)
|
0.842
|
NIHSS at admission
|
|
|
-0.04 (-0.17-0.09)
|
0.551
|
Smoking
|
|
|
1.91 (0.11-3.71)
|
0.038
|
Atrial fibrillation
|
|
|
-0.60 (-2.71-1.51)
|
0.576
|
Aspirin premedication
|
|
|
-0.5 (-2.48-1.49)
|
0.623
|
Anticoagulation
|
|
|
1.91 (-1.23-5.05)
|
0.232
|
ASPECT-Score
|
|
|
-0.25 (-0.94-0.43)
|
0.46
|
NIHSS at discharge
|
|
|
-0.09 (-0.29-0.12)
|
0.405
|
MRS = 0
|
|
|
|
|
Bridging-therapy
|
3.55 (0.78-6.31)
|
0.013
|
4.38 (0.67-8.08)
|
0.021
|
Sex
|
|
|
0.58 (-2.1-3.26)
|
0.669
|
Age
|
|
|
-0.07 (-0.21-0.07)
|
0.319
|
Symptom-onset to admission
|
|
|
-0.003 (-0.76-1.07)
|
0.721
|
NIHSS at admission
|
|
|
-0.06 (-0.24-0.13)
|
0.56
|
Smoking
|
|
|
0.80 (-2.50-4.11)
|
0.63
|
Dyslipidemia
|
|
|
2.49 (-0.28-5.27)
|
0.078
|
Aspirin premedication
|
|
|
-2.28 (-5.41-0.86)
|
0.154
|
Anticoagulation
|
|
|
-0.49 (-7.32-6.34)
|
0.881
|
NIHSS at discharge
|
|
|
0.16 (-0.76-1.07)
|
0.721
|
Table 2: Influence of variables on the 90d MoCA value; CI: Confidence Interval
|
Patients with strokes in the anterior circulation receiving combined EVT and IVT tended to show a higher MoCA-score compared to the EVT-IVT group (B=2.29; p=0.061; median MoCA 20 pts (IQR 17-24 pts) vs 18 points (IQR 16-21 pts)). There were no significant differences in MoCA-scores between both groups in patients with strokes in the posterior circulation (median MoCA 21 pts, IQR 18-28 in the EVT+IVT vs 20 pts, IQR 14-27, in the EVT-IVT group; B=2.12; p=0.603) (supplementary table 2).
Cognitive Impairment
Overall, 133 of the 166 patients included in the analysis (80%) showed cognitive impairment (defined as a MoCA-score <26 points) 90 days after the index event. The rate was 76% in the EVT+IVT and 86% in the EVT-IVT group. However, this difference was not statistically significant after correction for possible confounders (p=0.225; OR: 2.27). In the group with excellent functional outcome (mRS=0) the prevalence of cognitive impairment was significantly lower (66%) in the EVT+IVT group, compared to the EVT-IVT group (93%; p=0.034; OR: 23.15; table 3). In the subgroup analysis on individual examination of the stroke localization, there was no significant difference between the prevalence of cognitive impairment between the EVT+IVT and EVT-IVT group (suppl. table 3).
Table 3: Influence of variables on Cognitive Impairment after 90 days
|
Variable
|
Univariable regression
|
Multivariable regression
|
mRS ≤ 2
|
OR (95% CI)
|
p-value
|
OR (95% CI)
|
p-value
|
Bridging-therapy
|
1.92 (0.83-4.44)
|
0.126
|
2.27 (0.60-8.62)
|
0.225
|
Sex
|
|
|
1.84 (0.75-4.49)
|
0.181
|
Age
|
|
|
1.04 (1.00-1.07)
|
0.029
|
Symptom-onset to admission
|
|
|
1.00 (1.00-1.00)
|
0.84
|
NIHSS at admission
|
|
|
0.99 (0.93-1.07)
|
0.881
|
Smoking
|
|
|
0.47 (0.18-1.27)
|
0.136
|
Atrial fibrillation
|
|
|
0.39 (0.11-1.43)
|
0.154
|
Aspirin premedication
|
|
|
0.94 (0.33-2.71)
|
0.913
|
Anticoagulation
|
|
|
3.04 (0.41-22.69)
|
0.27
|
ASPECT-Score
|
|
|
1.12 (0.67-1.88)
|
0.635
|
NIHSS at discharge
|
|
|
1.06 (0.94-1.19)
|
0.354
|
mRS = 0
|
|
|
|
|
Bridging-therapy
|
7.00 (0.83-59.21)
|
0.074
|
23.15 (1.26-424.73)
|
0.034
|
Sex
|
|
|
1.61 (0.31-8.44)
|
0.569
|
Age
|
|
|
1.03 (0.95-1.12)
|
0.498
|
Symptom-onset to admission
|
|
|
1.00 (0.99-1.01)
|
0.734
|
NIHSS at admission
|
|
|
1.04 (0.93-1.16)
|
0.517
|
Smoking
|
|
|
2.21 (0.33-14.85)
|
0.412
|
Dyslipidemia
|
|
|
0.33 (0.05-2.23)
|
0.256
|
Aspirin premedication
|
|
|
0.13 (0.01-1.32)
|
0.084
|
Anticoagulation
|
|
|
0.03 (0.00-0.00)
|
1
|
NIHSS at discharge
|
|
|
0.96 (0.51-1.79)
|
0.882
|
Table 3: Influence of variables on Cognitive Impairment after 90 days; OR: Odds Ratio, CI: Confidence Interval
|
Severity of Cognitive-Impairment:
Rates of moderate and severe cognitive impairment were significantly higher in the EVT-IVT (25 of 63 patients; 39.6%) versus the EVT+IVT group (25 of 103 patients, 24%; p=0.040, OR 3.38). In patients with mRS=0, there also was a significant higher risk for moderate to severe cognitive impairment at 90 days with a prevalence of 13% in the EVT+IVT- and 33% in the EVT-IVT group (p=0.035, OR: 0.08).
Table 4: Severity of Cognitive Impairment
|
mRS ≤ 2
|
Bridging-group
|
Non-Bridging group
|
OR (95% CI)
|
p-value
|
(n, %)
|
(n, %)
|
No Cognitive Impairment
|
25 (24.3)
|
9 (14.3)
|
0.52 (0.23-1.20)
|
0.126
|
Mild Cognitive Impairment
|
53 (51.4)
|
29 (46)
|
0.66 (0.27-1.60)
|
0.355
|
Moderate Cognitive Impairment
|
25 (24.3)
|
24 (38.1)
|
0.38 (0.15-0.97)
|
0.042
|
Severe Cognitive Impairment
|
0 (0)
|
1 (1.5)
|
-
|
-
|
mRS = 0
|
|
|
|
|
No Cognitive Impairment
|
13 (33.3)
|
1 (6.6)
|
0.14 (0.02-1.21)
|
0.074
|
Mild Cognitive Impairment
|
21 (53.8)
|
9 (60)
|
0.18 (0.02-1.59)
|
0.122
|
Moderate Cognitive Impairment
|
5 (12.8)
|
5 (33.3)
|
0.08 (0.01-0.83)
|
0.035
|
Severe Cognitive Impairment
|
0 (0)
|
0 (0)
|
-
|
-
|
Table 4: Severity of Cognitive Impairment (CI): No CI: MoCA ≥ 26 pts, Mild CI: MoCA > 17 pts, Moderate CI: MoCA > 10 pts, Severe CI: MoCA < 10 pts
|