From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland.
Neurology. 2024 Jul 23;103(2):e209401. doi: 10.1212/WNL.0000000000209401. Epub 2024 Jun 20.
We recently developed a model (PROCEED) that predicts the occurrence of persistent perfusion deficit (PPD) at 24 hours in patients with incomplete angiographic reperfusion after thrombectomy. This study aims to externally validate the PROCEED model using prospectively acquired multicenter data.
Individual patient data for external validation were obtained from the Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection, Tenecteplase versus Alteplase Before Endovascular Therapy for Ischemic Stroke part 1 and 2 trials, and a prospective cohort of the Medical University of Graz. The model's primary outcome was the occurrence of PPD, defined as a focal, wedge-shaped perfusion delay on 24-hour follow-up perfusion imaging that corresponds to the capillary phase deficit on last angiographic series in patients with <Thrombolysis in Cerebral Infarction 3 reperfusion after thrombectomy. The model's performance was evaluated with discrimination, calibration accuracy, and clinical decision curves.
We included 371 patients (38% with PPD). The externally validated model had good discrimination (C-statistic 0.81, 95% CI 0.77-0.86) and adequate calibration (intercept 0.25, 95% CI 0.21-0.29 and slope 0.98, 95% CI 0.90-1.12). Across a wide range of probability thresholds (i.e., depending on the physicians' preferences on how the model should be used), the model shows net benefit on clinical decision curves, informing physicians on the likelihood of PPD. If a physician's attitude toward false-positive and false-negative ratings is equal, the model would reduce 13 in 100 unnecessary interventions by correctly predicting complete delayed reperfusion, without missing a patient with PPD.
The externally validated model had adequate predictive accuracy and discrimination. Depending on the acceptable threshold probability, the model accurately predicts persistent incomplete reperfusion and may advise physicians whether additional reperfusion attempts should be performed.
我们最近开发了一种模型（PROCEED），用于预测血栓切除术后不完全血管再通患者 24 小时时持续性灌注缺损（PPD）的发生。本研究旨在使用前瞻性多中心数据对 PROCEED 模型进行外部验证。
外部验证的个体患者数据来自血管内治疗缺血性卒中与灌注成像选择、替奈普酶与阿替普酶在血管内治疗缺血性卒中前 1 部分和 2 部分试验，以及格拉茨医科大学的一个前瞻性队列。该模型的主要结局是 PPD 的发生，定义为在 24 小时随访灌注成像上出现局灶性、楔形灌注延迟，与血栓切除术后＜血栓溶栓 3 再通患者最后一组血管造影系列上的毛细血管期缺损相对应。该模型的性能通过判别能力、校准准确性和临床决策曲线进行评估。
我们纳入了 371 例患者（38%有 PPD）。经外部验证的模型具有良好的判别能力（C 统计量 0.81，95%置信区间 0.77-0.86）和适当的校准（截距 0.25，95%置信区间 0.21-0.29，斜率 0.98，95%置信区间 0.90-1.12）。在广泛的概率阈值范围内（即，取决于医生如何使用该模型的偏好），该模型在临床决策曲线上显示出净收益，告知医生 PPD 的可能性。如果医生对假阳性和假阴性评分的态度相等，那么该模型通过正确预测完全延迟再通，将减少 13 例每 100 例不必要的干预，而不会漏诊 PPD 患者。
经外部验证的模型具有足够的预测准确性和判别能力。根据可接受的阈值概率，该模型可准确预测持续性不完全再通，并可告知医生是否应进行额外的再通尝试。
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