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Figure 2. Calibration of the THRIVE-EVT and THRIVEEVT
(+ ASPECTS) calculations in the development and
validation cohorts: (a) Receiver-Operator Characteristics
(ROC) curves for the performance of the THRIVE-EVT
multivariable logistic regression model in the development
cohort (n = 1107) and the validation cohort (n = 475). Area
under the ROC curve (AUC) in the development cohort
(0.716) was not significantly different from the AUC in
the validation cohort (0.727) (P = 0.30). (b) ROC curves
for the performance of the THRIVE-EVT (+ ASPECTS)
multivariable logistic regression model in the development
cohort (n = 1036) and the validation cohort (n = 448). ROC
curve AUC in the development cohort (0.718) was not
significantly different from the AUC in the validation cohort
(0.735) (P = 0.12). P values for each comparison are from the
Chi-square test.
THRIVE-EVT estimation are available at www.thrivescore.
org and www.mdcalc.com/thrive-score-for-stroke-outcome.
Discussion
We have developed and validated extensions to the
THRIVE-c calculation to serve as a tool to estimate the
potential benefit of EVT in individuals with large vessel
occlusion, using patient data that are readily available at
initial presentation.
In this study, we developed the THRIVE-EVT models
using contemporary data from endovascular trials. These
models improve outcome prediction in patients with LVO
and allow for a quantitative estimation of the impact of
EVT in an individualized clinical context. The ROC curve
AUCs for THRIVE-EVT (with or without ASPECTS) are
comparable to those of previously reported outcome prediction
models in acute ischemic stroke, including complex
models generated via machine learning.6-8,17-22 The addition
of ASPECTS, when available, appears to increase predictive
accuracy as evidenced by a higher AUC.
The outcome models generated here have several
strengths. Our derivation cohort (1107 patients) is one of
the largest cohorts studied in this context. In their machine
learning prediction models, Ramos et al included 1526
patients from the MR CLEAN registry, but the MR CLEAN
registry is of patients exclusively treated with EVT in the
Netherlands, without control subjects.8 The MR PREDICT
model was derived from the MR CLEAN trial,21 and validated
in the HERMES collaboration and MR CLEAN registry.23
While MR PREDICT is a robust and well-validated
prediction tool in this context, it does require 11 inputs to
calculate, including some which may not be readily available
or known at the time of clinical decision making.21,23
Many other models examining outcome in the setting of
EVT did so with the use of treated patients only, and thus
could not show the relative benefit of intervention in individual
patients.7,18,22 Our cohort, derived from VISTAEndovascular,
is of substantial diversity, includes data from
both EVT-treated and untreated patients, and can be determined
from a small number of inputs that are known at the
time of initial presentation.
Our results show that treatment of eligible patients with
hypertension and diabetes mellitus but no history of atrial
fibrillation, including outcome estimation based on whether
EVT is performed or not.
Using these two new calculations alongside the original
THRIVE-c calculation, probability of good outcome may be
estimated for patients with acute ischemic stroke, including
patients without LVO (using the THRIVE-c calculation) and
patients with LVO (using the THRIVE-EVT calculation, with
or without ASPECTS). Online calculators for THRIVE-c and
EVT results in improved outcome independent of age,
NIHSS, and original THRIVE calculation. We do not identify
a particular subgroup where endovascular therapy
would be definitively futile, with a zero probability of
improved outcome. The THRIVE-EVT calculations are not
intended to replace clinician judgment, nor should they be
used by clinicians to unilaterally exclude patients who are
otherwise candidates for EVT based on inclusion / exclusion
criteria from the original RCTs. Instead, THRIVE-EVT
should be used as aid to shared clinical decision-making.
Whether or not to pursue EVT for a particular individual can
be a complex decision made under emergent conditions,
International Journal of Stroke, 18(3)
http://www.thrivescore.org http://www.mdcalc.com/thrive-score-for-stroke-outcome
WSO - March 2023

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