Early Severe Midline Shift in Acute Ischemic Stroke Following Endovascular Thrombectomy Within 24 Hours

Purpose: Early and severe (ES) midline shift (MLS ≥10 mm) simultaneously occurring within 24 hours after endovascular thrombectomy (EVT) is a life-threatening emergency that requires immediate intervention. This study aims to describe ES-MLS and develop a predictive model in anterior circulation occlusion who have undergone EVT. Methods: This retrospective cohort study utilized data from a prospective registry. Functional outcome was defined as a modified Rankin Scale score of 0–2. Radiomic features extracted from pre-EVT diffusion-weighted imaging were subjected to LASSO regression with fourfold cross-validation. Clinical features were selected via multivariable regression and integrated into a nomogram, with performance evaluated through receiver operating characteristic curve analysis in both training and validation datasets. Results: A total of 481 patients (median age 68 [IQR 58–76], 39.7% female) were included in this study, which consisted of a training dataset (n = 361) and a validation dataset (n = 120). In the ES-MLS group, 85.7% had died and none had a functional outcome at the 90-day follow-up. Recanalization, NIHSS score, and two radiomic features were identified as factors associated with ES-MLS in the nomogram. The predictive model exhibited an area under the curve (AUC) of 0.844 (95% confidence interval [CI], 0.803–0.880) in the training dataset and 0.823 (95% CI, 0.743–0.887) in the validation dataset. Conclusion: This is the initial structured overview of ES-MLS after EVT, featuring a model designed for personalized prediction of ES-MLS. The tool may enhance patient selection before EVT and refine the aggressive monitoring strategy after EVT.