Admission-Parameter Nomogram for Early Neurological Deterioration after Minor Small Subcortical Infarction: A Retrospective Cohort Study

Summary

This study developed an admission-variable nomogram for early neurological deterioration after minor small subcortical infarction and reported bootstrap internal validation, imaging and treatment sensitivity analyses, and a 24-hlandmark analysis of blood pressure variability.

Abstract

Early neurological deterioration (END) was common after minor subcortical infarction, but prediction was complicated by heterogeneous mechanisms, including intrinsic small-vessel disease and branch atheromatous disease (BAD). A retrospective analysis included 240 patients admitted within 24 h of symptom onset with a National Institutes of Health Stroke Scale (NIHSS) score of 5 or less. END was defined as an increase of at least 2 NIHSS points within 72 h after admission. The primary logistic model retained admission systolic blood pressure (SBP) as a continuous variable and included baseline NIHSS, neutrophil-to-lymphocyte ratio (NLR), and vascular stenosis of at least 50%. A three-knot restricted cubic spline was used to assess SBP nonlinearity. Internal validation used 1,000 bootstrap resamples, and calibration used bootstrap out-of-bag predictions. END occurred in 54 of 240 patients (22.5%). For each 10 mmHg increase in SBP, the adjusted odds ratio (OR) was 1.19 (95% confidence interval [CI], 1.04–1.36); the corresponding ORs were 1.36 (1.04–1.78) per NIHSS point, 1.34 (1.10–1.62) per NLR unit, and 2.21 (1.13–4.31) for stenosis. Evidence of SBP nonlinearity was absent (P = 0.595). The primary model had an apparent area under the receiver operating characteristic curve (AUC) of 0.762 (95% bootstrap CI, 0.686–0.826), an optimism-corrected AUC of 0.741, and an out-of-bag Brier score of 0.158. MRI-only, parent-artery-stenosis exclusion, and ischemic-END analyses were directionally consistent. Suspected BAD was present in 83.3% of END cases and materially increased performance in an expanded exploratory model, emphasizing etiologic heterogeneity. In a 24-h landmark analysis, the addition of SBP variability improved discrimination for deterioration after 24 h, but these post-admission metrics were not included in the admission-only model. The nomogram provided an internally validated prognostic estimate for enhanced monitoring and reassessment; external validation was required before treatment selection or bedside implementation.

Introduction

Acute ischemic stroke remained a major cause of death and long-term disability worldwide¹. A low baseline National Institutes of Health Stroke Scale (NIHSS) score was often described as a minor stroke, but “minor” reflected the measured deficit at presentation rather than biological stability or the absence of disability. Initially, mild weakness, gait impairment, dysarthria, or loss of hand function could worsen during the first h or days. This early neurological deterioration (END) could alter monitoring needs, diagnostic reassessment, rehabilitation planning, and prognosis. In lacunar or small subcortical stroke, pooled data indi....

Protocol

The study was conducted in accordance with the Declaration of Helsinki and was approved by the institutional ethics committee of Jinhua Municipal Central Hospital (No. 2022129). The requirement for written informed consent was waived because only retrospective, de-identified data were analyzed. The research tools used in this protocol are listed in the Table of Materials.

1. Study design and source population
A retrospective observational cohort study was conducted at the comprehensive stroke center of Jinhua Municipal Central Hospital, Zhejiang, China. Consecutive admissions from June 2024 through Se....

Results

Cohort and baseline characteristics
Of 965 screened patients, 240 were included (Figure 1). Among the included patients, 194 (80.8%) underwent MRI, and 46 (19.2%) were classified using CT-only imaging. END occurred in 54 patients (22.5%). Baseline NIHSS was 3 (IQR, 2–4) in the END group and 2 (IQR, 1–3) in the no-END group (P < 0.001). NLR was 3.2 (IQR, 2.7–4.3) and 2.3 (IQR, 1.8–3.2), respectively (P < 0.001). Admission SBP was 169.1 ± 25.8 mmHg in the END group a.......

Discussion

In this development cohort, END occurred in 22.5%, closely matching contemporary pooled estimates for lacunar ischemic stroke². Continuous admission SBP, baseline NIHSS, NLR, and any recorded stenosis were associated with END in the four-variable model. However, the optimism-corrected AUC of 0.741 and the out-of-bag Brier score of 0.158 supported moderate, rather than definitive, prognostic performance.

The revised SBP analysis materially changed the interpretation. The.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Automated hematology analyzer	Sysmex Corporation	XN-1000	Routine blood counts used to derive the neutrophil-to-lymphocyte ratio
Computed tomography scanner	Siemens Healthineers	SOMATOM Drive	Noncontrast computed tomography and computed tomography angiography acquisition during routine clinical care
CTA/MRA image acquisition and stenosis assessment	Department of Radiology, Jinhua Municipal Central Hospital	Institutional clinical CTA/MRA protocols; WASID measurement convention for intracranial stenosis	Retrospective abstraction from signed routine-care radiology reports; no separate research imaging platform. No protocol identifier was assigned
Electronic medical record and clinical data source	Jinhua Municipal Central Hospital	Institutional hospital information, laboratory, medication, and radiology-report systems	Retrospective extraction of de-identified routine-care data; no standalone research electronic medical record product. Commercial catalog number, version, and RRID not applicable.
Magnetic resonance imaging scanner	GE HealthCare	SIGNA Pioneer 3.0T	Diffusion-weighted imaging, apparent diffusion coefficient imaging, and magnetic resonance angiography acquisition during routine clinical care
Microsoft Excel	Microsoft Corporation	Microsoft 365	Table review and submission packaging
Microsoft Word	Microsoft Corporation	Microsoft 365	Manuscript preparation
National Institutes of Health Stroke Scale	National Institute of Neurological Disorders and Stroke	NIHSS assessment form	Routine neurological assessments
NumPy	Open-source Python package	2.3.3	Numerical computation; no project-specific RRID was reported.
pandas	Open-source Python package	2.3.3	Data management; no project-specific RRID was reported.
Python	Python Software Foundation	3.13.5	Reproducible statistical analysis; RRID: SCR_008394.
SciPy	Open-source Python package	1.16.2	Statistical functions; no project-specific RRID was reported.