What does this research mean for the field?

The HERMES-24 score provides good discriminative accuracy for predicting 90-day functional outcomes in real-world patients treated for large vessel occlusion in the late time window, though its performance is slightly lower than in randomized trial populations. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This study aims to validate the HERMES-24 score in predicting outcomes for large vessel occlusion treatment in late time window patients in a real-world setting.

May 17, 2026

Real-World Validation of the HERMES-24 Score for Outcome Prediction After Large Vessel Occlusion Treatment in Late Time Window Patients

Key Points

This study aims to validate the HERMES-24 score in predicting outcomes for large vessel occlusion treatment in late time window patients in a real-world setting.
Analyzed data from German Stroke Registry patients with LVO treated beyond 6 hours from symptom onset.
Conducted complete case analysis excluding functionally dependent patients (mRS >2/>3).
Assessed HERMES-24 score for 90-day mRS prediction using bootstrap resampling and c-statistic.
The cohort comprised 2,117 patients with an AUC of 0.876 (95% CI 0.859-0.889) for mRS ≤2.
Achieved an AUC of 0.856 (95% CI 0.837-0.875) for mRS ≤3.
Lower performance observed for patients with NIHSS <18, AUC 0.850 (95% CI 0.832-0.870).

Abstract

OBJECTIVES: The HERMES-24 score recently demonstrated high accuracy for outcome prediction after large vessel occlusion (LVO) treatment in late time window patients from randomized clinical trials. In this study, we externally validate the score in a real-world patient cohort. METHODS: Data from German Stroke Registry patients with LVO treated with endovascular therapy beyond 6 hours from symptom onset or last seen well were used. We performed a complete case analysis, excluding functionally dependent patients (premorbid modified Rankin Scale mRS >2/>3 for prediction of mRS ≤2/≤3, respectively). We assessed the HERMES-24 score for 90-day mRS prediction using bootstrap resampling and the c-statistic. RESULTS: The analyzed cohort comprised 2,117 patients (mean age 74 ± 13.3 years; 55.4% female; median admission NIH Stroke Scale (NIHSS) 14 (Q1-Q3: 9-18)). The HERMES-24 score achieved an area under the curve (AUC) of 0.876 (95% CI 0.859-0.889) for mRS ≤2 and 0.856 (95% CI 0.837-0.875) for mRS ≤3. Subgroup analysis for mRS ≤2 prediction showed lower performance in patients with NIHSS <18 (AUC 0.850, 95% CI 0.832-0.870). DISCUSSION: In our real-world cohort of late time window patients with LVO, the HERMES-24 score showed good discriminative performance, supporting its cautious clinical applicability, considering its lower performance than in trial populations, especially in patients with lower baseline NIHSS scores.

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