Abstract 167: Collateral Flow and ASPECTS of Infarct Evolution Dominate Time to Reperfusion in Outcomes of TREVO2

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Background: Definitive reperfusion, or revascularization associated with good clinical outcomes, is likely dependent on key imaging variables. ASPECTS score on imaging before and after revascularization may chronicle the extent of ischemic injury in acute stroke. We hypothesized that ASPECTS and other key imaging variables would be associated with clinical outcome after endovascular therapy in the TREVO2 trial. Methods: TREVO2 utilized independent core labs for CT/MRI and angiography central review. Retrospective review of ASPECTS by expert consensus on baseline and 24 hour imaging was conducted in anterior circulation cases, blinded to all other data. Univariate and multivariate analyses determined the impact of key imaging variables (baseline ASPECTS, ASPECTS ≥ 8, collaterals, time to TICI 2a reperfusion or greater, final TICI, 24-hour ASPECTS) on good clinical outcome (mRS 0-2) and mortality at day 90. Results: 166/177 cases in TREVO2 were anterior circulation occlusions. Baseline ASPECTS was ≤ 7 in 83/166 (50%) cases. Baseline ASPECTS score ≤ 7 was unrelated to age, gender, or any other clinical parameter other than NIHSS score (median 19 (17-23) vs. 17 (13-20) for ASPECTS > 7, p<0.001) and clot location (more ICA than M2 occlusions, p=0.044). Baseline ASPECTS ≤ 7 was also unrelated to post-device TICI or post-procedure SICH. Baseline ASPECTS ≤ 7 was associated with asymptomatic hemorrhage at 24 hours (63.9% vs. 37.3%, p=0.001), 90-day mortality (35.4% vs. 19.3%, p=0.024), and less frequent good clinical outcome (21.5% vs. 42.0%, p=0.007). Univariate imaging predictors of good clinical outcome at day 90 included baseline ASPECTS (OR 1.82, p<0.001), baseline ASPECTS ≥ 8 (OR 2.64, p=0.006), collateral grade (OR 1.85, p=0.003), post-procedure TICI (OR 2.11, p<0.001), 24-hour ASPECTS (OR 1.67, p<0.001) and 24-hour ASPECTS ≥ 8 (OR 4.38, p<0.001). Time to TICI 2a or greater was not predictive. Multivariate analyses showed that 24-hour ASPECTS (OR 1.70, p<0.001) and post-procedure TICI (OR 2.49, p=0.003) best predicted good outcome. Conclusions: Better ASPECTS (≥ 8), collaterals, and reperfusion are strongly associated with good clinical outcome whereas the large proportion (50%) of TREVO2 cases with baseline ASPECTS ≤ 7 likely influenced mortality.