Alberta Stroke Program Early CT Score Research Articles

Collaterals at angiography guide clinical outcomes after endovascular stroke therapy in HERMES

BackgroundRobust collateral circulation has been linked with better reperfusion and clinical outcomes. It remains unclear how individual assessments of collateral circulation may be translated into clinical practice.MethodsThe pooled Highly Effective...

Symptomatic intracerebral hemorrhage in proximal and distal medium middle cerebral artery occlusion patients treated with mechanical thrombectomy

BackgroundAcute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in...

Dual-Energy CT in Acute Stroke: Could Non-Contrast CT Be Replaced by Virtual Non-Contrast CT? A Feasibility Study.

Purpose: We aimed to evaluate whether virtual non-contrast cerebral computed tomography (VNCCT) reconstructed from intravenous contrast-enhanced dual-energy CT (iv-DECT) could replace non-contrast CT (NCCT) in patients with suspected acute cerebral ischemia. Method: This retrospective study included all consecutive patients in whom NCCT followed by iv-DECT were performed for suspected acute ischemia in our emergency department over a 1-month period. The Alberta Stroke Program Early CT Score (ASPECTS) was used to determine signs of acute ischemia in the anterior and posterior circulation, the presence of hemorrhage, and alternative findings, which were randomly evaluated via the consensus reading of NCCT and VNCCT by two readers blinded to the final diagnosis. An intraclass correlation between VNCCT and NCCT was calculated for the ASPECTS values. Both techniques were evaluated for their ability to detect ischemic lesions (ASPECTS <10) when compared with the final discharge diagnosis (reference standard). Results: Overall, 148 patients (80 men, mean age 64 years) were included, of whom 46 (30%) presented with acute ischemia, 6 (4%) presented with intracerebral hemorrhage, 11 (7%) had an alternative diagnosis, and 85 (59%) had no pathological findings. The intraclass correlation coefficients of the two modalities were 0.97 (0.96-0.98) for the anterior circulation and 0.77 (0.69-0.83) for the posterior circulation. The VNCCT's sensitivity for detecting acute ischemia was higher (41%, 19/46) than that of NCCT (33%, 15/46). Specificity was similar between the two techniques, at 94% (97/103) and 98% (101/103), respectively. Conclusions: Our results show that VNCCT achieved a similar diagnostic performance as NCCT and could, thus, replace NCCT in assessing patients with suspected acute cerebral ischemia.

Cost-effectiveness of endovascular thrombectomy for acute ischemic stroke with established large infarct in Germany: a decision tree and Markov model

BackgroundRecent studies, including the TENSION trial, support the use of endovascular thrombectomy (EVT) in acute ischemic stroke with large infarct (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 3–5).ObjectiveTo evaluate...

Clinical and safety outcomes of acute stenting plus thrombectomy for carotid tandem lesions with large ischemic core

BackgroundWe evaluated the clinical and safety outcomes of emergent carotid artery stenting (eCAS) plus endovascular thrombectomy (EVT) among patients with anterior tandem lesion (TL) and large ischemic core (LIC).MethodsThis retrospective...

Number of passes and outcome of endovascular treatment of anterior circulation large core ischemic stroke: insights from the Endovascular Treatment in Ischemic Stroke (ETIS) registry

BackgroundThe effect of multiple attempts on the outcome of endovascular treatment (EVT) of anterior circulation large ischemic core (LIC) stroke has not been fully explored.MethodsWe analyzed data from the Endovascular...

Endovascular treatment of stroke in the late time window with large vessel occlusion using the ASPECTS as an imaging screening criterion

To assess the Alberta Stroke Program Early CT Score (ASPECTS) screening tool for effectiveness in endovascular treatment of late time window stroke with large vessel occlusion. A retrospective analysis was performed of individuals administered endovascular treatment in our neurology department between 2016 and 2020 for ischemic stroke induced by acute large vessel occlusion in the anterior circulation and ASPECTS ≥ 6. Detailed baseline and endovascular treatment data were collected. Patients were assigned to 2 groups based on stroke onset time, including the 0–6 h (treated within 6 h of stroke onset) and 6–24 h (earlier/unknown time of onset, up to 24 h from the last time of appearing normal) groups. Both groups were compared for baseline information, revascularization rates, symptomatic intracranial hemorrhage, and 90-day functional independence. Totally 221 individuals were enrolled. The 0–6 h and 6–24 h groups had 129 and 92 patients, respectively, whose median ages were 64 and 63 years, respectively. Both groups were similar in previous medical history, NIHSS score at onset, lesion location and surgical complications. The 6–24 h group had elevated intracranial atherosclerotic stenosis (48.9 vs. 33.3%, P = 0.020) and revascularization (96.7 vs. 86.8%, P = 0.011) rates versus the 6–24 h group. Upon adjustment for age, sex, National Institutes of Health Stroke Scale, ASPECTS, Intracranial atherosclerosis, intraoperative tirofiban, stent detachment, successful recanalization, and symptomatic intracranial hemorrhage, the 0-6 h group had a higher rate of individuals achieving functional independence (mRS score of 0–2; 52.7 vs. 47.8%, OR = 0.242 [0.070–0.833], P = 0.024). However, the rates of individuals with a favorable outcome (mRS scores of 0–3) were similar in both groups (66.7 vs. 69.6%; OR = 0.564 [0.140–2.266], P = 0.419) as well as 90-d mortality (OR = 0.889 [0.170–4.660], P = 0.889). The ASPECTS is effective for screening individuals for endovascular treatment of stroke in the late time window with large vessel occlusion. The ASPECTS should be considered a simple and practical patient screening strategy for stroke centers without multimodal imaging evaluation.

The lesion core extent modulates the impact of early perfusion mismatch imaging on outcome variability after thrombectomy in stroke.

Despite profitable group effects on functional outcomes after mechanical thrombectomy (MT) in large vessel occlusion (LVO), many patients with successful reperfusion show a non-favorable long-term outcome, highlighting the necessity to identify potential biomarkers predicting outcome variability. In this regard, the role of perfusion mismatch imaging for outcome variability in the early time window within 6 h after symptom onset is a matter of debate. We attempted to investigate under which conditions early perfusion mismatch imaging accounts for variability in functional outcomes after mechanical thrombectomy. In a retrospective single-center study, we examined 190 consecutive patients with LVO who were admitted to the Medical Center Lübeck within 6 h after symptom onset, all of whom underwent MT. Perfusion mismatch was quantified by applying the Alberta Stroke Program Early CT score (ASPECTS) on CT-measured cerebral blood flow (CBF-ASPECTS) and subtracting it from an ASPECTS application on cerebral blood volume (CBV-ASPECTS), i.e., ASPECTS mismatch. Using multivariate ordinal regression models, associations between ASPECTS mismatch and modified Rankin Scale (mRS) after 90 days were assessed. Furthermore, the interaction between ASPECTS mismatch and the core lesion volume was calculated to evaluate conditional associations. ASPECTS mismatch did not correlate with functional outcomes when corrected for multiple influencing covariables. However, interactions between ASPECTS mismatch and CBV-ASPECTS [OR: 1.12 (1.06-1.18), p-value < 0.001], as well as NCCT-ASPECTS [OR: 1.15 (1.06-1.25), p-value < 0.001], did show a significant association with functional outcomes. Model comparisons revealed that, profoundly, in patients with large core lesion volumes (CBV-ASPECTS < 6 or NCCT-ASPECTS < 6), perfusion mismatch showed a negative correlation with the mRS. Perfusion mismatch imaging within the first 6 h of symptom onset provides valuable insights into the outcome variability of LVO stroke patients receiving thrombectomy but only in patients with large ischemic core lesions.

Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in Early and Late Time Windows.

This study aimed to compare outcomes of low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) patients with stroke who underwent mechanical thrombectomy (MT) within 6 hours or 6 to 24 hours after stroke onset. A retrospective cohort study was conducted using data from a large multicenter international registry from 2013 to 2023. Patients with low ASPECTS (2-5) who underwent MT for anterior circulation intracranial large vessel occlusion were included. A propensity matching analysis was conducted for patients presented in the early (<6 hours) vs late (6-24 hours) time window after symptom onset or last known normal. Among the 10 229 patients who underwent MT, 274 met the inclusion criteria. 122 (44.5%) patients were treated in the late window. Early window patients were older (median age, 74 years [IQR, 63-80] vs 66.5 years [IQR, 54-77]; P < .001), had lower proportion of female patients (40.1% vs 54.1%; P = .029), higher median admission National Institutes of Health Stroke Scale score (20 [IQR, 16-24] vs 19 [IQR, 14-22]; P = .004), and a higher prevalence of atrial fibrillation (46.1% vs 27.3; P = .002). Propensity matching yielded a well-matched cohort of 84 patients in each group. Comparing the matched cohorts showed there was no significant difference in acceptable outcomes at 90 days between the 2 groups (odds ratio = 0.90 [95% CI = 0.47-1.71]; P = .70). However, the rate of symptomatic ICH was significantly higher in the early window group compared with the late window group (odds ratio = 2.44 [95% CI = 1.06-6.02]; P = .04). Among patients with anterior circulation large vessel occlusion and low ASPECTS, MT seems to provide a similar benefit to functional outcome for patients presenting <6 hours or 6 to 24 hours after onset.

Thrombectomy in ischemic stroke patients with large core but minor ischemic changes on non-enhanced computed tomography.

The Alberta Stroke Program Early CT Score (ASPECTS) is regularly used to guide patient selection for mechanical thrombectomy (MT). Similarly, penumbral imaging based on computed tomography perfusion (CTP) may serve as neuroimaging tool to guide treatment. Yet, patients with a large ischemic core on CTP may show only minor ischemic changes resulting in a high ASPECTS. We hypothesized twofold: (1) the treatment effect of vessel recanalization in patients with core volume > 50 mL but ASPECTS ⩾ 6 is not different compared to high ASPECTS patients with core volume < 50 mL, and (2) recanalization is associated with core overestimation. We conducted an observational study analyzing ischemic stroke patients consecutively treated with MT after triage by multimodal CT. Functional endpoint was the rate of functional independence at Day 90 defined as modified Rankin Scale (mRS) 0-2. Imaging endpoint was core overestimation, which was considered when CTP-derived core was larger than the final infarct volume assessed on follow-up imaging. Recanalization was evaluated with the extended Thrombolysis in Cerebral Infarction (eTICI) scale. Multivariable logistic regression analysis and propensity score matching (PSM) were used to assess the association of recanalization (eTICI ⩾ 2b) with functional outcome and core overestimation. Of 630 patients with ASPECTS ⩾ 6, 91 patients (14.4%) had a large ischemic core. Following 1:1 PSM, the treatment effect of recanalization was not different in patients with large core and ASPECTS ⩾ 6 (+ 25.8%, 95% CI: 16.3-35.4, p < 0.001) compared to patients with ASPECTS ⩾ 6 and core volume < 50 mL (+ 14.9%, 95% CI: 5.7-24.1, p = 0.002). Recanalization (aOR: 3.46, 95% CI: 1.85-6.47, p < 0.001) and higher core volume (aOR: 1.03, 95% CI: 1.02-1.04, p < 0.001) were significantly associated with core overestimation. In patients with ASPECTS ⩾ 6, core volumes did not significantly modify outcomes following recanalization. Reperfusion and higher core volume were significantly associated with core overestimation which may explain the treatment effect of MT for patients with a large ischemic core but minor ischemic changes on non-enhanced CT. The data analyzed in this study will be available and shared on reasonable request from any qualified researcher for the purpose of replicating the results after clearance by the local ethics committee.

Endovascular treatment versus standard medical treatment in patients with established large infarct: a cohort study.

Previous trials confirmed the benefit of endovascular treatment (EVT) in acute large core stroke, but the effect of EVT on outcomes in these patients based on non-contrast computed tomography (NCCT) in real-world clinical practice was unclear. The aim of this study was to explore the effect of EVT versus standard medical treatment (SMT) in patients with large ischemic core stroke defined as Alberta Stroke Program Early CT Score (ASPECTS)≤5 based on NCCT alone. Patients with acute large core stroke at 38 Chinese centers between November 2021 and February 2023 were reviewed from prospectively maintained databases. The primary outcome was favorable functional outcome (modified Rankin Scale score [mRS], 0-3) at 90 days. Safety outcomes included 48-hour symptomatic intracerebral hemorrhage (sICH) and 90-day mortality. Of 745 eligible patients recruited at 38 stroke centers between November 2021 and February 2023, 490 were treated with EVT and 255 with SMT alone. One hundred and eighty-one (36.9%) in the EVT group achieved favorable functional independence versus 48 (18.8%) treated with SMT only (adjusted risk ratio [RR], 1.86; 95% CI, 1.43 to 2.42, P<0.001; adjusted risk difference [RD], 13.77; 95% CI, 7.40 to 20.15, P<0.001). The proportion of sICH was significantly higher in patients undergoing EVT (13.3% vs. 2.4%; adjusted RR, 5.17; 95% CI, 2.17 to 12.32, P<0.001; adjusted RD, 10.10; 95% CI, 6.12 to 14.09, P<0.001). No significant difference of mortality between the groups was observed (41.8% vs. 49.0%; adjusted RR, 0.91; 95% CI, 0.77 to 1.07, P=0.24; adjusted RD, -5.91; 95% CI, -12.91 to 1.09, P=0.1). Among patients with acute large core stroke based on NCCT in real world, EVT is associated with better functional outcomes at 90 days despite of higher risk of sICH. Rates of procedure-related complications were high in the EVT group.

Endovascular Therapy and Outcomes Among Patients With Very Large Ischemic Core Stroke

The association of endovascular therapy (EVT) with outcomes is unclear for patients with very low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) within 24 hours of stroke onset. To explore the association of EVT with functional and safety outcomes among patients with ASPECTS of 0 to 2 scored with noncontrast computed tomography. This cohort study used data from an ongoing, prospective, observational, nationwide registry including all patients treated at 38 stroke centers in China with an occlusion in the internal carotid artery or M1 or M2 segment of the middle cerebral artery within 24 hours of witnessed symptom onset. Patients with ASPECTS of 0 to 2 between November 1, 2021, and February 8, 2023, were included in analysis. Data were analyzed October to November 2023. EVT vs standard medical treatment (SMT). The primary outcome was favorable functional outcome, defined as modified Rankin Scale score (mRS) of 0 to 3, at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 48 hours and mortality at 90 days. A total of 245 patients (median [IQR] age, 71 [63-78] years; 118 [48%] women) with ASPECTS of 0 to 2 were included, of whom 111 patients (45.1%) received SMT and 135 patients (54.9%) received EVT. The EVT group had significantly greater odds of favorable functional outcome at 90 days than the SMT group (30 patients [22.2%] vs 11 patients [9.9%]; P = .01; adjusted odds ratio [aOR], 3.07 [95% CI, 1.29-7.31]; P = .01). Patients in the EVT group, compared with the SMT group, had significantly greater odds of any ICH (56 patients [41.5%] vs 16 patients [11.4%]; P < .001; aOR, 4.27 [95% CI, 2.19-8.35]; P < .001) and sICH (24 patients [17.8%] vs 1 patient [0.9%]; P < .001; aOR, 23.07 [95% CI, 2.99-177.79]; P = .003) within 48 hours. There were no differences between groups for 90-day mortality (80 patients [59.3%] vs 59 patients [53.2%]; P = .34; aOR, 1.38 [95% CI, 0.77-2.47]; P = .28). The results remained robust in the propensity score-matched analysis. In this cohort study of patients with very low ASPECTS based on NCCT within 24 hours of stroke onset, those treated with EVT had higher odds of a favorable functional outcome compared with those who received SMT. Randomized clinical trials are needed to assess these findings.

Development of a Novel Statistical Model for Predicting Clinical Outcomes in Stroke Patients With Tandem Occlusions After Endovascular Therapy.

Tandem occlusions are intracranial large vessel occlusions (LVOs) with a concomitant ipsilateral extracranial internal carotid artery occlusionand can cause more severe stroke symptoms. To develop a simple, rigorously cross-validated novel tool to predict clinical outcomes following tandem occlusion in patients with acute LVO stroke, based on data that are easily available to clinicians. To have used machine learning approaches to utilize the available information from clinical and angiographic data to make predictive models able to distinguish between mortality versus survival and good (modified Rankin Scale (mRS) ≤ 2) versus unfavorable neurological outcomes (mRs ≥ 3) Materials and methods: Retrospective data from 87 consecutive patients with anterior circulation stroke and tandem occlusions who underwent mechanical thrombectomy and stenting between December 2009 and January 2020 were analyzed. Patients were stratified into three groups based on the location of their LVO, and these groups were compared using statistical tests. Predictive models were built and cross-validated 1000 times to estimate their predictive power, measured by accuracy and area under the receiver operating curve (AUROC). For distinguishing good outcome (mRS ≤ 2) versus poor outcome (mRS ≥ 3), the model comprised age, initial National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT Score (ASPECTS), NIHSS at 24 hours, NIHSS at discharge and intracranial haemorrhage and yielded an accuracy of 83% and the AUROC of 0.91. For mortality prediction, the model comprised age, initial NIHSS, intravenous thrombolysis, NIHSS at 24 hours and NIHSS at discharge and yielded an accuracy of 91% and an AUROC of 0.94. Models developed exhibit strong predictive performance and can distinguish between both the instances of survival versus mortality and good versus poor outcome with an aim to support clinicians in deciding on optimal management for these complex patients.The developed model will help identify those at risk of poorer outcomes and the prospective better selection of patients with acute ischaemic large vessel stroke secondary to tandem occlusions.

Endovascular Therapy in Large Core Ischemic Strokes: Real-World Indian Experience.

Large core acute ischemic strokes have predominantly been excluded from endovascular therapy (EVT) studies due to perceived higher risks of hemorrhage and poorer functional outcomes. However, recent randomized controlled trials (RCTs) indicate that EVT for large vessel occlusion (LVO) strokes improves functional outcomes compared to medical management alone, despite higher hemorrhagic transformation rates, with no corresponding increase in symptomatic intracerebral hemorrhage (sICH) rates. The real-world outcomes of this intervention in Indian patients remain underexplored. To evaluate the real-world outcomes of EVT for large core acute ischemic strokes with LVO in an Indian population. We conducted a single-center, retrospective observational study using a 7 years prospective database of EVT in anterior circulation stroke patients. Patients with Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 3-5 were included. Clinical and radiologic data were analyzed, with the primary endpoint being 90-day modified Rankin scale (mRS) scores. Safety outcomes included rates of sICH and mortality. Descriptive statistical analysis was done using Microsoft Excel. The study included 25 patients who met the inclusion criteria. Mean age of patients was 52.9 ± 14.3 years, and there were 13 (52%) males. Median ASPECTS was 5 (interquartile range 4-5). Successful recanalization, classified by modified Thrombolysis in Cerebral Infarction score, was 92%. Good functional recovery, that is, 90-day mRS 0-3, was achieved in nine (36%) patients. Safety outcomes: sICH was seen in four (16%) and mortality was reported in nine (36%) patients. Our results reaffirm findings from RCTs, provide updated real-world evidence, and suggest that EVT is a viable option to be considered in selected patients with large core ischemic infarcts.

Importance of computed tomography perfusion on assessing collateral circulation and prognosis of patients with acute anterior circulation large vessel occlusion after endovascular therapy

This study probed the importance of computed tomography perfusion (CTP) on assessing collateral circulation and prognosis in patients with acute anterior circulation large vessel occlusion (AAC-LVO) after endovascular therapy (EVT). Retrospective analysis was performed on the case data of 124 AAC-LVO patients who achieved EVT in the First People's Hospital of Lianyungang. All patients received computed tomography (CT) examination. Based on the multi-phase computed tomography angiography (mCTA) score, patients were separated into poor collateral circulation group and good collateral circulation group. Based on modified Rankin scale (mRS) score, patients were separated into good prognosis group and poor prognosis group. The receiver operating characteristic (ROC) curve was used to measure the efficacy of CTP parameters in predicting good collateral circulation or good prognosis. Correlation between CTP parameters with mCTA collateral and 90-day mRS circulation score was analyzed using the Spearman correlation analysis. The age and admission national Institutes of Health stroke scale (NIHSS) scores of the good collateral circulation group were lower than the poor collateral circulation group, and low perfusion area volume with Tmax > 6 s (VTmax>6 s), infarct core area volume (VCBF<30 %)and hypoperfusion intensity ratio (HIR) were also lower. The mCTA collateral cycle score was negatively related to VTmax>6s, VCBF<30 % and HIR. The area under the curve (AUC) values of VTmax>6s and VCBF<30 % and HIR for predicting good collateral circulation were 0.763, 0.884 and 0.842, respectively, which suggested that perfusion parameters VTmax>6s, VCBF<30 % and HIR could effectively indicate the status of patients’ collateral circulation. Relative to the poor prognosis group, patients in the good prognosis group possessed lower admission NIHSS score, younger age, smaller final infarct volume, lower HIR, VCBF<30 %, VTmax>6 s, Alberta Stroke Program Early CT(ASPECT) score, and higher mCTA score. Spearman correlation analysis unveiled that ASPECT score, mCTA score and 90-day mRS were negatively correlated. The final infarct volume, perfusion parameters HIR and VCBF<30 % were positively correlated with 90-day mRS. ROC analysis showed that all variates had good prognostic value for acute anterior circulation great vessel occlusion patients, while VCBF<30 % and HIR had high diagnostic value for prognosis. To sum up, CTP can provide a comprehensive imaging assessment of the collateral circulation of patients with AAC-LVO and has a higher predictive value for the prognosis assessment of patients with EVT in terms of VCBF<30 %, HIR score and mCTA collateral circulation score.

Automatic assessment of DWI-ASPECTS for acute ischemic stroke based on deep learning.

Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is a standardized semi-quantitative method for early ischemic changes in acute ischemic stroke. However, ASPECTS is still affected by expert experience and inconsistent results between readers in clinical. This study aims to propose an automatic ASPECTS scoring model based on diffusion-weighted imaging (DWI) mode to help clinicians make accurate treatment plans. Eighty-two patients with stroke were included in the study. First, we designed a new deep learning network for segmenting ASPECTS scoring brain regions. The network is improved based on U-net, which integrates multiple modules. Second, we proposed using hybrid classifiers to classify brain regions. For brain regions with larger areas, we used brain grayscale comparison algorithm to train machine learning classifiers, while using hybrid feature training for brain regions with smaller areas. The average DICE coefficient of the segmented hindbrain area can reach 0.864. With the proposed hybrid classifier, our method performs significantly on both region-level ASPECTS and dichotomous ASPECTS. The sensitivity and accuracy on the test set are 95.51% and 93.43%, respectively. For dichotomous ASPECTS, the intraclass correlation coefficient (ICC) between our automated ASPECTS score and the expert reading was 0.87. This study proposed an automated model for ASPECTS scoring of patients with acute ischemic stroke based on DWI images. Experimental results show that the method of segmentation first and then classification is feasible. Our method has the potential to assist physicians in the Alberta Stroke Program with early CT scoring and clinical stroke diagnosis.

Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: aMeta-analysis of Randomized Controlled Trials.

Randomized controlled trials (RCTs) demonstrated atreatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0-2 remain scarce. We conducted asystematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0-2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method. Literature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided asubgroup analysis of the mRS shift in patients with ASPECTS of 0-2. The pooled analysis showed asignificant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29-2.04, P < 0.001). This meta-analysis suggests atreatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0-2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0-2.

Serial ASPECTS to predict stroke-associated pneumonia after thrombolysis in patients with acute ischemic stroke.

Stroke-associated pneumonia (SAP) is a serious complication in stroke patients, significantly increasing mortality. The Alberta Stroke Program Early CT Score (ASPECTS) is a recognized predictor of acute ischemic stroke outcomes. We aimed to investigate the performance of serial ASPECTS assessments (baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS) for predicting SAP in patients with thrombolyzed acute anterior circulation ischemic stroke (AACIS). A retrospective observational cohort study of adult patients with thrombolyzed AACIS was conducted. Baseline and 24-h ASPECTS using non-contrast computed tomography (NCCT), complications of stroke, including SAP and swallowing dysfunction using the Modified Water Swallowing test, were collected. Baseline and 24-h ASPECTS were evaluated by a certified neurologist and neuroradiologist. The predictive performance was determined based on the receiver operating characteristic curve (ROC). Multivariable logistic regression analyses were employed to assess the impact of serial ASPECTS assessment on predicting SAP. Of the 345 patients with thrombolyzed AACIS in our study, 18.4% (64/345) experienced SAP. The patients' median age was 62 years [interquartile range (IQR): 52-73], with 53.4% being male. The median NIHSS score was 11 points (IQR: 8-17). The ROC analysis revealed areas under the curve for predicting SAP with baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS were 0.75 (95% CI, 0.69-0.82), 0.84 (95% CI, 0.79-0.89), and 0.82 (95% CI, 0.76-0.87), respectively. Of the three measures, 24-h ASPECTS was a better predictor of SAP (odds ratio: 5.33, 95%CI: 2.08-13.67, p < 0.001) and had a higher sensitivity (0.84 [95%CI, 0.74-0.92]) and specificity (0.79 [95%CI, 0.74-0.84]) than both baseline ASPECTS and change in ASPECTS. 24-h NCCT-ASPECTS outperformed both baseline ASPECTS and change in ASPECTS for predicting SAP. Notably, 24-h ASPECTS, with a cut-off value of ≤6, exhibited good predictive performance and emerged as the better predictor for SAP.

The role of blood protein biomarkers in acute ischemic stroke prognosis

BackgroundStroke is one of the most frequent causes of mortality and disability, blood protein biomarkers are used to determine patients at high risk for a severe illness and to estimate the outcome. This study aimed to detect the relation between serum levels of C-reactive protein, matrix metalloproteinase 9, S100 calcium-binding protein B, brain natriuretic peptide, D-dimer and stroke severity and outcome in acute ischemic stroke patients.ResultsOne hundred eighty-six patients with acute ischemic stroke participated and were subjected to complete general, neurological examination, assessment of stroke severity clinically and radiologically using National Institute of Health Stroke Scale (NIHSS), and Alberta Stroke Program Early CT (ASPECT) score and assessment of functional outcome using (modified Rankin Scale). C-reactive protein, matrix metalloproteinase 9, S100 calcium-binding protein B, brain natriuretic peptide and D-dimer were assessed. Higher C-reactive protein was found in patients with ASPECT score ≤ 7 and in patients with cerebral edema, seizures and was positively correlated with stroke severity according to NIHSS and modified Rankin Scale. C-reactive protein serum level at onset was negatively correlated with NIHSS at onset and is a significant predictor for mortality. D-dimer was negatively correlated with NIHSS. S100 calcium-binding protein B was significantly elevated in patients who developed hemorrhagic transformation.ConclusionsSerum C-reactive protein level can be used as a predictor for mortality and higher S100 calcium-binding protein B was detected in patients with hemorrhagic transformation.

Baseline clinical and neuroradiological predictors of outcome in patients with large ischemic core undergoing mechanical thrombectomy: A retrospective multicenter study.

Recent randomized trials have shown the benefit of mechanical thrombectomy (MT) also in patients with an established large ischemic core. The purpose of this study was to define baseline predictors of clinical outcome in patients with large vessel occlusion (LVO) in the anterior circulation and an Alberta Stroke Program Early CT score (ASPECTS) ⩽ 5, undergoing MT. The databases of 16 comprehensive stroke centers were retrospectively screened for patients with LVO and ASPECTS ⩽5 that received MT. Baseline clinical and neuroradiological features, including the differential contribution of all ASPECTS regions to the composite score, were collected. Primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. Statistical analysis used a logistic regression model and random forest algorithm. A total of 408 patients were available for analysis. In multivariate model, among baseline features, lower age (odd ratio (OR) = 0.962, 95% confidence interval (CI) = 0.943-0.982) and lower National Institute of Health Stroke Scale (NIHSS) score (OR = 0.911, 95% CI = 0.862-0.963) were associated with the mRS score 0-2. Involvement of the M2 (OR = 0.398, 95% CI = 0.206-0.770) or M4 (OR = 0.496, 95% CI = 0.260-0.945) ASPECTS regions was associated with an unfavorable outcome. Random forest analysis confirmed that age and baseline NIHSS score are the most important variables influencing clinical outcome, whereas involvement of cortical regions M5, M4, M2, and M1 can have a negative impact. Our retrospective analysis shows that, along with age and baseline clinical impairment, presence of early ischemic changes involving cortical areas has a role in clinical outcome in patients with large ischemic core undergoing MT. The data that support the findings of this study are available upon reasonable request.