Baseline Alberta Stroke Program Early CT Score Research Articles

Predictors of favorable functional outcomes for elderly patients undergoing endovascular thrombectomy for acute ischemic stroke

PurposeThe aim of this study was to identify factors that predict favorable functional outcomes in elderly patients with large-vessel occlusion acute ischemic stroke (LVO-AIS) who underwent mechanical thrombectomy (MT).MethodsWe conducted a retrospective observational study using the prospectively maintained Bigdata Observatory for Stroke of China (BOSC) to identify eligible patients who underwent MT for LVO-AIS at four comprehensive stroke centers between August 2019 and February 2022. Inclusion criteria included patients aged 80 years or older with a baseline modified Rankin Scale (mRS) 0–2, baseline National Institutes of Health Stroke Scale (NIHSS) > 6, baseline Alberta Stroke Program Early CT Score (ASPECTS) > 6 who received treatment within 24 h from symptom onset. Pertinent demographic, clinical, and procedural variables were collected. Multivariable regression analyses were performed to identify predictors of favorable long-term functional outcomes, defined as mRS 0–2 at 90 days.ResultsA total of 63 patients were included in the study with a mean age of 83 years. Patients with previous diagnosis of atrial fibrillation were more likely to have a favorable functional outcome (OR 2.09, 95% CI 2.09–407.33, p = 0.012), while a higher baseline NIHSS was associated with a less favorable functional outcome (OR 0.64, 95% CI 0.46–0.89, p = 0.007). In addition, there was an observed trend suggesting an association between higher baseline ASPECTS and favorable functional outcomes. This association did not reach statistical significance (OR 2.49, 95% CI 0.94–6.54, p = 0.065).ConclusionIn this study, we identified factors that predicted a favorable functional outcome in elderly LVO-AIS patients undergoing MT. A higher baseline NIHSS decreased the odds of mRS 0–2 at 90 days, whereas a history of atrial fibrillation increased the odds of a favorable functional outcome. These results emphasize the complex relationship between clinical factors and functional recovery in this vulnerable population.

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...

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.

Predicting functional outcome in acute ischemic stroke patients after endovascular treatment by machine learning.

Endovascular therapy (EVT) was the standard treatment for acute ischemic stroke with large vessel occlusion. Prognosis after EVT is always a major concern. Here, we aimed to explore a predictive model for patients after EVT. A total of 156 patients were retrospectively enrolled. The primary outcome was functional dependence (defined as a 90-day modified Rankin Scale score ≤ 2). Least absolute shrinkage and selection operator and univariate logistic regression were used to select predictive factors. Various machine learning algorithms, including multivariate logistic regression, linear discriminant analysis, support vector machine, k-nearest neighbors, and decision tree algorithms, were applied to construct prognostic models. Six predictive factors were selected, namely, age, baseline National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT (ASPECT) score, modified thrombolysis in cerebral infarction score, symptomatic intracerebral hemorrhage (sICH), and complications (pulmonary infection, gastrointestinal bleeding, and cardiovascular events). Based on these variables, various models were constructed and showed good discrimination. Finally, a nomogram was constructed by multivariate logistic regression and showed a good performance. Our nomogram, which was composed of age, baseline NIHSS score, ASPECT score, recanalization status, sICH, and complications, showed a very good performance in predicting outcome after EVT.

Abstract 219: Determining the Proportion of Patients with Poor Premorbid mRS presenting with Large Volume Stroke

Introduction Several lines of evidence demonstrate the effectiveness of endovascular treatment (EVT) for large volume stroke (LVS) as defined by Alberta Stroke Program Early CT Score (ASPECTS) of &lt;6 in decreasing severe disability and death. However EVT cannot improve the degree of disability as measured by modified Rankin Scale to be better than premorbid levels. Despite this limitation, patients with severe disabilities are transferred to acute care facilities for consideration of EVT and are hospitalized resulting in over‐medicalization during a terminal event. We aim to determine the proportion of patients with LVS who have poor premorbid mRS (4‐5) and the number of days this subset spent in hospital prior to palliation/death. Methods 2485 CT angiograms of head and neck and CT Head examinations performed between 2018‐2021 were obtained from the picture archiving and communication system (PACS). Cases presenting with ASPECTS&lt;6 as assigned by a neuroradiologist were identified. Functional outcome data, as defined by mRS, was obtained prior to the acute presenting event (premorbid mRS) and on discharge (outcome mRS). All patients with a documented outcome mRS were included in the analysis. Patients were excluded if presenting ASPECTS was &gt;=6, if stroke symptoms were attributable to etiology other than large vessel or tandem occlusion, or if the studies had been duplicated. Number of days spent hospitalized was calculated based on admission date and discharge date. Further subgroup analysis was performed to compare the cost of hospitalization with return to long term care (LTC) based on the Canadian national average of $7803 for hospitalization and $2406 for long term care as provided by Canadian Institute of Health Information and Ministry of long term care of Ontario. Results From the 2485 examinations, 62 had a baseline ASPECTS&lt;6 and 22 cases met exclusion criteria. 40 cases were available for analysis [premorbid mRS (n): 0=(18), 1=(5), 3=(6), 4=(7), 5=(2), ?=(2); age range: 28‐93; 19 male, 21 female]. 23% (9/40) of patients had premorbid mRS of 4‐5, and of these, 78% (7/9) were from LTC or a retirement home. On average, 5.9 days were spent hospitalized [range 4‐9 days]and $5397/person was spent per hospitalization. Conclusion LVS secondary to a LVO can be an acutely terminal illness. 23% of patients presenting with LVS had a poor premorbid mRS. 78% of these patients resided in long term care centers and spent an average of 5.9 days ($5397/person) being hospitalized prior to their demise/palliation.

The risk and outcome of malignant brain edema in post-mechanical thrombectomy: acute ischemic stroke by anterior circulation occlusion

Background and purposeMalignant brain edema (MBE) occurring after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) could lead to severe disability and mortality. We aimed to investigate the incidence, predictors, and clinical outcomes of MBE in patients with AIS after MT.MethodsThe clinical and imaging data of 155 patients with AIS of anterior circulation after MT were studied. Standard non-contrast CT was used to evaluate baseline imaging characteristics at admission. Clinical outcomes were measured using the 90-day modified Rankin Scale (mRS) score. Based on the follow-up CT scans performed within 72 h after MT, the patients were classified into MBE and non-MBE group. MBE was defined as a midline shift of ≥ 5 mm with signs of local brain swelling. Univariate and multivariate regression analyses were used to analyze the relationship between MBE and clinical outcomes and identify the predictors that correlate with MBE.ResultsMBE was observed in 19.4% of the patients who underwent MT and was associated with a lower rate of favorable 90-day clinical outcomes. Significant differences were observed in both MBE and non-MBE groups: baseline Alberta Stroke Program Early CT (ASPECT) score, hyperdense middle cerebral artery sign (HMCAS), baseline signs of early infarct, angiographic favorable collaterals, number of retrieval attempts, and revascularization rate. Multivariate analysis indicated that low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count, and poor revascularization independently influenced the occurrence of MBE in AIS patients with anterior circulation after MT.ConclusionMBE was associated with a lower rate of favorable 90-day clinical outcomes. Low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count and poor revascularization were independently associated with MBE after MT.

Abstract Number: LBA1 Endovascular Thrombectomy vs Best Medical Therapy for Late Presentation Ischaemic Stroke Selected using Non‐Contrast CT

Introduction The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients with proximal large vessel occlusion (LVO) selected without CT perfusion or MR imaging is undetermined in routine clinical practice. Methods In this single centre study, we identified consecutive AIS patients with an ICA or M1 MCA segment occlusion who were eligible for EVT based on non‐contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥ 6, and an NIHSS score of≥ 6, presenting beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours (between 18.00 and 08.00 on weekdays) or on weekends, consistently received best medical management (BMM). This systemic unavailability of EVT, allows a comparison of EVT and BMM in patients who meet the same inclusion criteria, in which selection based on physician‐related bias is significantly reduced. Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset‐to‐neuroimaging time, IV thrombolysis, and clot location.Pre‐specified subgroup analyses were performed. Results Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6‐hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR = 2.23, 95%CI 1.18‐4.22, p = 0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR = 4.73, 95%CI 1.64‐13.63, p = 0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p = 0.94) or mortality (20.2% vs 47.3%, p = 0.16) rates, respectively. EVT remained effective within the 6–12 hour and &gt;12 hour time window subgroups. No significant treatment interaction was observed in all subgroups. Conclusions In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset.

Futile reperfusion of endovascular treatment for acute anterior circulation large vessel occlusion in the ANGEL-ACT registry

BackgroundSome patients with large vessel occlusion (LVO) still cannot achieve functional independence despite successful reperfusion after endovascular treatment (EVT), named futile reperfusion. We aimed to explore the incidence and predictors...

Imaging mismatch between Alberta Stroke Program Early CT Score and perfusion imaging may be a good variable for endovascular treatment.

Some patients with acute large vessel occlusion (LVO) presented imaging mismatch, low Alberta Stroke Program Early CT Score (ASPECTS) with small ischemic core, or high ASPECTS with large ischemic core. The study was designed to explore whether patients with imaging mismatch could benefit from endovascular treatment (EVT). We retrospectively reviewed patients with LVO treated with EVT in our center from March 2018 to Jul 2020. Patients were divided into three groups, imaging mismatch, small ischemic core, and large ischemic core groups. Pooled analyses based on stroke onset to treatment time were done. Multivariate regression analysis was performed to explore the factors for good outcomes. Sixty-eight of 419 patients with LVO presented with imaging mismatch, and 35 of those (51%) achieved good outcomes after EVT at 90-day. No significant differences were noted in good outcomes and symptomatic intracranial hemorrhage (sICH) between patients with imaging mismatch and small ischemic core. Compared with large ischemic core, patients with imaging mismatch presented lower risk of sICH (95% confidence interval (CI) 0.04-0.75, p = 0.011) within 6 h and higher proportion of good outcomes (95% CI 0.37-0.82, p = 0.002) at 6 to 24 h. Baseline NIHSS (odds ratio (OR) = 0.91, 95% CI 0.88-0.95)), ASPECTS (OR = 1.14, 95% CI 1.01-1.29), ischemic core (OR = 0.99, 95% CI 0.98-1.00), and sICH (OR = 61.61, 95% CI 8.09-461.32) were associated with good outcomes. Patients with imaging mismatch treated within 24 h could benefit from EVT and without increasing the risk of sICH. • Patients with imaging mismatch between ASPECTS and ischemic core could achieve good outcomes after endovascular treatment. • Compared with large ischemic core, patients with imaging mismatch presented lower risk of symptomatic hemorrhage within 6 h and higher proportion of good outcomes within 6-24 h. • Baseline NIHSS score, ASPECTS, ischemic core, and symptomatic intracranial hemorrhage were associated with good outcomes.

Alberta Stroke Program Early CT Score applied to hyperdense lesion on noncontrast CT immediately post-thrombectomy is a predictor of poor outcome in acute ischemic stroke: A case-control study.

We aimed to evaluate whether Alberta Stroke Program Early CT Score (ASPECTS) applied to hyperdense lesion on noncontrast CT obtained immediately post-thrombectomy (post-ASPECTS) is useful for predicting poor outcome. We retrospectively reviewed patients who underwent noncontrast CT (NCCT) immediately after mechanical thrombectomy between January 2017 and July 2020 in our comprehensive stroke center. We collected baseline NCCT and post-ASPECTS score. The sensitivity, specificity, and positive and negative predictive values of the post-ASPECTS in predicting clinical outcome were calculated. A total of 223 patients were included. The hyperdense lesion on NCCT immediately after endovascular thrombectomy presented in 85.7% (191/223) patients, poor clinical outcome was in 56.1% (112/191) of hyperdense lesion patients. Low post-ASPECTS was associated with poor outcome (OR 0.390; 95% CI 0.258-0.589; P = .001), with an AUCROC curve of 0.753 (95% CI 0.684-0.822), while baseline NCCT-ASPECTS was not (OR 0. 754; 95% CI 0. 497-1.144; P = .185). A score ≤ 7 in post-ASPECTS was the best cut-off to poor clinical outcome (sensitivity 84.8%; specificity 52.7%; positive predictive value 68.4%; negative predictive value 73.8%). Our results point to the proportion of patients who present hyperdense lesion on NCCT is very high, post-ASPECTS could predict poor clinical outcomes in patients with stroke treated with endovascular mechanical thrombectomy, and post-ASPECTS may achieved better predictive value than baseline ASPECTS.

ASPECTS as a clinical outcome marker for MCA infarction treated with thrombolytic therapy: Non-contrast CT versus CTA source images

Background &amp; Objective: Computed tomography angiography (CTA) in acute stroke has been widely used to demonstrate arterial occlusion. Alberta Stroke Program Early CT Score (ASPECTS) is used to detect early ischemic signs in non-contrast computed tomography (NCCT) in the middle cerebral artery region. We hypothesized that computed tomography angiography source image (CTA-SI) is superior to NCCT in predicting final infarct volume, 24 hour National Institutes of Health Stroke Scale (NIHSS) score and 90-day clinical outcome. Methods: Patients who had an acute ischemic stroke due to middle cerebral artery (MCA) occlusion and treated with tissue plasminogen activator (tPA) were retrospectively evaluated. ASPECTS was evaluated by two experienced stroke neurologists in acute NCCT, CTA-SI, and follow up imaging. The final ASPECTS was compared with the mean baseline ASPECTS of NCCT and CTA-SI. The relation of both scores with 24-hour NIHSS and clinical outcome was compared. The Modified Rankin Scale (mRS) was utilized to evaluate the 90-day outcomes. mRS score of 0-2 was considered a “good outcome”. Results: Fifty-three patients were evaluated. We observed a significant relation among CTA-SI ASPECTS and after treatment 24hr ASPECTS (y= -3.9 + 1.4 x; 95% CI, -7.6 to -0.2) (y= -26.04 + 3.5 x; CI, -41 to -10). The median baseline 24-hr NHISS was 6 (0 - 22). We found a better correlation between CTA-SI ASPECTS and 24-hr NHISS (y= 363.06 + -37.03 x; CI, -148 to 864) than between NCCT ASPECTS and 24h NHISS (y=529.80 + -62.55 x; CI, 180 - 829). Median 90 days mRS score was 2 (0 - 6). According to Deming regression analysis, the CTA-SI ASPECTS (y= 76.10 + -7.69 x; 95% CI, -36 to 188) was more consistent with the 90 day mRS compared to NCCT ASPECTS (y=149.86 + -17.67 x; 95% CI, 23 - 267) CTA-SI was superior in predicting 24hr NIHSS and day 90 mRS compared to NCCT ASPECTS. Conclusion: Prediction of CTA-SI ASPECTs is better than NCCT ASPECTs at 24hr NIHSS, 3-month mRS and final infarct size in acute ischemic stroke patients treated with tPA.

Impact of Encephalomalacia and White Matter Hyperintensities on ASPECTS in Patients With Acute Ischemic Stroke: Comparison of Automated and Radiologist-Derived Scores.

BACKGROUND. Automated software-based Alberta Stroke Program Early CT Score (ASPECTS) on unenhanced CT is associated with clinical outcomes after acute stroke. However, encephalomalacia or white matter hyperintensities (WMH) may result in a falsely low automated ASPECTS if such findings are interpreted as early ischemia. OBJECTIVE. The purpose of this study was to assess the impact of encephalomalacia and WMH on the automated ASPECTS in patients with acute stroke, in comparison with the radiologist-derived ASPECTS and clinical outcomes. METHODS. This retrospective three-center study included 459 patients (322 men, 137 women; median age, 65 years) with acute ischemic stroke treated by IV thrombolysis who underwent baseline unenhanced CT within 6 hours after symptom onset and MRI within 24 hours after treatment. ASPECTS was determined by automated software and by three radiologists in consensus. Presence of encephalomalacia and extent of WMH (categorized using the modified Scheltens score [mSS]) were also determined using MRI. Kappa coefficients were used to compare the ASPECTS between automated- and radiologist-derived methods. Multivariable logistic regression analyses and ROC analyses were performed to explore the predictive utility of the baseline ASPECTS for unfavorable clinical outcomes (90-day modified Rankin score of 3-6) after thrombolysis. RESULTS. The median automated software-derived ASPECTS was 9, and the median radiologist consensus-derived ASPECTS was 10. Agreement between automated and radiologist-consensus ASPECTS, expressed as kappa, was 0.68, though agreement was 0.76 in patients without encephalomalacia and 0.08 in patients with encephalomalacia. In patients without encephalomalacia, agreement decreased as the mSS increased (e.g., 0.78 in subgroup with mSS < 10 vs 0.19 in subgroup with mSS > 20). By anatomic region, agreement was highest for the lateral middle cerebral artery (κ, 0.52) and lowest for the internal capsule (κ, 0.18). In multivariable analyses, both the automated (odds ratio, 0.69) and the radiologist-consensus (odds ratio, 0.57) ASPECTS independently predicted an unfavorable clinical outcome. For unfavorable outcome, the automated ASPECTS had an AUC of 0.70, sensitivity of 60.4%, and specificity of 70.7%, whereas the radiologist-consensus ASPECTS had an AUC of 0.72, sensitivity of 60.4%, and specificity of 80.5%. CONCLUSION. Presence of encephalomalacia or extensive WMH results in a lower automated than radiologist-consensus ASPECTS, which may impact predictive utility of automated ASPECTS. CLINICAL IMPACT. When using an automated software-derived ASPECTS, radiologists should manually confirm the score in patients with encephalomalacia or extensive leukoencephalopathy.

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis.

Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials. The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial. Systematic review and meta-analysis of available studies in accordance with the PRISMA statement. We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months. Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71). EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients. The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.

Cerebrovascular Collateral Integrity in Pediatric Large Vessel Occlusion: Analysis of the Save ChildS Study.

Robust cerebrovascular collaterals in adult patients with large vessel occlusion stroke have been associated with longer treatment windows, better recanalization rates, and improved outcomes, but the role of collaterals in pediatric stroke is not known. The primary aim was to determine whether favorable collaterals correlated with better radiographic and clinical outcomes in children with ischemic stroke who underwent thrombectomy. This study analyzed a subset of children enrolled in SaveChildS, a retrospective, multicenter, observational cohort study of 73 pediatric patients with stroke who underwent thrombectomy between 2000 and 2018 at 27 US and European centers. Included patients had baseline angiographic imaging and follow-up modified Rankin Scale scores available for review. Posterior circulation occlusions were excluded. Cerebrovascular collaterals were graded on acute neuroimaging by 2 blinded neuroradiologists according to the Tan collateral score, in which favorable collaterals are defined as >50% filling and unfavorable collaterals as <50% filling distal to the occluded vessel. Collateral status was correlated with clinical and neuroimaging characteristics and outcomes. Between-group comparisons were performed with the Wilcoxon rank-sum test for continuous variables or Fisher exact test for binary variables. Thirty-three children (mean age 10.9 [SD ±4.9]) years were included; 14 (42.4%) had favorable collaterals. Median final stroke volume as a percent of total brain volume (TBV) was significantly lower in patients with favorable collaterals (1.35% [interquartile range (IQR) 1.14%-3.76%] vs 7.86% [IQR 1.54%-11.07%], p = 0.049). Collateral status did not correlate with clinical outcome, infarct growth, or final Alberta Stroke Program Early CT Score (ASPECTS) in our cohort. Patients with favorable collaterals had higher baseline ASPECTS (7 [IQR 6-8] vs 5.5 [4-6], p = 0.006), smaller baseline ischemic volume (1.57% TBV [IQR 1.09%-2.29%] vs 3.42% TBV [IQR 1.26%-5.33%], p = 0.035), and slower early infarct growth rate (2.4 mL/h [IQR 1.5-5.1 mL/h] vs 10.4 mL/h [IQR 3.0-30.7 mL/h], p = 0.028). Favorable collaterals were associated with smaller final stroke burden and slower early infarct growth rate but not with better clinical outcome in our study. Prospective studies are needed to determine the impact of collaterals in childhood stroke. This study provides Class II evidence that in children with ischemic stroke undergoing thrombectomy, favorable collaterals were associated with improved radiographic outcomes but not with better clinical outcomes.

Serial ASPECTS in the DAWN Trial: Infarct Evolution and Clinical Impact.

The impact of baseline ischemia on Alberta Stroke Program Early CT Score (ASPECTS) and evolution over 24 hours may be distinct in late thrombectomy. We analyzed predictors of serial ASPECTS and clinical outcomes in the DAWN trial (Diffusion-Weighted Imaging or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo). The DAWN Imaging Core Laboratory independently scored ASPECTS at baseline and 24 hours. Descriptive statistics characterized ASPECTS on computed tomography/magnetic resonance imaging at baseline and 24 hours, delineating ASPECTS change over 24 hours. 206 subjects (mean age 70.0±13.7 years; 54.9% (n=113) female; baseline National Institutes of Health Stroke Scale median (interquartile range) 17 (13, 21) were included. Baseline ASPECTS was median (interquartile range) 8.0 (7–8), with 92/205 (44.9%) between 0 and 7 and 113/205 (55.1%) 8 and 10. 24-hour ASPECTS was median 6.0 (4–8), with ASPECTS change or infarct evolution having median −1, ranging from −8 to +2. Multivariable logistic regression showed older age (odds ratio [OR] for 10-year interval, 1.26 [95% CI, 1.02–1.55], P=0.030) and dyslipidemia (OR, 1.84 [95% CI, 1.06–3.19], P=0.031) were independently associated with higher baseline ASPECTS. Higher 24-hour ASPECTS was predicted by endovascular treatment (OR, 2.76 [95% CI, 1.58–4.81], P=0.0004), baseline glucose <150 mg/dL (OR, 2.86 [95% CI, 1.50–5.46], P=0.001), lower baseline National Institutes of Health Stroke Scale (OR, 0.93 [95% CI, 0.89–0.98], P=0.010), and older age (OR for 10-year interval, 1.25 [95% CI, 1.01–1.55], P=0.041). Internal carotid artery lesion location (OR, 0.47 [95% CI, 0.24–0.89], P=0.021) was inversely related to 24-hour ASPECTS. Good clinical outcome (day 90 modified Rankin Scale score 0–2) was predicted by 24-hour ASPECTS (OR, 1.46 [95% CI, 1.08–1.96], P=0.014). Extensive infarct evolution (ASPECTS decrease ≥6) occurred in 14/201 (7.0%). Elevated baseline serum glucose ≥150 mg/dL was a predictor of ASPECTS decrease of ≥4 points (OR, 2.78 [95% CI, 1.21–6.35] P=0.016) as was internal carotid artery occlusion (OR, 2.49 [95% CI, 1.05–5.88]; P=0.038). ASPECTS change was influenced by treatment arm (P=0.001 by Wilcoxon), including 0 ASPECTS change in 42/105 (40.0%) of the endovascular arm and only 20/96 (20.8%) of the medical arm. DAWN subjects enrolled with small infarct cores had a broad range of baseline ASPECTS. Twenty-four-hour ASPECTS, strikingly influenced by endovascular therapy, predicted good clinical outcomes. https://www.clinicaltrials.gov; Unique identifier: NCT02142283.

Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

BackgroundM2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but...

Combined Effect of Age and Baseline Alberta Stroke Program Early Computed Tomography Score on Post-Thrombectomy Clinical Outcomes in the MR CLEAN Registry.

Ischemic brain tissue damage in patients with acute ischemic stroke, as measured by the Alberta Stroke Program Early CT Score (ASPECTS) may be more impactful in older than in younger patients, although this has not been studied. We aimed to investigate a possible interaction effect between age and ASPECTS on functional outcome in acute ischemic stroke patients undergoing endovascular treatment, and compared reperfusion benefit across age and ASPECTS subgroups. Patients with ischemic stroke from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; March 2014-November 2017) were included. Multivariable ordinal logistic regression was performed to obtain effect size estimates (adjusted common odds ratio) on functional outcome (modified Rankin Scale score) for continuous age and granular ASPECTS, with a 2-way multiplicative interaction term (age×ASPECTS). Outcomes in four patient subgroups based on age (< versus ≥ median age [71.8 years]) and baseline ASPECTS (6-10 versus 0-5) were assessed. We included 3279 patients. There was no interaction between age and ASPECTS on modified Rankin Scale (P=0.925). The highest proportion of modified Rankin Scale 5 to 6 was observed in patients >71.8 years with baseline ASPECTS 0 to 5 (68/107, 63.6%). There was benefit of reperfusion in all age-ASPECTS subgroups. Although the adjusted common odds ratio was lower in patients >71.8 years with ASPECTS 0 to 5 (adjusted common odds ratio, 1.60 [95% CI, 0.66-3.88], n=110), there was no significant difference from the main effect (P=0.299). Although the proportion of poor outcomes following endovascular treatment was highest in older patients with low baseline ASPECTS, outcomes did not significantly differ from the main effect. These results do not support withholding endovascular treatment based n a combination of high age and low ASPECTS.

Effect of age and baseline ASPECTS on outcomes in large-vessel occlusion stroke: results from the HERMES collaboration

BackgroundPatient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the...

The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy.

Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry. Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5°C) was maintained for at least 48h. We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants. Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.

Baseline ASPECTS and hypoperfusion intensity ratio influence the impact of first pass reperfusion on functional outcomes

BackgroundFirst pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to...