Circulation Acute Stroke Prognosis Early Research Articles

Prognostic value of the baseline magnetic resonance score in patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy

To investigate the prognostic value of the composite posterior circulation Acute Stroke Prognosis Early Computed tomography (CT) Score (ASPECTS)-Collaterals (pcASCO) score, which combines diffusion-weighted imaging (DWI) posterior circulation ASPECTS (pcASPECTS) and the magnetic resonance angiography (MRA)-collateral circulation score at baseline among patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy. Patients with acute posterior circulation ischaemic stroke who underwent mechanical thrombectomy were analysed retrospectively. The DWI-pcASPECTS and MRA-collateral circulation score before treatment and the modified Rankin Scale (mRS) at 90 days after treatment were used as the endpoints. An mRS ≤2 was defined as a good prognosis, and an mRS ≥3 was defined as a poor prognosis. Multivariate logistic regression was used to analyse independent predictors of functional outcome 90 days after mechanical thrombectomy. Mechanical thrombectomy was performed in 57 patients; 38 patients had a good prognosis, 19 patients had a poor prognosis, and 33 patients were successfully recanalised. Univariate logistic regression found that National Institute of Health Stroke Scale (NIHSS) score (OR: 1.18, p<0.001), pcASPECTS (OR: 1.91, p=0.028) and pcASCO score (OR: 0.51, p=0.001) were factors of good functional outcome. Receiver operating characteristic curve (ROC curve) analysis showed that the diagnostic efficiency of the NIHSS and pcASCO was better (AUC=0.88, 0.83, p<0.05) than that of the pcASPECTS (AUC=0.65). The prediction model was established by age, NIHSS, and pcASCO, and the diagnostic efficiency of the prediction model was better (AUC=0.94). The composite MR-pcASCO score can be used as an important predictor of the prognosis of patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy.

Outcomes of Endovascular Treatment versus Standard Medical Treatment for Acute Ischemic Stroke with Basilar Artery Occlusion: A Systematic Review and Meta-Analysis.

Although endovascular treatment (EVT) is beneficial for large vessel occlusion in anterior circulation stroke, whether these benefits exist for basilar artery occlusion (BAO) remains unclear. This systematic review and meta-analysis compared the outcomes of patients with BAO undergoing EVT and standard medical treatment (SMT). The PubMed, Embase, and Cochrane Library databases were searched for eligible randomized control trials (RCTs) and non-RCTs involving patients with acute ischemic stroke and BAO undergoing EVT or SMT. The following outcomes were assessed: 90-day functional outcomes (favorable outcome and functional independence: modified Rankin scale [mRS] score of 0-3 or 0-2, respectively), mortality, and symptomatic intracranial hemorrhage (sICH) incidence. The summary effect sizes were determined as risk ratios (RRs) through the Mantel-Haenszel method with a random-effects model. Four RCTs and four non-RCTs were included. Compared with SMT, EVT resulted in a higher proportion of patients with 90-day mRS scores of 0-3 (RR: 1.54 [1.16-2.06] in RCTs and 1.88 [1.11-3.19] in non-RCTs), a higher proportion of patients achieving functional independence (90-day mRS score of 0-2; RR: 1.83 [1.07-3.12] and 1.84 [0.97-3.48], respectively), a lower risk of mortality (RR: 0.76 [0.65-0.89] and 0.72 [0.62-0.83], respectively), and a higher sICH risk (RR: 5.98 [2.11-16.97] and 4.95 [2.40-10.23], respectively). Severe neurological deficits, intravenous thrombolysis, and higher posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) were associated with EVT benefits. In patients with BAO, EVT results in superior functional outcomes, lower mortality risk, and higher sICH risk than does SMT, independent of age and sex. Higher National Institutes of Health Stroke Scale scores, intravenous thrombolysis, and higher pc-ASPECTSs before treatment are associated with greater benefits from EVT.

Abstract Number ‐ 183: pcASPECTS can help predict clinical outcome in basilar artery occlusion strokes who undergo endovascular thrombectomy

Introduction Basilar artery occlusion (BAO) is a life‐threatening condition associated with high morbidity and mortality. The clinical effectiveness of endovascular therapy (EVT) in patients with stroke due to BAO is not well established. The objective of our study is to investigate the role of Posterior circulation Acute Stroke Prognosis Early CT Score (pcASPECTS) in predicting clinical outcome in patients with BAO who undergo EVT. Methods We conducted a retrospective analysis on 45 patients with acute BAO who received EVT from November 2015 to June 2022. Information was collected on demographic variables, medical history, clinical parameters, and CT based pcASPECTS on admission. Functional outcomes were assessed via binarization of the following variables: the modified Rankin scale score on discharge, NIH stroke scale on discharge, and the modified Rankin scale score 90 days following discharge. A series of logistic regression models adjusted for age, gender, atrial fibrillation, systolic blood pressure at admission, tPA receipt, and NIH stroke scale on admission were run to assess the association of pcASPECTS score on admission with binarized outcome measures. Results Among 45 patients (mean age 63.6+11.4 years, 73.3% males), binarized pcASPECTS score on admission (&lt; 7: greater severity, &gt;7: lower severity) was not shown to be significantly associated with functional outcome across a series of logistic regression models. When assessing for binarized modified Rankin scale at discharge (0‐3: good outcome, 4–6: poor outcome), a lower severity of pcASPECTS showed 5.47 times the odds of a good outcome (OR: 5.47; 95% CI: 0.17, 173.25; p‐value: 0.34). When assessing for binarized NIH stroke scale on discharge (0‐15: mild/moderate; &gt;15: severe), a lower severity pcASPECTS showed 6.05 times the odds of a mild/moderate outcome as opposed to a severe outcome (OR: 6.05; 95% CI: 0.32, 114.62; p‐value: 0.23). When assessing for a modified Rankin scale at 90 days post‐discharge, binarized as above, a lower severity pcASPECTS showed 4.36 times the odds of a good outcome (OR: 4.36; 95% CI: 0.27, 69.40; p‐value: 0.30). Conclusions Our study revealed that pcASPECTS on admission may help predict clinical outcomes in patients receiving EVT for BAO and therefore could be used as a guide for medical and endovascular management. These findings have far‐reaching applicability but will require larger studies to confirm significant clinical benefit.

Outcome of endovascular treatment in acute basilar artery occlusion with National Institutes of Health Stroke Scale score 10-19.

Authors of this study aimed to investigate the efficacy and safety of endovascular treatment (EVT) versus standard medical treatment (SMT) alone in patients with acute basilar artery occlusion (BAO) and moderate deficit (National Institutes of Health Stroke Scale [NIHSS] score 10-19). Patients with moderate deficit caused by acute BAO in the period from January 2014 to May 2019 were included in the study. The patients were divided into groups based on treatment: EVT plus SMT group or SMT-alone group. The primary outcome was favorable functional outcome (modified Rankin Scale score 0-3) at 90 days, and safety outcomes were symptomatic intracerebral hemorrhage (sICH) and mortality at 90 days. A total of 173 patients had moderate deficits, 128 of whom had been treated with EVT and 45 with SMT alone. EVT was associated with a significant higher proportion of 90-day favorable outcomes compared with SMT (adjusted odds ratio [aOR] 4.09, 95% CI 1.39-12.04, p = 0.011). Younger age (aOR 0.96, 95% CI 0.92-0.99, p = 0.017), absence of diabetes mellitus (aOR 0.35, 95% CI 0.12-0.99, p = 0.048), higher baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS; aOR 1.48, 95% CI 1.07-2.05, p = 0.018), and modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b-3 (aOR 15.15, 95% CI 3.07-74.72, p = 0.001) were independent factors for a favorable outcome in the EVT group. Rates of mortality and sICH were comparable in the EVT and SMT groups. EVT leads to improved outcomes compared to those with SMT alone. Younger age, absence of diabetes mellitus, higher baseline pc-ASPECTSs, and mTICI score of 2b-3 were associated with better functional outcome in the EVT group.

Effect of Gastrointestinal Hemorrhage on Outcome After Endovascular Treatment in Acute Basilar Artery Occlusion.

Background and PurposeGastrointestinal hemorrhage (GIH) is associated with a poorer prognosis and a higher mortality rate after acute ischemic stroke (AIS), but its association with outcomes after endovascular treatment (EVT) remains unclear. This study aimed to assess the incidence, risk factors, and relationships among clinical outcomes of GIH after EVT in patients with acute basilar artery occlusion (BAO).MethodsConsecutive patients treated with EVT were identified from the EVT for Acute Basilar Artery Occlusion Study (BASILAR) registry. All enrolled patients were divided into GIH and non-GIH subgroups, and the independent predictors of GIH after EVT were explored. An ordinal logistic regression model was used to assess the association between GIH and primary outcome [distribution of modified Rankin scale (mRS)] at 90 days, while binary logistic regression models for other outcomes were also employed.ResultsAmong 647 patients with acute BAO, 114 (17.6%) patients experienced GIH after EVT. Higher glucose levels at admission, longer procedure time, and general anesthesia were the independent predictors of GIH after EVT, while protective factors include the posterior circulation-Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) ≥ 5 and a history of hyperlipidemia. Compared with the non-GIH group, the GIH group was associated with a worse functional outcome [adjusted common odds ratio (OR), 2.12 (95% CI, 1.39–3.25)], lower rates of functional independence [adjusted OR,.47 (95% CI, 0.26–0.88)], a favorable outcome [adjusted OR, 0.41 (95% CI, 0.22–0.73)], and a higher risk of 90-day mortality [adjusted OR, 1.76 (95% CI, 1.08–2.85)].ConclusionThis study concluded that GIH is not uncommon after EVT in patients with acute BAO and is associated with worse functional disability and higher mortality.

Hyperdense Artery Sign and Clinical Outcomes After Endovascular Treatment in Acute Basilar Artery Occlusion

BackgroundThis study aimed to investigate the association between the hyperdense basilar artery sign (HBAS) on non-enhanced computed tomography (CT) and clinical outcomes in patients with acute basilar artery occlusion (BAO) who underwent endovascular treatment (EVT).MethodsEligible patients who underwent EVT due to acute BAO between January 2014 and May 2019 were divided into two groups based on HBAS. HBAS was assessed by two neuroradiologists using five grades on nonenhanced CT. The primary outcome was a favorable functional outcome (defined as a modified Rankin Scale [mRS] of 0–3) at 90 days. Secondary outcomes included successful recanalization and mortality within 90 days.ResultsAmong 829 patients with BAO as assessed with CT angiography, magnetic resonance angiography, or digital subtraction angiography, 643 patients were treated with EVT. Of these, 51.32% (330/643) had HBAS. Patients with HBAS were older and had more severe neurological deficits and a higher frequency of atrial fibrillation than those without HBAS. There was no significant difference in favorable outcome (adjusted odds ratio [aOR]: 1.354, 95% confidence interval [CI]: 0.906–2.024; p = 0.14), successful recanalization (aOR: 0.926, 95% CI: 0.616-−1.393; p = 0.71), and mortality (aOR: 1.193, 95% CI: 0.839–1.695; p = 0.33) between patients with or without HBAS. Subgroup analysis showed that the HBAS predicted a favorable outcome in patients aged <60 years (aOR: 2.574, 95% CI: 1.234–5.368; p = 0.01) and patients with vertebral artery-V4 segment occlusion (aOR: 3.738, 95% CI: 1.212–11.530; p = 0.02). In patients with HBAS, the baseline National Institutes of Health Stroke Scale (NIHSS) score, posterior circulation–Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS), and stent retriever were associated with successful recanalization.ConclusionsOur study did not find a significant association between HBAS and favorable outcomes and successful recanalization in patients with BAO who underwent EVT. Moreover, large prospective studies are warranted to further investigate this relationship.

New imaging score for outcome prediction in basilar artery occlusion stroke.

In ischemic posterior circulation stroke, the utilization of standardized image scores is not established in daily clinical practice. We aimed to test a novel imaging score that combines the collateral status with the rating of the posterior circulation Acute Stroke Prognosis Early CT score (pcASPECTS). We hypothesized that this score (pcASCO) predicts functional outcome and malignant cerebellar edema (MCE). Ischemic stroke patients with acute BAO who received multimodal-CT and underwent thrombectomy on admission at two comprehensive stroke centers were analyzed. The posterior circulation collateral score by van der Hoeven et al was added to the pcASPECTS to define pcASCO as a 20-point score. Multivariable logistic regression analyses were performed to predict functional independence at day 90, assessed using modified Rankin Scale scores, and occurrence of MCE in follow-up CT using the established Jauss scale score as endpoints. A total of 118 patients were included, of which 84 (71%) underwent successful thrombectomy. Based on receiver operating characteristic curve analysis, pcASCO ≥ 14 classified functional independence with higher discriminative power (AUC: 0.83, 95%CI: 0.71-0.91) than pcASPECTS (AUC: 0.74). In multivariable logistic regression analysis, pcASCO was significantly and independently associated with functional independence (aOR: 1.91, 95%CI: 1.25-2.92, p = 0.003), and MCE (aOR: 0.71, 95%CI: 0.53-0.95, p = 0.02). The pcASCO could serve as a simple and feasible imaging tool to assess BAO stroke patients on admission and might be tested as a complementary tool to select patients for thrombectomy in uncertain situations, or to predict clinical outcome. • The neurological assessment of basilar artery occlusion stroke patients can be challenging and there are yet no validated imaging scores established in daily clinical practice. • The pcASCO combines the rating of early ischemic changes with the status of the intracranial posterior circulation collaterals. • The pcASCO showed high diagnostic accuracy to predict functional outcome and malignant cerebellar edema and could serve as a simple and feasible imaging tool to support treatment selection in uncertain situations, or to predict clinical outcome.

Posterior Circulation ASPECTS on CT Angiography Predicts Futile Recanalization of Endovascular Thrombectomy for Acute Basilar Artery Occlusion.

BackgroundAcute basilar artery occlusion (BAO) is the most potentially disastrous outcome and has a high risk of recurrence stroke in posterior circulation infarction (PCI). However, the rate of futile recanalization remains high despite successful recanalization. The objective of this study was to investigate 90 days functional outcomes among patients with BAO who underwent endovascular thrombectomy (EVT) and to identify the risk factors associated with futile recanalization.MethodsWe retrospectively analyzed 72 patients with acute BAO who received EVT from January 2018 to June 2021. CT angiography source images posterior circulation Acute Stroke Prognosis Early CT Score (CTA-SI pc-ASPECTS) evaluated the extensive hypoattenuation in patients with BAO. Futile recanalization defined an modified Rankin Scale (mRS) of 3-6 at 90 days despite a successful recanalization. Logistic regression analysis was performed to investigate the predictors of futile recanalization.ResultsOur sample included a total of 55 eligible patients. Patients with poor outcomes showed that the pc-ASPECTS score was lower in patients with poor outcomes than that in patients with good outcomes (P = 0.017). Longer time from symptoms onset-to-the puncture (P = 0.014) and elevation of leucocytes (P = 0.012) were associated with poor outcomes. The multivariable logistic analysis showed that pc-ASPECTS and onset-to-puncture time (OPT) were independent predictors of futile recanalization.ConclusionsThis study suggested that pc-ASPECTS and OPT are independent predictors of futile recanalization after EVT in patients with BAO. The lower pc-ASPECTS score and longer puncture time will have a poor clinical outcome.

Imaging-based outcome prediction in posterior circulation stroke

Background and purposeWe developed a machine learning model to allow early functional outcome prediction for patients presenting with posterior circulation (pc)-stroke based on CT-imaging and clinical data at admission. The proposed algorithm utilizes quantitative information from automated multidimensional assessments of posterior circulation Acute Stroke Prognosis Early CT-Score (pc-ASPECTS) regions. Discriminatory power was compared to predictions based on conventional pc-ASPECTS ratings.MethodsWe retrospectively analyzed non-contrast CTs and clinical data of 172 pc-stroke patients. 90 days outcome was dichotomized into good and poor using modified Rankin Scale (mRS) cut-offs. Predictive performance was assessed for outcome differentiation at mRS 2, 3, 4 and survival prediction (mRS ≤ 5) using random forest algorithms. Results were compared to conventional pc-ASPECTS and clinical parameters. Models were evaluated in a nested fivefold cross-validation approach.ResultsReceiver operating characteristic areas under the curves (ROC-AUCs) of the test sets using conventionally rated pc-ASPECTS reached 0.63 for mRS ≤ 4 to 0.68 for mRS ≤ 5 and 0.73 for mRS ≤ 5 to 0.85 for mRS ≤ 2 if clinical data were considered. Pure imaging-based machine learning classifier ROC-AUCs were lowest for mRS ≤ 4 (0.81) and highest for mRS ≤ 5 (0.87). The combined clinical data and machine learning-based model had the highest predictive performance with ROC-AUCs reaching 0.90 for mRS ≤ 2.ConclusionMachine learning-based evaluation of pc-ASPECTS regions predicts functional outcome of pc-stroke patients with higher accuracy than conventional assessments. This could optimize triage for additional diagnostics and allocation of best possible medical care and might allow required arrangements of the social environment at an early point of time.

Novel Diffusion-Weighted Imaging Score Showed Good Prognostic Value for Acute Basilar Artery Occlusion Following Endovascular Treatment: The Pons-Midbrain and Thalamus Score.

Prognostic factors for outcome of endovascular treatment remains to be investigated in patients with acute basilar artery occlusion. We aimed to assess the prognostic value of a novel pretreatment diffusion-weighted imaging score: The Pons-Midbrain and Thalamus (PMT) score. Eligible patients who underwent endovascular treatment due to acute basilar artery occlusion were reviewed. The PMT score was a diffusion-weighted imaging-based semiquantitative scale in which the infarctions of pons, midbrain, and thalamus were fully considered. The PMT score was assessed as well as the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score and Brain Stem Score. Good outcomes were defined as a modified Rankin Scale score of ≤3 at 90-day and successful reperfusion as Thrombolysis in Cerebral Infarction grades 2b/3. The associations between baseline clinical parameters and good outcomes were evaluated with logistic regression. A total of 107 patients with pretreatment magnetic resonance imaging were included in this cohort. The baseline PMT score (median [interquartile range], 3 [1-5] versus 7 [5-9]; P<0.001) and Brain Stem Score (median [interquartile range], 2 [1-4] versus 3 [2-5]; P=0.001) were significantly lower in good outcome group; the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score was higher in good outcome group without statistical significance. As a result of receiver operating characteristic curve analyses, the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score showed poor prognostic accuracy for good outcome (area under the curve, 0.60 [95% CI, 0.49-0.71]; P=0.081); The baseline PMT score showed significantly better prognostic accuracy for 90-day good outcome than the Brain Stem Score and National Institutes of Health Stroke Scale (area under the curve, 0.80 versus 0.68 versus 0.78, P=0.003). In addition, favorable PMT score <7 (odds ratio, 22.0 [95% CI, 6.0-80.8], P<0.001), Brain Stem Score <3 (odds ratio, 4.65 [95% CI, 2.05-10.55], P<0.001) and baseline National Institutes of Health Stroke Scale <23 (odds ratio, 8.0 [95% CI, 2.5-25.6], P<0.001) were associated with improved good outcome. In patients with acute basilar artery occlusion following endovascular treatment, the pretreatment diffusion-weighted imaging based PMT score showed good prognostic value for clinical outcome.

Posterior circulation collateral flow modifies the effect of thrombectomy on outcome in acute basilar artery occlusion.

In basilar artery occlusion stroke, the impact of the collateral circulation on infarct progression in the context of endovascular treatment is yet poorly studied. This study investigates the impact of the posterior circulation collateral score (PCCS) on functional outcome according to the extent of early ischemic changes and treatment. We hypothesized that the presence of collaterals, quantified by the PCCS, mediates the effect of endovascular treatment on functional outcome in patients with acute basilar artery occlusion. In this multicenter observational study, patients with basilar artery occlusion and admission computed tomography were analyzed. At baseline, Posterior circulation Acute Stroke Prognosis Early Computed Tomography score (pcASPECTS) was assessed and PCCS was quantified using an established 10-point grading system. Logistic regression analyses were performed to identify factors associated with good functional outcome (modified Rankin Scale scores 0-2 at day 90). A total of 151 patients were included, of which 112 patients (74%) underwent endovascular treatment. In patients with a better PCCS (&gt;5), the rate of good outcome was significantly higher (55% vs. 11%; p = 0.001). After adjusting for PCCS, vessel recanalization was significantly associated with improved functional outcome (aOR: 4.53, 95%CI: 1.25-16.4, p = 0.02), while there was no association between recanalization status and outcome in univariable analysis. Patients with low pcASPECTS generally showed very poor outcomes (mean modified Rankin Scale score 5.3, 95%CI: 4.9-5.8). PCCS modified the effect of recanalization on functional outcome, particularly in patients with less pronounced ischemic changes in admission computed tomography. These results should be validated to improve patient selection for endovascular treatment in basilar artery occlusion, particularly in uncertain indications, or to triage patients at risk for very poor outcomes.

Comatose With Basilar Artery Occlusion: Still Odds of Favorable Outcome With Recanalization Therapy.

Background: Around 30–60% of patients with basilar artery occlusion (BAO) present with coma, which is often considered as a hallmark of poor prognosis.Aim: To examine factors that will help predict outcomes in patients with BAO comatose on admission.Methods: A total of 312 patients with angiography-proven BAO were analyzed. Comas were assessed as Glasgow Coma Scale (GCS) of ≤8 or impaired level of consciousness ascertained in the medical records. Outcomes were evaluated with the modified Rankin Scale (mRS) over a phone call at 3 months. In our study, 53 patients were excluded due to inadequate data on the level of consciousness.Results: In total, 103/259 (39.8%) of BAO patients were comatose on admission. Factors associated with acute coma were higher age, coronary artery disease, convulsions, extent of early ischemia by posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) < 8, absence of patent posterior collateral vasculature, and occlusion over multiple segments of BA. A total of 21/103 (20.4%) of comatose patients had a favorable outcome (mRS 0–3), and 12/103 (11.7%) had a good outcome (mRS 0–2). Factors associated with a favorable outcome in comatose BAO patients were younger age (p = 0.010), less extensive baseline ischemia (p = 0.027), recanalization (p = 0.013), and avoiding symptomatic intracranial hemorrhage (sICH) (p = 0.038). Factors associated with the poorest outcome or death (mRS 5–6) were older age (p = 0.001), diabetes (p = 0.022), atrial fibrillation (p = 0.016), lower median GCS [4 (IQR 3.6) vs. 6 (5–8); p = 0.006], pc-ASPECTS < 8 (p = 0.003), unsuccessful recanalization (p = 0.006), and sICH (p = 0.010). Futile recanalization (mRS 4–6) was significantly more common in comatose patients (49.4 vs. 18.5%, p < 0.001).Conclusions: One in five BAO patients with acute coma had a favorable outcome. Older patients with cardiovascular comorbidities and already existing ischemic lesions before reperfusion therapies tended to have a poor prognosis, especially if no recanalization is achieved and sICH occurred.

Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake.

Malignant cerebellar edema (MCE) is a life-threatening complication of ischemic posterior circulation stroke that requires timely diagnosis and management. Yet, there is no established imaging biomarker that may serve as predictor of MCE. Early edematous water uptake can be determined using quantitative lesion water uptake, but this biomarker has only been applied in anterior circulation strokes. To test the hypothesis that lesion water uptake in early posterior circulation stroke predicts MCE. A total 179 patients with posterior circulation stroke and multimodal admission CT were included. A total of 35 (19.5%) patients developed MCE defined by using an established 10-point scale in follow-up CT, of which ≥4 points are considered malignant. Posterior circulation net water uptake (pcNWU) was quantified in admission CT based on CT densitometry and compared with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) as predictor of MCE using receiver operating curve (ROC) analysis and logistic regression analysis. Acute pcNWU within the early ischemic lesion was 24.6% (±8.4) for malignant and 7.2% (±7.4) for nonmalignant infarctions, respectively (P<.0001). Based on ROC analysis, pcNWU above 14.9% identified MCE with high discriminative power (area under the curve: 0.94; 95% CI: 0.89-0.97). Early pcNWU (odds ratio [OR]: 1.28; 95% CI: 1.15-1.42, P<.0001) and pc-ASPECTS (OR: 0.71, 95% CI: 0.53-0.95, P=.02) were associated with MCE, adjusted for age and recanalization status. Quantitative pcNWU in early posterior circulation stroke is an important marker for MCE. Besides pc-ASPECTS, lesion water uptake measurements may further support identifying patients at risk for MCE at an early stage indicating stricter monitoring and consideration for further therapeutic measures.

Values of Baseline Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Score for Treatment Decision of Acute Basilar Artery Occlusion.

This study aimed to analyze the impact of baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) on the efficacy and safety of endovascular therapy (EVT) for patients with acute basilar artery occlusion. The BASILAR was a nationwide prospective registry of consecutive patients with a symptomatic and radiologically confirmed acute basilar artery occlusion within 24 hours of symptom onset. We estimated the effect of standard medical therapy alone (SMT group) versus SMT plus EVT (EVT group) for patients with documented pc-ASPECTS on noncontrast CT, both as a categorical (0-4 versus 5-7 versus 8-10) and as a continuous variable. The primary outcomes included favorable functional outcomes (modified Rankin Scale ≤3) at 90 days and mortality within 90 days. In total, 823 cases were included: 468 with pc-ASPECTS 8 to 10 (SMT: 71; EVT: 397), 317 with pc-ASPECTS 5 to 7 (SMT: 85; EVT: 232), and 38 with pc-ASPECTS 0 to 4 (SMT: 13; EVT: 25). EVT was associated with higher rate of favorable outcomes (adjusted relative risk with 95% CI, 4.35 [1.30-14.48] and 3.20 [1.68-6.09]; respectively) and lower mortality (60.8% versus 77.6%, P=0.005 and 35.0% versus 66.2%, P<0.001; respectively) than SMT in the pc-ASPECTS 5 to 7 and 8 to 10 subgroups. Continuous benefit curves also showed the superior efficacy and safety of EVT over SMT in patients with pc-ASPECTS ≥5. Furthermore, the prognostic effect of onset to puncture time on favorable outcome with EVT was not significant after adjustment for pc-ASPECTS (adjusted odds ratio, 0.98 [95% CI, 0.94-1.02]). Patients of basilar artery occlusion with pc-ASPECTS ≥5 could benefit from EVT. The baseline pc-ASPECTS appears more important for decision making and predicting prognosis than time to EVT. Registration: URL: http://www.chictr.org.cn. Unique identifier: ChiCTR1800014759.

Basilar artery thrombectomy: assessment of outcome and identification of prognostic factors.

Mechanical thrombectomy (MT) has been demonstrated as an effective treatment for acute ischemic stroke (AIS), thanks to large vessel occlusion (LVO), especially in case of anterior cerebral artery with many randomized clinical trials (RCTs) every year. On the other hand, there is a limited number of basilar artery occlusion (BAO)-related studies which have been conducted. The fact prompts our range of case studies, which furnish BAO understanding with our experience, results and some prognosis factors of MT. This retrospective and single-center study was conducted on 22 patients who were diagnosed with BAO and underwent the treatment of MT from October 2012 to January 2018. Clinical feature such as radiological imaging, procedure complications, and intracranial hemorrhage were all documented and evaluated. All the studies' results based on performance using modified Rankin scale score (mRS) and mortality at 90days. The results from these BAO patients study indicated that the posterior circulation Acute Stroke Prognosis Early CT Score (pcASPECTS) recorded before the intervention was 7.7 ± 1.6, while the admission National Institutes of Health Stroke Scale (NIHSS) was 17.5 ± 5.4. 15/22 cases achieved successful recanalization (TICI, Thrombolysis in Cerebral Infarction scale, of 2b-3), accounting for 68.2%. The results highlighted 50% of the favorable outcome (mRS 0-2) occupying 11 out of 22 patients in total and the overall mortality was 36.4%. The intracranial hemorrhagic complication was detected in three cases (13.6%). Placing in juxtaposition the poor-outcome group and the favorable-outcome group, we could witness statistically significant difference (P < 0.05) suggesting both good baseline image (pc-ASPECTS ≥ 7) and recanalization (TICI 2b-3) were two good prognosis factors. Our case series showed that MT would be an effective and feasible treatment for BAO. The pre-procedural pcASPECTS ≥ 7 and post-procedural good recanalization (TICI 2b-3) were two important prognosis factors for predicting good clinical outcome.

Mechanical Thrombectomy Using Solitaire in Acute Ischemic Stroke Patients with Vertebrobasilar Occlusion: A Prospective Observational Study

The safety and effectiveness of endovascular mechanical thrombectomy in patients with acute vertebrobasilar occlusion (VBO) are debatable and undergoing evaluation. We report the clinical outcome and prognostic factors in a prospective cohort of acute ischemic stroke patients with VBO. In total, 48 consecutive patients with acute VBO underwent mechanical thrombectomy using Solitaire. We analyzed clinical and imaging data and searched for predictors of good clinical outcome (modified Rankin scale score: 0-3). The median prethrombectomy National Institutes of Health Stroke Scale score was 22.0. The median duration from symptom onset to recanalization was 493.5 minutes. A total of 35.4% of the patients received rescue therapy. Recanalization (modified Thrombolysis In Cerebral Infarction: 2b-3) was successful in all patients. Clinically relevant intracranial hemorrhage was observed in 2 patients. After 90 days, good outcomes were obtained in 27 patients. The baseline National Institutes of Health Stroke Scale score, posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS), anesthesia type, and posterior communicating artery (PComA) patency were significantly associated with outcomes at 90 days in univariate analysis. Multivariate logistic regression indicated that high pc-ASPECTS at admission and PComA patency were independent predictors of good outcome at 90 days. Up to 60.4% of the patients reached good outcomes after endovascular treatment and 35.4% of the patients received rescue therapy, suggesting that mechanical thrombectomy using Solitaire in patients with stroke with VBO is safe and effective and that rescue therapy is readily required and employed. High baseline pc-ASPECTS and PComA patency were associated with better outcomes after thrombectomy in these patients.

Perfusion computed tomography in posterior circulation stroke: predictors and prognostic implications of focal hypoperfusion.

The aim was to determine the predictors of focal hypoperfusion on computed tomography (CT) perfusion (CTP) in patients with acute posterior circulation stroke and its association with long-term outcome. Patients with posterior circulation stroke were selected from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) who underwent CTP within 24h of stroke onset as part of the stroke imaging protocol. Hypoperfusion was defined as an area of visually well demarcated mean transit time prolongation corresponding to an arterial territory on standard reconstruction CTP imaging maps. Areas of hypoperfusion were assessed with the posterior circulation Acute Stroke Prognosis Early CT Score. Clinical and imaging associations with focal hypoperfusion were identified using multiple imputation analyses, and the adjusted functional outcome measured by the modified Rankin Scale at 3 and 12months was determined. Of the 3595 consecutive patients from the ASTRAL registry between 2003 and 2014, 1070 (29.7%) had a posterior circulation stroke and 436 of these (40.7%) patients had a good quality baseline CTP. 23.1% had early ischaemic changes and 37.4% had focal hypoperfusion. In multiple imputation analysis, visual field deficits, reduced level of consciousness, cardiac and multiple stroke mechanisms, significant vessel pathology and ischaemic changes visible on plain CT were associated with focal hypoperfusion. Focal hypoperfusion was independently associated with outcome at 12months (odds ratio 2.04, 95% confidence interval 1.22-3.42, P<0.01). In posterior circulation stroke patients undergoing acute CTP, multiple clinical, aetiological and radiological variables were associated with focal hypoperfusion. Patients with focal hypoperfusion had a worse 12-month outcome.

Early Imaging Prediction of Malignant Cerebellar Edema Development in Acute Ischemic Stroke.

Malignant cerebellar edema (MCE) is a life-threatening complication of acute ischemic stroke that requires timely diagnosis and management. Aim of this study was to identify imaging predictors in initial multiparametric computed tomography (CT), including whole-brain CT perfusion (WB-CTP). We consecutively selected all subjects with cerebellar ischemic WB-CTP deficits and follow-up-confirmed cerebellar infarction from an initial cohort of 2635 patients who had undergone multiparametric CT because of suspected stroke. Follow-up imaging was assessed for the presence of MCE, measured using an established 10-point scale, of which scores ≥4 are considered malignant. Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was determined to assess ischemic changes on noncontrast CT, CT angiography (CTA), and parametric WB-CTP maps (cerebellar blood flow [CBF]; cerebellar blood volume; mean transit time; time to drain). Fisher's exact tests, Mann-Whitney U tests, and receiver operating characteristics analyses were performed for statistical analyses. Out of a total of 51 patients who matched the inclusion criteria, 42 patients (82.4%) were categorized as MCE- and 9 (17.6%) as MCE+. MCE+ patients had larger CBF, cerebellar blood volume, mean transit time, and time to drain deficit volumes (all with P<0.001) and showed significantly lower median pc-ASPECTS assessed using WB-CTP (CBF, cerebellar blood volume, mean transit time, time to drain; all with P<0.001) compared with MCE- patients, while median pc-ASPECTS on noncontrast CT and CTA was not significantly different (both P>0.05). Receiver operating characteristics analyses yielded the largest area under the curve values for the prediction of MCE development for CBF (0.979) and cerebellar blood volume deficit volumes (0.956) and pc-ASPECTS on CBF (0.935), whereas pc-ASPECTS on noncontrast CT (0.648) and CTA (0.684) had less diagnostic value. The optimal cutoff value for CBF deficit volume was 22 mL, yielding 100% sensitivity and 90% specificity for MCE classification. WB-CTP provides added diagnostic value for the early identification of patients at risk for MCE development in acute cerebellar stroke.

Abstract WP53: The prognostic value of Posterior Circulation Acute Stroke Prognosis Early Ct Score (pcaspects) on CT perfusion in patients with basilar artery occlusion

Background: CT perfusion (CTP) increases diagnostic confidence in ischaemic stroke. Despite bone-related artefacts, CTP has been shown to improve diagnostic sensitivity compared to non contrast-CT (NCCT) and Computed Tomography Angiography source images (CTA-SI) in posterior circulation strokes. The posterior circulation Acute Stroke Prognosis Early CT score (pcASPECTS) on CTA-SI predicts clinical outcome in patients with basilar artery occlusion (BAO). We assessed the prognostic value of pcASPECTS on CTP in BAO patients. Methods: A retrospective analysis of consecutive patients with BAO diagnosed on CT angiography was performed. pcASPECTS was assessed as evident hypoattenuation on CTA-SI, focally reduced cerebral blood flow (CBF) or cerebral blood volume (CBV), focally increased time to peak of the residue function (Tmax) or mean transit time (MTT). Two investigators independently reviewed the images blinded to clinical outcome. Reliability was assessed with intraclass correlation coefficient (ICC). Good outcome was defined as modified Rankin Scale≤3 at 3 months. Results: We included 43 BAO patients with whole-brain CTP images. In receiver-operating-characteristic (ROC) analysis, the area-under-curve (AUC) was 0.79 (95% CI 0.6-0.9) for pcASPECTS on CBF, 0.77 (95% CI 0.6-0.9) on Tmax, 0.73 (95% CI 0.6-0.9) on MTT, 0.72 (95% CI 0.6-0.9) on CBV, 0.67 (95% CI 0.5-0.8) on CTA-SI. In logistic regression adjusted for age and clinical severity, pcASPECTS&lt;8 was associated with poor outcome on Tmax (OR 14.6, 95% CI 2.3-115; p=0.007) and CBF (OR 15.1, 95% CI 1.3-121; p=0.02). Although CTP AUC did not show higher accuracy in comparison with CTA-SI AUC (p=0.2), in logistic regression, CTA-SI pcASPECTS was not significantly associated with clinical outcome (OR 6.9, 95% CI 0.7-70; p=0.1, adjusted for age, NHSS). Higher pcASPECTS on CBF (OR 0.5 95%CI 0.2-0.9, p=0.04) and Tmax (OR 0.5 95% 0.3-0.9; p=0.02) were associated with lower mortality. Interrater reliability was good for CTP maps (ICC between 0.74 and 0.86 95% CI 0.6-0.9 versus 0.66 for CTA-SI 95% CI 0.4-0.8). Conclusions: The CTP pcASPECTS may identify BAO patients at higher risk of disability and mortality.

CT-angiography source images indicate less fatal outcome despite coma of patients in the Basilar Artery International Cooperation Study.

Background Coma is associated with poor outcome in patients with basilar artery occlusion. Aims We sought to assess whether the posterior circulation Acute Stroke Prognosis Early CT Score and the Pons-Midbrain Index applied to CT angiography source images predict the outcome of comatose patients in the Basilar Artery International Cooperation Study. Methods Basilar Artery International Cooperation Study was a prospective, observational registry of patients with acute basilar artery occlusion with 48 recruiting centers worldwide. We applied posterior circulation Acute Stroke Prognosis Early CT Score and Pons-Midbrain Index to CT angiography source images of Basilar Artery International Cooperation Study patients who presented with coma. We calculated adjusted risk ratios to assess the association of dichotomized posterior circulation Acute Stroke Prognosis Early CT Score (≥8 vs. <8) and Pons-Midbrain Index (<3 vs. ≥3) with mortality and favourable outcome (modified Rankin Scale score 0-3) at one month. Results Of 619 patients in the Basilar Artery International Cooperation Study registry, CT angiography source images were available for review in 158 patients. Among these, 78 patients (49%) presented with coma. Compared to non-comatose patients, comatose patients were more likely to die (risk ratios 2.34; CI 95% 1.56-3.52) and less likely to have a favourable outcome (risk ratios 0.44; CI 95% 0.24-0.80). Among comatose patients, a Pons-Midbrain Index < 3 was related to reduced mortality (adjusted RR 0.66; 95% CI 0.46-0.96), but not to favourable outcome (adjusted RR 1.19; 95% CI 0.39-3.62). Posterior circulation Acute Stroke Prognosis Early CT Score dichotomized at ≥ 8 vs. <8 was not significantly associated with death (adjusted RR 0.70; 95% CI 0.46-1.05). Conclusion In comatose patients with basilar artery occlusion, the extent of brainstem ischemia appears to be related to mortality but not to favourable outcome.