Stroke Prognosis Early CT Score Research Articles

Endovascular treatment effect in vertebrobasilar artery occlusion patients with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS)

BackgroundEndovascular treatment (EVT) has revolutionized the standard treatment of vertebrobasilar artery occlusion (VBAO) with moderate infarct core, but its effectiveness in patients with a low posterior circulation Acute Stroke Prognosis...

AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS: new imaging scales to assess territorial and total cerebral hemispheric ischemic injury.

The extent of ischemic injury in acute stroke is assessed in clinical practice using the Acute Stroke Prognosis Early CT Score (ASPECTS) rating system. However, current ASPECTS semi-quantitative topographic scales assess only the middle cerebral artery (MCA) (original ASPECTS) and posterior cerebral (PC-ASPECTS) territories. For treatment decision-making in patients with anterior cerebral artery (ACA) occlusions and internal carotid artery (ICA) occlusions with large ischemic cores, measures of all hemispheric regions are desirable. In this cohort study, anatomic rating systems were developed for the anterior cerebral (AC-ASPECTS, 3 points) and anterior choroidal artery (ACh-ASPECTS, 1 point) territories. In addition, a total supratentorial hemisphere (H-ASPECTS, 16 points) score was calculated as the sum of the MCA ASPECTS (10 regions), supratentorial PC-ASPECTS (2 regions), AC-ASPECTS (3 regions), and ACh-ASPECTS (1 region). Three raters applied these scales to initial and 24 h CT and MR images in consecutive patients with ischemic stroke (IS) due to ICA, M1-MCA, and ACA occlusions. Imaging ratings were obtained for 96 scans in 50 consecutive patients with age 74.8 (±14.0), 60% female, NIHSS 15.5 (9.25-20), and occlusion locations ICA 34%; M1-MCA 58%; and ACA 8%. Treatments included endovascular thrombectomy +/- thrombolysis in 72%, thrombolysis alone in 8%, and hemicraniectomy in 4%. Among experienced clinicians, inter-rater reliability for AC-, ACh-, and H-ASPECTS scores was substantial (kappa values 0.61-0.80). AC-ASPECTS abnormality was present in 14% of patients, and ACh-ASPECTS abnormality in 2%. Among patients with ACA and ICA occlusions, H-ASPECTS scores compared with original ASPECTS scores were more strongly associated with disability level at discharge, ambulatory status at discharge, discharge destination, and combined inpatient mortality and hospice discharge. AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS expand the scope of acute IS imaging scores and increase correlation with functional outcomes. This additional information may enhance prognostication and decision-making, including endovascular thrombectomy and hemicraniectomy.

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 (< 7: greater severity, >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; >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.

Prognostic value of pretreatment diffusion-weighted imaging score for acute basilar artery occlusion with successful endovascular recanalization.

The aim of this study is to test the prognostic value of a diffusion-weighted imaging (DWI) score in acute basilar artery occlusion (ABAO) with successful recanalization. The DWI-based pons-midbrain and thalamus (PMT) score was developed to assess posterior circulation infarcts. We test its prognostic value and compare it with other two established scales, the DWI-based posterior circulation acute stroke prognosis Early CT score (PC-ASPECTS) and brain stem score (BSS). A retrospective cohort of consecutive ABAO patients with pretreatment magnetic resonance imaging and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction 2b-3) were analyzed. A favorable outcome was defined as a 90-day modified Rankin Scale (mRS) score of 2 or less. The prognostic performance of three scales was estimated by receiver operating characteristic (ROC) curve analyses. One hundred and sixteen eligible patients (mean age, 59.1 ± 11.7 [standard deviation]; 96 [82.8%] man) were included and evaluated. Between favorable (mRS ≤ 2) and unfavorable groups, the baseline PMT score (median [interquartile range], 3 [1-4] versus 6 [5-8]; P < 0.001) differs significantly. ROC curve analyses showed the PMT score had the best prognostic value for favorable outcome (area under the curve, PMT versus BSS versus PC-ASPECTS = 0.80 versus 0.72 versus 0.68, P = 0.010). Multivariate logistic regression analyses showed baseline National Institute of Health stroke scale (OR, 0.90 [95%CI, 0.86-0.95], P = 0.004) and PMT score < 5 (OR, 17.83 [95%CI, 3.91-81.19], P < 0.001) were independent prognostic factors of favorable outcome. The PMT score seems to predict clinical outcome of ABAO patients with successful recanalization.

Locked-in syndrome responding to endovascular treatment

BackgroundLocked-in syndrome (LiS) is a rare and devastating condition in patients with acute basilar artery occlusion. However, the benefits of endovascular treatment (EVT) for LiS remain unclear.ObjectiveTo assess the outcomes...

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.

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.

The efficacy and risk factors of mechanical thrombectomy for the treatment of vertebrobasilar artery occlusion: a single center study.

The mortality of acute ischemic stroke patients caused by vertebrobasilar artery occlusion (VBAO) is high and mechanical thrombectomy has gradually become a promising treatment for acute ischemic stroke. This study analyzed the efficacy of mechanical thrombectomy and the risk factors associated with poor outcomes in VBAO patients caused by severe local atherosclerotic stenosis. This retrospective study enrolled patients with acute ischemic stroke caused by VBAO between March 1, 2016 and August 31, 2019. Patient demographic and clinical data were collected retrospectively. All enrolled patients were retrospectively interviewed for at least 3 months. Patients with a modified Rankin scale (mRS) score between 0 and 3 points were defined as having satisfactory outcomes while those with more than 3 points were defined as having unsatisfactory outcomes. In-hospital mortality, the rates of recanalization, and the rates of intracerebral hemorrhage were also recorded. Multivariable logistic regression was used to determine the risk factors of unsatisfactory outcomes in enrolled patients. A total of 65 patients were enrolled in this study with a median age 69.0 (63.0-78.0) years and 48 patients (73.8%) were male. Approximately 50% of patients had a mRS score of 0 or 1 point within 90 days after treatment with mechanical thrombectomy and 14 patients had a mRS score of 6 points. A total of 11 patients died in hospital. Out of the 65 patients, 7 required recanalization and 9 patients suffered from intracerebral hemorrhage. Multivariate logistic regression analysis showed that older age, lower baseline posterior circulation acute stroke prognosis early CT score (pcASPECTS), higher baseline National Institutes of Health stroke scale (NIHSS) score, and residual stenosis were independent risk factors of both unsatisfactory outcomes and mortality of VBAO patients. This study confirmed the important role of mechanical thrombectomy in the treatment of acute ischemic stroke caused by VBAO and may provide some guidance for improving the prognosis of patients.

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.

Predictors of favorable outcomes for vertebrobasilar artery occlusion after endovascular therapy within 24 hours of symptom onset

ObjectiveThe aim of the present study was to describe our results of endovascular therapy (EVT) for vertebrobasilar artery occlusion (VBAO) within 24 h of symptom onset, and to evaluate prognostic factors associated with favorable outcomes. MethodsThe present study enrolled patients who underwent EVT for acute ischemic stroke (AIS) caused by VBAO. Inclusion criteria for EVT to treat VBAO were as follows: (1) computed tomography angiography (CTA) or magnetic resonance angiography (MRA) confirmed acute VBAO; (2) baseline National Institutes of Health Stroke Scale (NIHSS) score ≥2; (3) premorbid modified Rankin scale (mRS) score ≤2; (4) onset or last known time to puncture within 24 h; and (5) posterior-circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS) ≥6. Favorable outcomes were defined as mRS scores of 0–3 at three months following EVT. The associations among baseline parameters, procedural parameters, and favorable outcomes were assessed. ResultsA total of 67 patients were recruited in this study, of which 40 patients (59.7 %) had favorable outcomes. Of the 50 patients with a late-window (6–24 h), 29 patients (58 %) had favorable outcomes. Univariate analysis revealed significant associations of the following parameters with favorable outcomes in the enrolled patients: age, sex, smoking status, baseline NIHSS score, baseline Glasgow coma scale (GCS) score, Pons-midbrain index (PMI), and intracranial atherosclerosis (ICAS). Multivariate logistic regression indicated that only age (OR 0.914, 95 % CI: 0.849 to 0.984; p = 0.017), baseline GCS score (OR 1.234, 95 % CI: 1.061–1.435; p = 0.006), and PMI (OR 0.448, 95 % CI: 0.252 to 0.798; p = 0.006) were independently associated with favorable outcomes at three months following EVT. After adjustments for confounding factors in patients with a late-window, only age (OR 0.879, 95 % CI: 0.799 to 0.967; p = 0.008) was associated with favorable outcomes. ConclusionsYounger age, lower PMI, and higher GCS scores in patients with VBAO-induced AIS were associated with more favorable outcomes. In late-window (6–24 h) patients, younger age associated to favorable outcomes, and lower NIHSS scores and lower PMI each also had a tendency to associated with favorable outcomes.

Qualitative versus automatic evaluation of CT perfusion parameters in acute posterior circulation ischaemic stroke

PurposeTo compare the diagnostic accuracy (ACC) in the detection of acute posterior circulation strokes between qualitative evaluation of software-generated colour maps and automatic assessment of CT perfusion (CTP) parameters.MethodsWere retrospectively collected 50 patients suspected of acute posterior circulation stroke who underwent to CTP (GE “Lightspeed”, 64 slices) within 24 h after symptom onset between January 2016 and December 2018. The Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was used for quantifying the extent of ischaemic areas on non-contrast (NC)CT and colour-coded maps generated by CTP4 (GE) and RAPID (iSchemia View) software. Final pc-ASPECTS was calculated on follow-up NCCT and/or MRI (Philips Intera 3.0 T or Philips Achieva Ingenia 1.5 T). RAPID software also elaborated automatic quantitative mismatch maps.ResultsBy qualitative evaluation of colour-coded maps, MTT-CTP4D and Tmax-RAPID showed the highest sensitivity (SE) (88.6% and 90.9%, respectively) and ACC (84% and 88%, respectively) compared with the other perfusion parameters (CBV, CBF). Baseline NCCT and CBF provided by RAPID quantitative perfusion mismatch maps had the lowest SE (29.6% and 6.8%, respectively) and ACC (38% and 18%, respectively). CBF and Tmax assessment provided by quantitative RAPID perfusion mismatch maps showed significant lower SE and ACC than qualitative evaluation. No significant differences were found between the pc-ASPECTSs assessed on colour-coded MTT and Tmax maps neither between the scores assessed on colour-coded CBV-CTP4D and CBF-RAPID maps.ConclusionQualitative analysis of colour-coded maps resulted more sensitive and accurate in the detection of ischaemic changes than automatic quantitative analysis.

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.

Abstract TP52: Comparison Early Neuroimaging Findings in Patients With Basilar Artery Occlusion Who Received Endovascular Treatment

Introduction: The natural history of acute ischemic stroke due to basilar artery occlusion is poor. Several early neuroimaging derived predictors of outcome have been proposed in posterior circulation infarction. Early neuroimaging predictors in posterior circulation infarction may be primarily subdivided into those that evaluate for early ischemic changes (posterior circulation acute stroke prognosis early CT score(pc-ASPECTS) or pc-ASPECTS score on DWI), collateral flow(Collateral score(CS)), thrombus location and burden(Basilar artery on computed tomography angiography (BATMAN) score). Method: We retrospective acquired data for 52 patients with acute cerebral infarction due to basilar artery occlusion who received endovascular treatment at multicenter registry. All patient underwent brain CTA and diffusion MRI before endovascular treatment. We measured pc-ASPECTS, pc-ASPECTS score on DWI, CS and BATMAN score in all patients. We compared which early neuroimaging protector is most correlated with the modified Rankin scale at 3 months. Result: In receiver operating characteristic (ROC) analysis, pc-ASPECTS had an area under ROC curve of 0.568 (95% confidence interval (CI), 0.41-0.72: P=0.402). Pc-ASPECTS score on DWI had an area under ROC curve of 0.737 (95% confidence interval (CI), 0.61-0.87: P=0.004). CS had an area under ROC curve of 0.589(95% confidence interval (CI), 0.43-0.74: P=0.273). BATMAN score had an area under ROC curve of 0.676(95% confidence interval (CI), 0.53-0.82: P=0.30). Conclusion: Pc-ASPECTS score on DWI and BATMAN score were significantly associated with clinical outcome among early neuroimaging findings. Pc-ASPECTS score on DWI is the best predictor of prognosis in basilar artery occlusion patients.

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.

Symptomatic intracranial haemorrhage after thrombolysis with adjuvant anticoagulation in basilar artery occlusion.

Our aim was to determine factors associated with symptomatic intracranial haemorrhage (sICH) in basilar artery occlusion patients treated with intravenous thrombolysis (IVT) and adjuvant anticoagulant therapy. A registry of 176 consecutive patients with angiography-proven basilar artery occlusion who received IVT with alteplase and heparin between 1995 to 2013 was assessed. Post-treatment sICH was evaluated with the European Cooperative Acute Stroke Study II criteria. Unfavourable outcome was defined as a modified Rankin Scale score of 3-6 at 3months. Twenty-four patients developed sICH (13.6%, sICH+), all of whom had unfavourable outcome and only two (8.3%) sICH+ patients survived. On admission, sICH+ patients more frequently had extensive ischaemic changes defined as posterior circulation Acute Stroke Prognosis Early CT Score (PC-ASPECTS) < 8 (50% vs. 27% in sICH-, P=0.031) and lower platelet counts (183 vs. 218 E9/l; P=0.011). They also had higher systolic blood pressure (SBP) (median 160 vs. 147mmHg, P=0.034) immediately after IVT. In multivariable regression analysis, lower platelet values [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.97-0.996; P=0.006], PC-ASPECTS < 8 on admission (OR 3.6, 95% CI 1.3-10.3; P=0.017) and higher SBP after treatment (OR 1.03, 95% CI 1.01-1.05; P=0.017) were independently associated with sICH. Ninety per cent of the sICHs occurred within 48h from IVT/anticoagulation treatment. No differences in activated partial thrompoplastin times prior to or after the treatment were observed between sICH+ and sICH- patients. The risk of sICH was largely determined by extension of ischaemic changes on admission computed tomography. Clinically relevantly, also higher post-thrombolytic SBP as described earlier and lower perithrombolytic platelet counts do increase the risk, a finding requiring confirmation in other patient series.

Diagnostic and Prognostic Impact of pc-ASPECTS Applied to Perfusion CT in the Basilar Artery International Cooperation Study.

The posterior circulation Acute Stroke Prognosis Early CT Score (pc-APECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). We assessed the diagnostic and prognostic impact of pc-ASPECTS applied to perfusion CT (CTP) in the BASICS registry population. We applied pc-ASPECTS to CTA-SI and cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) parameter maps of BASICS patients with CTA and CTP studies performed. Hypoattenuation on CTA-SI, relative reduction in CBV or CBF, or relative increase in MTT were rated as abnormal. CTA and CTP were available in 27/592 BASICS patients (4.6%). The proportion of patients with any perfusion abnormality was highest for MTT (93%; 95% confidence interval [CI], 76%-99%), compared with 78% (58%-91%) for CTA-SI and CBF, and 46% (27%-67%) for CBV (P < .001). All 3 patients with a CBV pc-ASPECTS < 8 compared to 6/23 patients with a CBV pc-ASPECTS ≥ 8 had died at 1 month (RR 3.8; 95% CI, 1.9-7.6). CTP was performed in a minority of the BASICS registry population. Perfusion disturbances in the posterior circulation were most pronounced on MTT parameter maps. CBV pc-ASPECTS < 8 may indicate patients with high case fatality.