Differential Contribution of ASPECTS Regions to Clinical Outcome after Thrombectomy for Acute Ischemic Stroke

Abstract

BACKGROUND AND PURPOSE: Ischemic stroke is the leading cause of long-term disability in adults, but our ability to prognosticate from baseline imaging data is limited. The ASPECTS measures ischemic change in the middle cerebral artery territory on noncontrast CT based on 10 anatomic regions. Here, we investigated whether infarction in particular regions was associated with worse long-term outcome. MATERIALS AND METHODS:We identified consecutive patients receiving mechanical thrombectomy for ICA/MCA occlusion at 2 comprehensive stroke centers. Pretreatment ASPECTS was assessed by 2 blinded reviewers. Clinical data including demographics, baseline NIHSS score, and 90-day mRS were collected. The relationship between individual ASPECTS regions and the mRS score (0-2 versus 3-6) was assessed using multivariable logistic regression.RESULTS: Three hundred fifty-three patients were included (mean age, 70 years; 46% men), of whom 214 had poor outcome (mRS ¼ 3-6). Caudate (OR ¼ 3.26; 95% CI, 1.33-8.82), M4 region (OR ¼ 2.94; 95% CI, 1.09-9.46), and insula (OR ¼ 1.75; 95% CI, 1.08-2.85) infarcts were associated with significantly greater odds of poor outcome, whereas M1 region infarction reduced the odds of poor outcome (OR ¼ 0.38; 95% CI, 0.14-0.99). This finding remained unchanged when restricted to only patients with good recanalization. No significant associations were found by laterality. Similarly, no region was predictive of neurologic improvement during the first 24 hours or of symptomatic intracerebral hemorrhage. CONCLUSIONS:Our results indicate that ASPECTS regions are not equal in their contribution to functional outcome. This finding suggests that patient selection based on total ASPECTS alone might be insufficient, and infarct topography should be considered when deciding eligibility for thrombectomy.

Association of Lesion Topography with Functional Outcomes in Acute Ischemic Stroke Patients Considered for, or Receiving, Reperfusion Therapy: A Meta-Analysis

“…Mean and median of reported ORs for poor functional outcome, with infarcts in each ASPECTS region, were estimated from six studies ( Table 4 ) [ 17 , 18 , 27 , 28 , 32 ]. Infarcts in the internal capsule (OR 4.07 ± 6.17) and M3 (OR 4.10 ± 5.70) regions were associated with the highest mean ORs for poor functional outcomes.…”

Unequal Efficacy of Different Infarct Location in Predicting Futile Recanalization of Patients With Acute Ischemic Stroke

“…BYQ Tan reported that the M5 region served as a reliable biomarker for predicting prognosis in thrombolyzed patients with AIS (22). However, there were few relevant studies focusing on EVT, and although they mainly used the ASPECTS to mark the infarct sites, their results were inconsistent (7,21). The reasons may be that these studies were mostly retrospective case-control studies with small sample sizes, enrollment of cases was time-consuming, and outdated or inconsistent devices and techniques were used (5,7,19,21).…”

“…However, there were few relevant studies focusing on EVT, and although they mainly used the ASPECTS to mark the infarct sites, their results were inconsistent (7,21). The reasons may be that these studies were mostly retrospective case-control studies with small sample sizes, enrollment of cases was time-consuming, and outdated or inconsistent devices and techniques were used (5,7,19,21). The data in the present study were obtained from two large sample sizes, multicenter, prospective, and RCTs with a strict trial design and rigorous protocol performed using the mainstream EVT devices and techniques, with a unified and standardized evaluation and supervision system, ensuring the accuracy and homogeneity of the data.…”

“…However, the relevant studies mainly concentrated on the prediction of its volume (1,5), the prognosis of patients with the same infarct volume may remarkably differ, suggesting that other parameters may also significantly influence the outcomes (6). For instance, in terms of the infarct topography, different regions and different brain hemisphere are likely to have different efficacy affecting prognosis (7,8). If this hypothesis is confirmed, regions with high weight are located preoperatively in the infarct core or penumbra may be an important factor in making treatment decisions.…”

“…If this hypothesis is confirmed, regions with high weight are located preoperatively in the infarct core or penumbra may be an important factor in making treatment decisions. Previous relevant studies have not presented a consistent conclusion yet (6)(7)(8), although the majority of them used the Alberta Stroke Program Early CT score (ASPECTS) subregions to mark infarct location. Therefore, in the present study, we retrospectively combined data from two multicenter, prospective RCTs with large sample sizes (Skyflow study, ChiCTR1800015166; Jrecan study, ChiCTR-TOC-17013822), which were concurrently conducted in China (9), to explore the efficacy of different infarct sites in predicting futile recanalization of patients with AIS.…”