Early diagnosis of intracranial atherosclerotic large vascular occlusion: A prediction model based on DIRECT-MT data

Abstract

AimsThis study aimed to build a prediction model to early diagnose intracranial atherosclerosis (ICAS)-related large vascular occlusion (LVO) in acute ischemic stroke patients before digital subtractive angiography.MethodsPatients enrolled in the DIRECT-MT trial (NCT03469206) were included in our secondary analysis and distributed into ICAS-LVO and non-ICAS-LVO groups. We also retrieved demographic data, medical histories, clinical characteristics, and pre-operative imaging data. Hypothesis testing was used to compare data of the two groups, and univariate logistic regression was used to identify the predictors of ICAS-LVO primarily. Then, we used multivariate logistic regression to determine the independent predictors and formulate the prediction model. Model efficacy was estimated by the area under the receiver operating characteristic (ROC) curve (AUC) and diagnostic parameters generated from internal and external validations.ResultsThe subgroup analysis included 45 cases in the ICAS-LVO group and 611 cases in the non-ICAS-LVO group. Variates with p < 0.1 in the comparative analysis were used as inputs in the univariate logistic regression. Next, variates with p < 0.1 in the univariate logistic regression were used as inputs in the multivariate logistic regression. The multivariate logistic regression indicated that the atrial fibrillation history, hypertension and smoking, occlusion located at the proximal M1 and M2, hyperdense artery sign, and clot burden score were related to the diagnosis of ICAS-LVO. Then, we constructed a prediction model based on multivariate logistics regression. The sensitivity and specificity of the model were 84.09 and 74.54% in internal validation and 73.11 and 71.53% in external validation.ConclusionOur current prediction model based on clinical data of patients from the DIRECT-MT trial might be a promising tool for predicting ICAS-LVO.

Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease

“…36 In addition, ICAD is more likely to be found in proximal M1 and basilar artery occlusions. 31 37 High clot burden scores (CBS) assessed by CTA also can independently predict ICAD-LVO. 31 Other essential information provided by CTA is collateral circulation, and patients with ICAD-LVO often have better collateral circulation than those without ICAD-LVO.…”

“…As there is a lower clot burden in ICAD-LVO than in embolic-LVO, 31 43 balloon angioplasty/stenting as the first MT strategy may be a feasible EVT strategy for ICAD-LVO. Kang et al compared the outcomes of primary angioplasty/stenting with primary arterial tirofiban infusion for ICAD-LVO and found the above two strategies were effective and safe.…”

“…28 29 As a result, Kuo et al found that HCAS was less prevalent in large artery atherosclerotic stroke, and the DIRECT-MT trial further found that absence of HCAS was associated with ICAD-LVO. 30 31 Patients with ICAD may also have patchy areas of established, usually subcortical infarcts in the same territory of the involved artery. 32…”

“…31 37 High clot burden scores (CBS) assessed by CTA also can independently predict ICAD-LVO. 31 Other essential information provided by CTA is collateral circulation, and patients with ICAD-LVO often have better collateral circulation than those without ICAD-LVO. Rebello et al and Guglielmi et al both demonstrated that ICAD-LVO was associated with better collateral flow assessed by CTA than cardioembolic stroke.…”

“…57 An ICAD-LVO predictive model derived from the DIRECT-MT trial, including clinical and imaging characteristics, also had a good predictive performance. 31…”