Effect of baseline Alberta Stroke Program Early CT Score on safety and efficacy of intra-arterial treatment: a subgroup analysis of a randomised phase 3 trial (MR CLEAN)

Yoo, Albert J.; Berkhemer, Olvert A.; Fransen, Puck S.S.; Berg, Lucie A. van den; Beumer, Debbie; Lingsma, Hester F.; Schonewille, Wouter J.; Sprengers, Marieke E.S.; Berg, René van den; Walderveen, Marianne A.A. van; Beenen, Ludo F. M.; Wermer, Marieke J.H.; Nijeholt, Geert J. Lycklama à; Boiten, Jelis; Jenniskens, Sjoerd F.M.; Bot, Joseph C.J.; Boers, Anna M. M.; Marquering, Henk A.; Roos, Yvo B.W.E.M.; Oostenbrugge, Robert J. van; Dippel, Diederik W.J.; Lugt, Aad van der; Zwam, Wim H. van; Majoie, Charles B. L. M.

doi:10.1016/s1474-4422(16)00124-1

Cited by 108 publications

(109 citation statements)

References 26 publications

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“…Only the MR CLEAN trial did not use additional imaging criteria. A subgroup analysis of MR CLEAN showed that NCCT ASPECTS 5–7 patients can be safely treated with EVT [26]. According to these results, the vast majority of the WUS patients with a proximal anterior circulation occlusion in our study (96% with ASPECTS > 5) would have been eligible for EVT.…”

Section: Discussionmentioning

confidence: 51%

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

et al. 2018

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Background: Current guidelines for the treatment of acute ischemic stroke are mainly based on the time between symptom onset and initiation of treatment. This time is unknown in patients with wake-up stroke (WUS). We investigated clinical and multimodality CT imaging characteristics on admission in patients with WUS and in patients with a stroke with a known onset time. Methods: All patients were selected from a large prospective cohort study (Dutch acute stroke study). WUS patients last seen well > 4.5 and ≤4.5 h were separately compared to patients with a known onset time ≤4.5 h. In addition, WUS patients with a proximal occlusion of the anterior circulation last seen well > 6 and ≤6 h were separately compared to patients with a known onset time ≤6 h and a proximal occlusion. National Institute of Health Stroke Score, age, gender, history of atrial fibrillation, non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS), CT-perfusion abnormalities, proximal occlusions, and collateral filling on CT angiography were compared between groups using the Mann-Whitney U test and Fisher’s exact test. Results: WUS occurred in 149/1,393 (10.7%) patients. Admission clinical and imaging characteristics of WUS patients last seen well > 4.5 h (n = 81) were not different from WUS patients last seen well ≤4.5 h (n = 68). Although WUS patients last seen well > 4.5 h had a significantly lower NCCT ASPECTS than patients with a known time of stroke symptom onset of ≤4.5 h (n = 1,026), 85.2% had an NCCT ASPECTS > 7 and 75% had a combination of favorable ASPECTS > 7 and good collateral filling. There were no statistically significant differences between the admission clinical and imaging characteristics of WUS patients with proximal occlusions last seen well > 6 h (n = 23), last seen well ≤6 h (n = 40), and patients with a known time to stroke symptom onset ≤6 h (n = 399). Of all WUS patients with proximal occlusions last seen well > 6 h, only 4.3% had severe ischemia (ASPECTS < 5), 13 (56.5%) had ASPECTS > 7 and good collateral filling. Conclusions: There are only minor differences between clinical and imaging characteristics of WUS patients and patients who arrive in the hospital within the time criteria for intravenous or endovascular treatment. Therefore, CT imaging may help to identify WUS patients who would benefit from treatment and rule out those patients with severe ischemia and poor collaterals.

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Section: Discussionmentioning

confidence: 51%

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

et al. 2018

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“…Desilles et al described a positive although non-significant trend towards better functional outcome (23.1% vs 9.5%), lower mortality rate (45.7% vs 57.1%), and lower rate of sICH (23.9% vs 45.5%) in successfully reperfused patients compared with non-reperfused patients from the DWI-ASPECTS 0–4 subgroup 21. Nevertheless, given these patients’ overall poor prognosis, any absolute benefit with current treatment would be likely to be minimal 23. Therefore, ASPECTS ≤4 may offer a viable exclusion criterion in the selection of patients for EVT to prevent futile or even harmful recanalization.…”

Section: Discussionmentioning

confidence: 99%

Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis

Phan¹,

Saleh²,

Dmytriw

et al. 2018

J NeuroIntervent Surg

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BackgroundPrompt revascularization of the ischemic penumbra following an acute ischemic event (AIS) has established benefit within the literature. However, use of the semi-quantitative Alberta Stroke Program Early CT Score (ASPECTS) to evaluate patient suitability for revascularization has been inconsistent in patient risk stratification and selection.ObjectiveTo conduct a meta-analysis to evaluate the available evidence for a clinically valid ASPECTS threshold in assessment of suitability for revascularization following AIS.MethodsTwo independent reviewers searched Medline (Ovid) and Cochrane Central Register of Systematic Reviews databases for studies appraising outcomes of endovascular thrombectomy (EVT) in relation to a variably-defined preoperative ASPECTS.ResultsA total of 13 articles were included. The pooled good outcome proportion after EVT was 41.4% (95% CI 36.4% to 46.6%; p<0.001), with subjective study-specific definitions of favorable and unfavorable subgroup outcomes of 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) and 33.2% (95% CI 28.5% to 38.3%; I2=33.16%), respectively. Objective trichotomization into low (0–4), intermediate (5–7), and high (8–10) subgroups yielded pooled good outcome proportions of 17.1% (95% CI 6.8% to 36.8%; I2=64.24%; p=0.039), 35.7% (95% CI 30.5% to 41.3%; I2=23.11%; p=0.245), and 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) for low, intermediate, and high ASPECTS, respectively.ConclusionsA subjectively favorable ASPECTS is associated with significantly better outcomes after EVT than an unfavorable ASPECTS, regardless of the cut-off used. EVT is unlikely to be useful in patients with an objectively low ASPECTS and is likely to be useful for those with high ASPECTS; findings in patients with intermediate ASPECTS were equivocal.

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“…A recent subgroup analysis of MR CLEAN suggested that patients with ASPECTS 5-7 should be treated with intra-arterial therapy [11]. Compared to patients with ASPECTS 8-10, slightly fewer ASPECTS 5-7 patients had good functional outcomes, while an equivalent number demonstrated moderate functional outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…In many of these landmark trials an ASPECTS ≥6 was required for inclusion, and as a result the American Heart Association guidelines that soon followed the release of these studies adopted this criterion [10]. While this criterion helped contribute to the large treatment effect sizes of the trials, it opens up questions about why not all patients with favorable ASPECTS do well in spite of rapid reperfusion, and whether patients with lower ASPECTS may still benefit from therapy [11].…”

Section: Introductionmentioning

confidence: 99%

Regional Contributions to Poststroke Disability in Endovascular Therapy

et al. 2018

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Background and Purpose: The relative contribution of each Alberta Stroke Program Early CT Score (ASPECTS) region to poststroke disability likely varies across regions. Determining the relative weights of each ASPECTS region may improve patient selection for endovascular stroke therapy (EST). Methods: In the combined Solitaire Flow Restoration with the Intention for Thrombectomy (SWIFT), Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), and Solitaire Flow Restoration with the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) databases, we identified patients treated with the Solitaire stent retriever. Using 24-h CT scan, a multivariate ordinal regression was used to determine the relative contribution of each ASPECTS region to clinical outcome separately in each hemisphere. The coefficients from the regression were used to create a weighted ASPECTS (wASPECTS), which was compared with the original ASPECTS to predict 90-day modified Rankin Scale disability outcomes in an independent validation cohort. Results: Among 342 patients treated with EST, the average age was 67 years, 57% were female, and the median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13–20). The median ASPECTS at presentation was 8 (IQR 7–10). The most commonly involved ASPECTS regions on 24-h CT were the lentiform nuclei (70%), insula (55%), and caudate (52%). In multivariate analysis, preservation of M6 (β = 9.7) and M4 (β = 4.4) regions in the right hemisphere was most strongly predictive of good outcome. For the left hemisphere, M6 (β = 5.5), M5 (β = 4.1), and M3 (β = 3.1) generated the greatest parameter estimates, though they did not reach statistical significance. A wASPECTS incorporating all 20 parameter estimates resulted in improved discrimination against the original ASPECTS in the independent cohort (C-statistic 0.78 vs. 0.67, right hemisphere). Conclusions: For both right and left hemisphere, preservation of the high cortical regions was more strongly associated with improved outcomes compared to the deep regions. Our findings support taking into consideration the location and relative weightings of the involved ASPECTS regions when evaluating a patient for EST.

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Effect of baseline Alberta Stroke Program Early CT Score on safety and efficacy of intra-arterial treatment: a subgroup analysis of a randomised phase 3 trial (MR CLEAN)

Cited by 108 publications

References 26 publications

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis

Regional Contributions to Poststroke Disability in Endovascular Therapy

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