Optimizing Prediction Scores for Poor Outcome After Intra-Arterial Therapy in Anterior Circulation Acute Ischemic Stroke

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A variety of imaging-based predictors of clinical outcomes have been reported. Patients with target mismatch profile (TMM) have a relatively small ischemic core and a substantially larger region of critical hypoperfusion; these patients have a strong association between early reperfusion and favorable clinical outcomes. [1][2][3][4] In contrast, patients with the malignant profile have either a large ischemic core or a large and severe perfusion deficit. These patients have more rapid early infarct growth and a poor prognosis irrespective of intravenous reperfusion. 4,5 Background and Purpose-Imaging findings can predict outcomes in patients with acute stroke. Relationships between imaging findings and clinical and imaging outcomes in patients randomized to intravenous tissue-type plasminogen activator-alone versus tissue-type plasminogen activator plus endovascular therapy (Solitaire device) in the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) study were assessed. Methods-We evaluated associations between imaging assessments (baseline mismatch profiles/ischemic core volumes and successful reperfusion) with imaging outcomes (27-hour infarct volume/growth) and clinical outcomes (modified Rankin Scale scores at 90 days). Imaging variables that predict favorable clinical outcomes were assessed in both univariate and multivariate models. Results-One hundred and ninety-five patients were included. Successful reperfusion and infarct volume (assessed at 27 hours) were powerful independent predictors of favorable clinical outcomes (modified Rankin Scale score of 0-2 at 90 days). Patients with the target mismatch profile at baseline had a higher rate of reperfusion, lesser infarct growth, smaller infarct volumes, and better clinical outcomes in the Solitaire plus tissue-type plasminogen activator (intervention) group than those in the tissue-type plasminogen activator-alone (control) group. Patients with larger mismatch volumes at baseline had a trend toward better treatment response in the intervention group than patients who had smaller (<50 mL) mismatch volumes. Conclusions-Patients who achieved reperfusion had substantially more favorable clinical and imaging outcomes in both the intervention and the control groups. Infarct volume at 27 hours strongly correlated with clinical outcome at 90 days in both treatment groups. SWIFT PRIME patients with the target mismatch profile had a highly favorable response to endovascular therapy on both clinical and imaging outcomes. Both reperfusion and infarct volumes at 27 hours were powerful and independent predictors of 90-day clinical outcomes. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Albers et al Imaging Assessments and Outcomes in SWIFT PRIME 2787Other commonly reported outcome predictors on baseline imaging studies are ischemic core volume, perfusion lesion severity and volume, and mismatch volume (differences between the volume of critical hypoperfusion and the ischemic core vol...

“…[11][12][13] Patients who have complete, or near complete, reperfusion have considerably better outcomes than those with lesser degrees of reperfusion.…”

Section: Albers Et Al Imaging Assessments and Outcomes In Swift Primementioning

confidence: 99%

Section: Albers Et Al Imaging Assessments and Outcomes In Swift Primementioning

confidence: 99%

Relationships Between Imaging Assessments and Outcomes in Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke

Albers

Goyal

Jahan

et al. 2015

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“…Many prediction tools that incorporate established clinical and imaging parameters have been developed and validated to predict outcomes in patients with LVOS before endovascular therapy, but the main use of these preintervention scales is to identify patients most likely to benefit from endovascular therapy. [7][8][9][10][11] These do not incorporate postintervention variables such as FIV or hemorrhagic complications, both major factors that influence outcome after LVOS, 4,12 thereby limiting their predictive value for clinical outcomes. An outcome prediction tool in LVOS that incorporates postintervention variables has not been developed.…”

mentioning

confidence: 99%

Pittsburgh Outcomes After Stroke Thrombectomy Score Predicts Outcomes After Endovascular Therapy for Anterior Circulation Large Vessel Occlusions

Rangaraju

Liggins

Aghaebrahim

et al. 2014

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A cute large vessel occlusion strokes (LVOS) account for 25% to 40% of all acute ischemic strokes, resulting in significant morbidity and mortality. Data from a natural history study of patients with LVOS with moderate-severe deficits (National Institutes of Health Stroke Scale [NIHSS] ≥10) also suggested low rates of good outcome (modified Rankin Score [mRS], 0-2) in internal carotid artery (14%) and M1 middle cerebral artery (23%) occlusions.1 Proximal occlusions are also less likely to recanalize with intravenous thrombolysis, and clinical trials are underway to determine whether endovascular therapy improves clinical outcome. 2,3 In anterior circulation LVOS patients, the final infarct volume (FIV) is a strong and independent predictor of clinical outcome. 4,5After endovascular therapy for LVOS, aggressive medical measures including continuation of life support and surgical therapies (hemicraniectomy, gastrostomy, and tracheostomy) are frequently considered. The decision to pursue aggressive treatment versus de-escalation of care often depends on an estimation of the chance of long-term functional independence. Stroke and critical care physicians are the ones guiding families in this complex decision-making process. Results from the Clinician Judgment vs Risk Score to Predict Stroke Outcomes Background and Purpose-Prognostication tools that predict good outcome in patients with anterior circulation large vessel occlusions after endovascular therapy are lacking. We aim to develop a tool that incorporates clinical and imaging data to predict outcomes after endovascular therapy. Methods-In a derivation cohort of anterior circulation large vessel occlusion stroke patients treated with endovascular therapy within 8 hours from time last seen well (n=247), we performed logistic regression to identify independent predictors of good outcome (90-day modified Rankin Scale, 0-2). Factors were weighted based on β-coefficients to derive the Pittsburgh Outcomes After Stroke Thrombectomy (POST) score. POST was validated in an institutional endovascular database (University of Pittsburgh Medical Center, n=393) and the Diffusion-Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 (DEFUSE-2) data set (n=105), as well as in patients treated beyond 8 hours (n=194) and in octogenarians (n=111). Results-In the derivation cohort, independent predictors (P<0.1) of good outcome included 24-to 72-hour final infarct volume (in cm 3 , P<0.001), age (years, P<0.001), and parenchymal hematoma types 1 and 2 (H, P=0.01). POST was calculated as age+0.5×final infarct volume+15×H. Patients with POST score <60 had a 91% chance of good outcome compared with 4% with POST score ≥120. POST accurately predicted good outcomes in the derivation (area under the curve [AUC]=0.85) and validation cohorts (University of Pittsburgh Medical Center, AUC=0.81; DEFUSE-2, AUC=0.86), as well as in patients treated beyond 8 hours (AUC, 0.85) and octogenarians (AUC=0.76). POST had better predictive accuracy for good and poor outcome than the isch...

“…6 The THRIVE point was assigned according to the following criteria: 1 point, aged between 60 and 79 years; 2 points, age ≥80 years; 2 points, National Institutes of Health Stroke Scale (NIHSS) score between 11 and 20; 4 points, NIHSS score ≥21; and 1 point each for hypertension, diabetes mellitus, and atrial fibrillation. 7 The THRIVE score was compared with 5 other scales: (1) Sugar, Early Infarct Signs, Dense Artery Sign, Age, and NIHSS (SEDAN), 2 (2) Stroke Prognostication using Age and NIHSS (SPAN-100), 8 (3) Houston Intra-Arterial Therapy 2 score (HIAT2), 9 (4) Dense Artery Sign, Rankin Score, Age, Glucose, Onset to Treatment Time, and NIHSS (DRAGON), 3 and (5) NIHSS/age (a model with NIHSS and age).…”

Section: Methodsmentioning

confidence: 99%

Totaled Health Risks in Vascular Events Score Predicts Clinical Outcome and Symptomatic Intracranial Hemorrhage in Chinese Patients After Thrombolysis

Chen

Pan

Zhao

et al. 2015

Background and Purpose— The performance of the Totaled Health Risks in Vascular Events (THRIVE) score in predicting clinical outcomes in Chinese patients with acute ischemic stroke post intravenous thrombolysis is unknown. Methods— Data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) study was used to compare the THRIVE score with other scores used to predict clinical outcomes and symptomatic intracranial hemorrhage after intravenous thrombolysis. Results— Among the 1128 patients with acute ischemic stroke who were included in this study, areas under the curve of the THRIVE score for symptomatic intracranial hemorrhage, 3-month poor functional outcomes, and death rate were 0.69, 0.71, and 0.78, respectively. The increased THRIVE score was related to the higher risk of developing symptomatic intracranial hemorrhage, poor functional outcomes, or death in patients with acute ischemic stroke at 3 months after thrombolysis. Conclusions— The THRIVE score predicted reliably the risks of developing symptomatic intracranial hemorrhage, poor functional outcome, or death after intravenous thrombolysis therapy in Chinese patients with acute ischemic stroke.