Predictive Value of the Alberta Stroke Program Early CT Score (ASPECTS) in the Outcome of the Acute Ischemic Stroke and Its Correlation with Stroke Subtypes, NIHSS, and Cognitive Impairment

Ahmed Esmael, Mohammed Elsherief, Khaled Eltoukhy, Ahmed Esmael, Mohammed Elsherief, Khaled Eltoukhy

Abstract

Objectives: This study is aimed at correlating ASPECTS with mortality and morbidity in patients with acute middle cerebral artery territory infarction and at determining the cutoff value of ASPECTS that may predict the outcome.

Methods: 150 patients diagnosed with acute middle cerebral artery territory infarction were involved in this study. Risk factors, initial NIHSS, and GCS were determined. An initial or follow-up noncontrast CT brain was done and assessed by ASPECTS. Outcomes were determined by mRS during the follow-up of cases after 3 months. Correlations of ASPECTS and outcome variables were done by Spearman correlation. Logistic regression analysis and ROC curve were done to detect the cutoff value of ASPECTS that predicts unfavorable outcomes.

Results: The most common subtypes of ischemic strokes were lacunar stroke in 66 patients (44%), cardioembolic stroke in 39 patients (26%), and LAA stroke in 30 cases (20%). The cardioembolic stroke had a statistically significant lower ASPECT score than other types of ischemic strokes (P < 0.05). Spearman correlation showed that lower ASPECTS values (worse outcome) were more in older patients and associated with lower initial GCS. ASPECTS values were inversely correlated with initial NIHSS, inpatient stay, inpatient complications, mortality, and mRS. The ASPECTS cutoff value determined for the prediction of unfavorable outcomes was equal to ≤7. The binary logistic regression analysis detected that patients with ASPECTS ≤ 7 were significantly associated with about fourfold increased risk of poor outcomes (OR 3.95, 95% CI 2.09-11.38, and P < 0.01).

Conclusions: ASPECTS is a valuable and appropriate technique for the evaluation of the prognosis in acute ischemic stroke. Patients with high ASPECTS values are more likely to attain favorable outcomes, and the cutoff value of ASPECTS is a strong predictor for unfavorable outcomes. This trial is registered with ClinicalTrials.gov NCT04235920.

Conflict of interest statement

The authors declare that there is no conflict of interest regarding the publication of this article.

Copyright © 2021 Ahmed Esmael et al.

Figures

Figure 1
Figure 1
Alberta Stroke Program Early Computed Tomography Score template on noncontrast CT with 10 regions distributed over the MCA territory in (a) ganglionic and (b) supraganglionic levels. The template consists of 10 anatomically defined regions, 4 for subcortical structures (caudate (C), lentiform (L), internal capsule (IC), and insular ribbon (I)) and 6 for cortical structures in the MCA territory, labeled M1-M6.
Figure 2
Figure 2
ASPECTS according to stroke subtypes (P < 0.05).
Figure 3
Figure 3
Relationship of ASPECTS with NIHSS.
Figure 4
Figure 4
Relationship of ASPECTS with the modified Rankin Scale.
Figure 5
Figure 5
ROC curve for estimation of cutoff scores of ASPECTS for the outcome of acute ischemic stroke.

References

    1. Gattringer T., Posekany A., Niederkorn K., et al. Predicting early mortality of acute ischemic stroke. Stroke. 2019;50(2):349–356. doi: 10.1161/STROKEAHA.118.022863.
    1. Ganesh A., Lindsay P., Fang J., et al. Integrated systems of stroke care and reduction in 30-day mortality: a retrospective analysis. Neurology. 2016;86(10):898–904. doi: 10.1212/WNL.0000000000002443.
    1. Sundaram V. K., Goldstein J., Wheelwright D., et al. Automated ASPECTS in acute ischemic stroke: a comparative analysis with CT perfusion. AJNR. American Journal of Neuroradiology. 2019;40(12):2033–2038. doi: 10.3174/ajnr.A6303.
    1. Goyal M., Demchuk A. M., Menon B. K., et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. The New England Journal of Medicine. 2015;372(11):1019–1030. doi: 10.1056/NEJMoa1414905.
    1. Saver J. L., Goyal M., Bonafe A., et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. The New England Journal of Medicine. 2015;372(24):2285–2295. doi: 10.1056/NEJMoa1415061.
    1. Powers W. J., Rabinstein A. A., Ackerson T., et al. 2018 guidelines for the early management of patients with acute schemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110. doi: 10.1161/STR.0000000000000158.
    1. Schröder J., Thomalla G. A critical review of Alberta Stroke Program Early CT Score for evaluation of acute stroke imaging. Frontiers in Neurology. 2017;7:p. 245. doi: 10.3389/fneur.2016.00245.
    1. Zafar F., Tariq W., Shoaib R. F., et al. Frequency of ischemic stroke subtypes based on TOAST classification at a tertiary care center in Pakistan. Asian J Neurosurg. 2018;13(4):984–989. doi: 10.4103/ajns.AJNS_365_16.
    1. Hao Z., Liu M., Wang D., Wu B., Tao W., Chang X. Etiologic subtype predicts outcome in mild stroke: prospective data from a hospital stroke registry. BMC Neurology. 2013;13(1):p. 154. doi: 10.1186/1471-2377-13-154.
    1. Purroy F., Montaner J., Molina C. A., Delgado P., Ribo M. Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes. Stroke. 2007;38(12):3225–3229. doi: 10.1161/STROKEAHA.107.488833.
    1. Rosenbaum Halevi D., Bursaw A. W., Karamchandani R. R., et al. Cognitive deficits in acute mild ischemic stroke and TIA and effects of rt-PA. Annals of Clinical Translational Neurology. 2019;6(3):466–474. doi: 10.1002/acn3.719.
    1. Mohd Zulkifly M. F., Ghazali S. E., Che Din N., Singh D. K., Subramaniam P. A review of risk factors for cognitive impairment in stroke survivors. ScientificWorldJournal. 2017;2016, article 3456943 doi: 10.3389/fneur.2016.00245.
    1. Gupta D., Sharma A., Uchino K., et al. Accuracy of NIHSS in predicting the site of arterial occlusion in acute stroke: a transcranial Doppler study. Journal of Stroke and Cerebrovascular Diseases. 2016;25:2109–2115. doi: 10.1016/j.jstrokecerebrovasdis.2016.06.004.
    1. Hill M. D., Demchuk A. M., Goyal M., et al. Alberta Stroke Program Early Computed Tomography Score to select patients for endovascular treatment: Interventional Management of Stroke (IMS)-III trial. Stroke. 2014;45(2):444–449. doi: 10.1161/STROKEAHA.113.003580.
    1. Sarraj A., Sangha N., Hussain M. S., et al. Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment. JAMA Neurology. 2016;73(11):1291–1296. doi: 10.1001/jamaneurol.2016.2773.
    1. Zhao G., Wang Z., Lin F., Cui Y., Xu S. The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage. Brazilian Journal of Medical and Biological Research. 2019;52(2, article e7739) doi: 10.1590/1414-431x20187739.
    1. Mokin M., Primiani C. T., Siddiqui A. H., Turk A. S. ASPECTS (Alberta Stroke Program Early CT Score) measurement using Hounsfield unit values when selecting patients for stroke thrombectomy. Stroke. 2017;48(6):1574–1579. doi: 10.1161/STROKEAHA.117.016745.
    1. Kuster G. W., Dutra L. A., Brasil I. P., et al. Performance of four ischemic stroke prognostic scores in a Brazilian population. Arquivos de Neuro-Psiquiatria. 2016;74(2):133–137. doi: 10.1590/0004-282X20160002.
    1. Linn B. S., Linn M. W., Gurel L. Cumulative illness rating scale. Journal of the American Geriatrics Society. 1968;16(5):622–626. doi: 10.1111/j.1532-5415.1968.tb02103.x.
    1. Miller M. D., Paradis C. F., Houck P. R., et al. Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Research. 1992;41(3):237–248. doi: 10.1016/0165-1781(92)90005-N.
    1. Hudon C., Fortin M., Vanasse A. Cumulative Illness Rating Scale was a reliable and valid index in a family practice context. Journal of Clinical Epidemiology. 2005;58(6):603–608. doi: 10.1016/j.jclinepi.2004.10.017.
    1. Modi J., Menon B., Goyal M. Alberta Stroke Program Early CT Score (ASPECTS) July 2016, .
    1. Adams H. P., Jr., Bendixen B. H., Kappelle L. J., et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41. doi: 10.1161/01.str.24.1.35.
    1. Taylor-Rowan M., Wilson A., Dawson J., Quinn T. J. Functional assessment for acute stroke trials: properties, analysis, and application. Frontiers in Neurology. 2018;9:p. 191. doi: 10.3389/fneur.2018.00191.
    1. Nasreddine Z. S., Phillips N. A., Bédirian V., et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment [published correction appears in J Am Geriatr Soc. 2019 Sep;67(9):1991] Journal of the American Geriatrics Society. 2005;53(4):695–699. doi: 10.1111/j.1532-5415.2005.53221.x.
    1. Tan J. P., Li N., Gao J., et al. Optimal cutoff scores for dementia and mild cognitive impairment of the Montreal Cognitive Assessment among elderly and oldest-old Chinese population. Journal of Alzheimer’s Disease. 2014;43(4):1403–1412. doi: 10.3233/JAD-141278.
    1. Etherton M. R., Barreto A. D., Schwamm L. H., Wu O. Neuroimaging paradigms to identify patients for reperfusion therapy in stroke of unknown onset. Frontiers in Neurology. 2018;9:p. 327. doi: 10.3389/fneur.2018.00327.
    1. Ryu C. W., Shin H. S., Park S., Suh S. H., Koh J. S., Choi H. Y. Alberta Stroke Program Early CT Score in the prognostication after endovascular treatment for ischemic stroke: a meta-analysis. Neurointervention. 2017;12(1):20–30. doi: 10.5469/neuroint.2017.12.1.20.
    1. Boehme A. K., Esenwa C., Elkind M. S. Stroke risk factors, genetics, and prevention. Circulation Research. 2017;120(3):472–495. doi: 10.1161/CIRCRESAHA.116.308398.
    1. Habibi-Koolaee M., Shahmoradi L., Niakan Kalhori S. R., Ghannadan H., Younesi E. Prevalence of stroke risk factors and their distribution based on stroke subtypes in Gorgan: a retrospective hospital-based study-2015-2016. Neurology Research International. 2018;2018:2709657. doi: 10.1155/2018/2709654.
    1. Kim B. J., Kim J. S. Ischemic stroke subtype classification: an Asian viewpoint. Journal of stroke. 2014;16(1):8–17. doi: 10.5853/jos.2014.16.1.8.
    1. Hansen C. K., Christensen A., Ovesen C., Havsteen I., Christensen H. Stroke severity and incidence of acute large vessel occlusions in patients with hyper-acute cerebral ischemia: results from a prospective cohort study based on CT-angiography (CTA) International Journal of Stroke. 2015;10(3):336–342. doi: 10.1111/ijs.12383.
    1. Díaz G. J. Cardioembolic stroke: epidemiology. Neurología. 2012;27(Supplement 1):4–9. doi: 10.1016/S0213-4853(12)70002-6.
    1. Kaul S., Venketswamy P., Meena A. K., Sahay R., Murthy J. M. Frequency, clinical features and risk factors of lacunar infarction (data from a stroke registry in South India) Neurology India. 2000;48(2):116–119.
    1. Horie N., Tateishi Y., Morikawa M., et al. Acute stroke with major intracranial vessel occlusion: characteristics of cardioembolism and atherosclerosis-related in situ stenosis/occlusion. Journal of Clinical Neuroscience. 2016;32:24–29. doi: 10.1016/j.jocn.2015.12.043.
    1. Caplan L. R. Caplan’s Stroke: A Clinical Approach. 4th. Philadelphia, PA: Saunders Elsevier; 2009.
    1. Glymour M. M., Berkman L. F., Ertel K. A., Fay M. E., Glass T. A., Furie K. L. Lesion characteristics, NIH stroke scale, and functional recovery after stroke. American Journal of Physical Medicine & Rehabilitation. 2007;86(9):725–733. doi: 10.1097/PHM.0b013e31813e0a32.
    1. Saposnik G., Kapral M. K., Liu Y., et al. IScore: a risk score to predict death early after hospitalization for an acute ischemic stroke. Circulation. 2011;123(7):739–749. doi: 10.1161/CIRCULATIONAHA.110.983353.
    1. Bhalla A., Wang Y., Rudd A., Wolfe C. D. Does admission to hospital affect trends in survival and dependency after stroke using the South London Stroke Register? Stroke. 2016;47:2269–2277. doi: 10.1161/STROKEAHA.116.014136.
    1. Turner M., Barber M., Dodds H., et al. The impact of stroke unit care on outcome in a Scottish stroke population, taking into account case mix and selection bias. Journal of Neurology, Neurosurgery & Psychiatry. 2015;86:314–318. doi: 10.1136/jnnp-2013-307478.
    1. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 2013;9, article CD000197 doi: 10.1002/14651858.CD000197.
    1. Kent D. M., Hill M. D., Ruthazer R., et al. "Clinical-CT mismatch" and the response to systemic thrombolytic therapy in acute ischemic stroke. Stroke. 2005;36(8):1695–1699. doi: 10.1161/01.STR.0000173397.31469.4b.
    1. Amalia L., Furqani M., Parwati I., Rizal A., Panigoro R., Anwary F. Clinical significance Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and National Institute of Health Stroke Score (NIHSS) on first ever acute ischemic stroke patients. The Internet Journal of Neurology. 2019;21:p. 1.
    1. Hill M. D. Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study. CMAJ. 2005;172(10):1307–1312. doi: 10.1503/cmaj.1041561.
    1. Prabhakar A., Kishore L. Correlation of Alberta Stroke Program Early Computed Tomography Score on CT and volume on diffusion weighted MRI with National Institutes of Health Stroke Scale. WebmedCentral Neuroradiology. 2015;6(1, article WMC004795)
    1. Abdelrasoul A. A., Elsebaie N. A., Gamaleldin O. A., Khalifa M. H., Razek A. A. K. A. Imaging of brain infarctions: beyond the usual territories. Journal of Computer Assisted Tomography. 2019;43(3):443–451. doi: 10.1097/RCT.0000000000000865.
    1. González R. G., Lev M. H., Goldmacher G. V., et al. Improved outcome prediction using CT angiography in addition to standard ischemic stroke assessment: results from the STOP Stroke study. PLoS One. 2012;7(1, article e30352) doi: 10.1371/journal.pone.0030352.
    1. Barber P. A., Demchuk A. M., Zhang J., Buchan A. M., for the ASPECTS study group Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000;355(9216):1670–1674. doi: 10.1016/S0140-6736(00)02237-6.
    1. Demchuk A. M., Hill M. D., Barber P. A., Silver B., Patel S. C., Levine S. R. Importance of early ischemic computed tomography changes using ASPECTS in NINDS rtPA Stroke Study. Stroke. 2005;36(10):2110–2115. doi: 10.1161/01.STR.0000181116.15426.58.
    1. Dzialowski I. Extent of early ischemic changes on computed tomography (CT) before thrombolysis. Stroke. 2006;37(4):973–978. doi: 10.1161/01.STR.0000206215.62441.56.
    1. Eriksson M., Norrving B., Terént A., Stegmayr B. Functional outcome 3 months after stroke predicts long-term survival. Cerebrovascular Diseases. 2008;25(5):423–429. doi: 10.1159/000121343.
    1. Ghosh K. C., Bhattacharya R., Ghosh S., et al. Predictors of severity and outcome and roles of intravenous thrombolysis and biomarkers in first ischemic stroke. Neuroimmunol Neuroinflammation. 2018;5(9):38–48. doi: 10.20517/2347-8659.2018.28.
    1. Khan M., Baird G. L., Goddeau R. P., Jr., Silver B., Henninger N. Alberta Stroke Program Early CT Score infarct location predicts outcome following M2 occlusion. Frontiers in Neurology. 2017;8:p. 98. doi: 10.3389/fneur.2017.00098.
    1. Jauch E. C., Saver J. L., Adams H. P., Jr., et al. Guidelines for the early management of patients with acute ischemic stroke. Stroke. 2013;44(3):870–947. doi: 10.1161/STR.0b013e318284056a.
    1. Powers W. J., Derdeyn C. P., Biller J., et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment. Stroke. 2015;46(10):3020–3035. doi: 10.1161/STR.0000000000000074.
    1. Powers W. J., Rabinstein A. A., Ackerson T., et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110. doi: 10.1161/STR.0000000000000158.
    1. Hallevi H., Barreto A. D., Liebeskind D. S., et al. Identifying patients at high risk for poor outcome after intra-arterial therapy for acute ischemic stroke. Stroke. 2009;40(5):1780–1785. doi: 10.1161/STROKEAHA.108.535146.
    1. Saposnik G., Kapral M. K., Liu Y., et al. IScore. Circulation. 2011;123(7):739–749. doi: 10.1161/CIRCULATIONAHA.110.983353.
    1. Ntaios G., Faouzi M., Ferrari J., Lang W., Vemmos K., Michel P. An integer-based score to predict functional outcome in acute ischemic stroke: the ASTRAL score. Neurology. 2012;78(24):1916–1922. doi: 10.1212/WNL.0b013e318259e221.
    1. O’Donnell M. J., Fang J., D’Uva C., et al. Investigators of the Registry of the Canadian Stroke Network. The PLAN score: a bedside prediction rule for death and severe disability following acute ischemic stroke. Archives of Internal Medicine. 2012;172:1548–1556. doi: 10.1001/2013.jamainternmed.30.
    1. Flint A. C., Xiang B., Gupta R., et al. THRIVE score predicts outcomes with a third-generation endovascular stroke treatment device in the TREVO-2 trial. Stroke. 2013;44(12):3370–3375. doi: 10.1161/STROKEAHA.113.002796.
    1. Saposnik G., Guzik A. K., Reeves M., Ovbiagele B., Johnston S. C. Stroke prognostication using age and NIH stroke scale: SPAN-100. Neurology. 2012;80:21–28. doi: 10.1212/WNL.0b013e31827b1ace.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться