Regional Contributions to Poststroke Disability in Endovascular Therapy

Sunil A Sheth; Konark Malhotra; David S Liebeskind; Conrad W Liang; Albert J Yoo; Reza Jahan; Raul G Nogueira; Vitor Pereira; Jan Gralla; Greg Albers; Mayank Goyal; Jeffrey L Saver

doi:10.1159/000492400

Regional Contributions to Poststroke Disability in Endovascular Therapy

Interv Neurol. 2018 Oct;7(6):533-543. doi: 10.1159/000492400. Epub 2018 Sep 3.

Authors

Sunil A Sheth¹, Konark Malhotra², David S Liebeskind³, Conrad W Liang⁴, Albert J Yoo⁵, Reza Jahan⁶, Raul G Nogueira⁷, Vitor Pereira⁸, Jan Gralla⁹, Greg Albers¹⁰, Mayank Goyal¹¹, Jeffrey L Saver³

Affiliations

¹ Department of Neurology, UT Health McGovern School of Medicine, Houston, Texas, USA.
² Department of Neurology, Charleston Area Medical Center, West Virginia University, Charleston, West Virginia, USA.
³ Department of Neurology and Stroke Center, University of California, Los Angeles, California, USA.
⁴ Department of Neurosurgery, Kaiser Permanente, Fontana, California, USA.
⁵ Texas Stroke Institute, Plano, Texas, USA.
⁶ Division of Interventional Neuroradiology, University of California, Los Angeles, California, USA.
⁷ Department of Neurology, Emory University, Atlanta, Georgia, USA.
⁸ Divisions of Neuroradiology and Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.
⁹ Department of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland.
¹⁰ Department of Neurology, Stanford University, Stanford, California, USA.
¹¹ Diagnostic and Interventional Neuroradiology, University of Calgary, Calgary, Alberta, Canada.

Abstract

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.

Keywords: ASPECTS; Eloquence; Large vessel occlusion; Neuroimaging; Stroke.