ASTRAL-R score predicts non-recanalisation after intravenous thrombolysis in acute ischaemic stroke

Abstract

Intravenous thrombolysis (IVT) as treatment in acute ischaemic strokes may be insufficient to achieve recanalisation in certain patients. Predicting probability of non-recanalisation after IVT may have the potential to influence patient selection to more aggressive management strategies. We aimed at deriving and internally validating a predictive score for post-thrombolytic non-recanalisation, using clinical and radiological variables. In thrombolysis registries from four Swiss academic stroke centres (Lausanne, Bern, Basel and Geneva), patients were selected with large arterial occlusion on acute imaging and with repeated arterial assessment at 24 hours. Based on a logistic regression analysis, an integer-based score for each covariate of the fitted multivariate model was generated. Performance of integer-based predictive model was assessed by bootstrapping available data and cross validation (delete-d method). In 599 thrombolysed strokes, five variables were identified as independent predictors of absence of recanalisation: Acute glucose > 7 mmol/l (A), significant extracranial vessel STenosis (ST), decreased Range of visual fields (R), large Arterial occlusion (A) and decreased Level of consciousness (L). All variables were weighted 1, except for (L) which obtained 2 points based on β-coefficients on the logistic scale. ASTRAL-R scores 0, 3 and 6 corresponded to non-recanalisation probabilities of 18, 44 and 74 % respectively. Predictive ability showed AUC of 0.66 (95 %CI, 0.61-0.70) when using bootstrap and 0.66 (0.63-0.68) when using delete-d cross validation. In conclusion, the 5-item ASTRAL-R score moderately predicts non-recanalisation at 24 hours in thrombolysed ischaemic strokes. If its performance can be confirmed by external validation and its clinical usefulness can be proven, the score may influence patient selection for more aggressive revascularisation strategies in routine clinical practice.

Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

“…Longer thrombus and more proximal occlusion have been previously found to be the main predictors of lack of early post-IVT recanalization, both in minor stroke and nonminor stroke . In turn, lack of early recanalization may be one pathophysiological link explaining the association observed here between END i and these variables .…”

Eligibility and Predictors for Acute Revascularization Procedures in a Stroke Center

“…Also, scores associated with a low likelihood of IVT-induced recanalization may be used to select patients for rapid EVT treatment. 20 A further increase in eligible patients may stem from broader selection criteria than recommended by the AHA/ASA, as simulated in our analysis with the more liberal criteria. Also, some patients with unknown stroke onset may benefit from such treatment, pending ongoing trials.…”

Predicting Penumbra Salvage and Infarct Growth in Acute Ischemic Stroke: A Multifactor Survival Game

“…We could also suggest that the presence of extracranial arterial pathology was a stronger independent predictor of IG than collateral status by itself. Furthermore, patients with tandem lesions show poorer recanalization, independently of performing acute treatment [31,49], as well as poorer clinical outcome [50][51][52]. Whether very aggressive acute recanalization strategies for such patients could prevent this increased risk of IG and poorer outcome needs further assessment.…”