Effect of workflow metrics on clinical outcomes of low diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) patients subjected to mechanical thrombectomy

Panni, Pietro; Michelozzi, Caterina; Richard, Sébastien; Marnat, Gaultier; Blanc, Raphaël; Consoli, Arturo; Mazighi, Mikaël; Piotin, Michel; Dargazanli, Cyril; Arquizane, Caroline; Sibon, Igor; Anxionnat, René; Hossu, Gabriela; Bourcier, Romain; Anadani, Mohammad; Lapergue, Bertrand; Gory, Benjamin

doi:10.1136/neurintsurg-2019-015519

Cited by 5 publications

(7 citation statements)

References 27 publications

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“…After initial screening, we retrieved the full text of 68 records that were considered potentially eligible for inclusion, and after reading the full-text articles, 14 were further excluded (Supplemental eTable 2). Finally, we identified 24 eligible studies for inclusion, of which 1 was an individual patient data (IPD) meta-analysis of RCT-derived data conducted by the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) collaborators, 31 2 were RCTs not included in the previous meta-analysis, 32,33 16 were observational studies based on prospectively collected data (prospective registries), [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] and 5 were retrospective cohort studies (Table 1), [50][51][52][53][54] comprising a total of 2539 AIS patients with low ASPECTS score treated with EVT.…”

Section: Literature Search and Included Studiesmentioning

confidence: 99%

“…The risk of bias in the included observational studies was assessed by the ROBINS-I tool and is presented in Supplemental eFigures 3-4. Overall, 16 studies were not controlled; 34,35,[37][38][39][40][41]43,45,46,48,49,[51][52][53][54] therefore, the assessment of confounding bias, bias in the classification of intervention, and bias due to deviations from intended interventions were not applicable. Yet, significant confounding bias was detected in all five controlled studies as there were several baseline differences between the patients' groups (EVTtreated versus BMT-treated).…”

Section: Quality Control Of Included Studiesmentioning

confidence: 99%

“…[37][38][39]41,46,52,53 Only five studies reported a blinded outcome assessment performed by investigators not involved in the acute management of LVO patients. 38,40,41,46,51…”

Section: Quality Control Of Included Studiesmentioning

confidence: 99%

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Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Safouris

Palaiodimou

Szikora

et al. 2022

Ther Adv Neurol Disord

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Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0–5 has not yet proven safe and effective by clinical trials. Objectives: The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial. Design: Systematic review and meta-analysis of available studies in accordance with the PRISMA statement. Data sources and Methods: We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0–3 at 3 months, (2) mRS score 0–2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months. Results: Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0–5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0–3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0–2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0–3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71). Conclusion: EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients. Registration: The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.

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Section: Literature Search and Included Studiesmentioning

confidence: 99%

Section: Quality Control Of Included Studiesmentioning

confidence: 99%

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Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Safouris

Palaiodimou

Szikora

et al. 2022

Ther Adv Neurol Disord

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“…In a multivariable analysis, voxel-based DWI reversibility >50%, but not volumetric DWI reversibility, was associated with outcome at 90 days. Previous studies found DWI reversibility to be associated with short- 14,15,18,20,22,28 and long-term outcome. 19–21,25,28 Since stroke lesions in our population were small, reversible lesion volumes were also not very large, potentially precluding an unambiguous effect on 90-day outcome.…”

Section: Discussionmentioning

confidence: 89%

Reversibility of Diffusion-Weighted Imaging Lesions in Patients With Ischemic Stroke in the WAKE-UP Trial

Scheldeman

Wouters

Bertels

et al. 2023

Stroke

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BACKGROUND: Reversibility of the diffusion-weighted imaging (DWI) lesion means that not all of the DWI lesion represents permanently injured tissue. We investigated DWI reversibility and the association with thrombolysis, reperfusion and functional outcome in patients from the WAKE-UP trial (Efficacy and Safety of Magnetic Resonance Imaging–Based Thrombolysis in Wake-Up Stroke). METHODS: In this retrospective analysis of WAKE-UP, a randomized controlled trial (RCT) between September 2012 and June 2017 in Belgium, Denmark, France, Germany, Spain and United Kingdom, a convolutional neural network segmented the DWI lesions (b=1000 s/mm 2 ) at baseline and follow-up (24 hours). We calculated absolute and relative DWI reversibility in 2 ways: first, a volumetric (baseline volume−24-hour volume >0) and second, a voxel-based (part of baseline lesion not overlapping with 24-hour lesion) approach. We additionally defined relative voxel-based DWI-reversibility >50% to account for coregistration inaccuracies. We calculated the odds ratio for reversibility according to treatment arm. We analyzed the association of reversibility with excellent functional outcome (modified Rankin Scale score of 0–1), in a multivariable model. RESULTS: In 363 patients, the median DWI volume was 3 (1–10) mL at baseline and 6 (2–20) mL at follow-up. Volumetric DWI reversibility was present in 19% (69/363) with a median absolute reversible volume of 1 mL (0–2) or 28% (14–50) relatively. Voxel-based DWI reversibility was present in 358/363 (99%) with a median absolute volume of 1 mL (0–2), or 22% (9–38) relatively. In 18% of the patients (67/363), relative voxel-based DWI reversibility >50% was present. Volumetric DWI reversibility and relative voxel-based DWI reversibility >50% was more frequent in patients treated with alteplase versus placebo (OR, 1.86 [95% CI, 1.09–3.17] and OR, 2.03 [95% CI, 1.18–3.50], respectively). Relative voxel-based DWI reversibility >50% was associated with excellent functional outcome (OR, 2.30 [95% CI, 1.17–4.51]). CONCLUSIONS: Small absolute volumes of DWI reversibility were present in a large proportion of randomized patients in the WAKE-UP trial. Reversibility was more often present after thrombolysis.

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“…Nevertheless, only 6% (n=225) of patients in the HERMES collaboration had low ASPECTS (≤5) making it difficult to draw any conclusions 4. In addition, a number of studies using registry data on patients with low ASPECTS have shown that older age, good collateral status, alteplase use, successful reperfusion, short onset to recanalization times, and baseline infarct volumes could potentially influence outcomes in these patients 5–9…”

Section: Introductionmentioning

confidence: 99%

Prediction of 90 day home time among patients with low baseline ASPECTS undergoing endovascular thrombectomy: results from Alberta’s Provincial Stroke Registry (QuICR)

Singh

Holodinsky²,

Kashani

et al. 2022

J NeuroIntervent Surg

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BackgroundThe benefit of endovascular thrombectomy (EVT) in stroke patients with a low baseline Alberta Stroke Program Early CT Score (ASPECTS, ≤5) is uncertain. We aim to use random forest regression modeling to predict 90 day home time in patients with low ASPECTS.MethodsWe used the Quality Improvement and Clinical Research (QuICR) provincial stroke registry and administrative data from southern Alberta to identify patients who underwent EVT in our center from July 2015 to November 2020. Baseline ASPECTS on non-contrast CT and CT angiography data were scored by a two physician consensus. The primary outcome was the predicted 90 day home time (the number of nights a patient is back at their premorbid living situation without an increase in level of care within 90 days of the stroke) using random forests regression. Estimates were generated using 200 bootstrapped datasets. Covariate contribution to home time was determined using partial dependence plots.ResultsOf 657 EVT patients, 85 (12.9%) had baseline ASPECTS ≤5 (mean age 70.9 years, 44.7% women, 93.9% good–moderate collaterals, 60% M1–middle cerebral artery occlusion). Using partial dependence estimates, mean predicted home times were similar in the low ASPECTS (44.3 days) versus higher ASPECTS (43.1) groups. Factors predicting lower 90 day home time in this population were diabetes mellitus (−8.8 days), hypertension (−5.7 days), and atrial fibrillation (−3.6 days). There was no meaningful difference in predicted 90 day home time by sex, baseline National Institutes of Health Stroke Severity Scale score, occlusion site, tandem lesion, collateral grade or thrombolysis.ConclusionsPatients with low ASPECTS who are selected for EVT using demographic and clinical profiles similar to higher ASPECTS patients achieved comparable outcomes.

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Effect of workflow metrics on clinical outcomes of low diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) patients subjected to mechanical thrombectomy

Cited by 5 publications

References 27 publications

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Reversibility of Diffusion-Weighted Imaging Lesions in Patients With Ischemic Stroke in the WAKE-UP Trial

Prediction of 90 day home time among patients with low baseline ASPECTS undergoing endovascular thrombectomy: results from Alberta’s Provincial Stroke Registry (QuICR)

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