Acute Imaging Does Not Improve ASTRAL Score's Accuracy despite Having a Prognostic Value

Abstract

Background

The ASTRAL score was recently shown to reliably predict three-month functional outcome in patients with acute ischemic stroke.

Aim

The study aims to investigate whether information from multimodal imaging increases ASTRAL score's accuracy. Methods All patients registered in the ASTRAL registry until March 2011 were included. In multivariate logistic-regression analyses, we added covariates derived from parenchymal, vascular, and perfusion imaging to the 6-parameter model of the ASTRAL score. If a specific imaging covariate remained an independent predictor of three-month modified Rankin score > 2, the area-under-the-curve (AUC) of this new model was calculated and compared with ASTRAL score's AUC. We also performed similar logistic regression analyses in arbitrarily chosen patient subgroups.

Results

When added to the ASTRAL score, the following covariates on admission computed tomography/magnetic resonance imaging-based multimodal imaging were not significant predictors of outcome: any stroke-related acute lesion, any nonstroke-related lesions, chronic/subacute stroke, leukoaraiosis, significant arterial pathology in ischemic territory on computed tomography angiography/magnetic resonance angiography/Doppler, significant intracranial arterial pathology in ischemic territory, and focal hypoperfusion on perfusion-computed tomography. The Alberta Stroke Program Early CT score on plain imaging and any significant extracranial arterial pathology on computed tomography angiography/magnetic resonance angiography/Doppler were independent predictors of outcome (odds ratio: 0·93, 95% CI: 0·87–0·99 and odds ratio: 1·49, 95% CI: 1·08–2·05, respectively) but did not increase ASTRAL score's AUC (0·849 vs. 0·850, and 0·8563 vs. 0·8564, respectively). In exploratory analyses in subgroups of different prognosis, age or stroke severity, no covariate was found to increase ASTRAL score's AUC, either.

Conclusions

The addition of information derived from multimodal imaging does not increase ASTRAL score's accuracy to predict functional outcome despite having an independent prognostic value. More selected radiological parameters applied in specific subgroups of stroke patients may add prognostic value of multimodal imaging.

Keywords

ASTRAL score CT angiography CT functional outcome multimodal imaging perfusion CT

Get full access to this article

View all access options for this article.

References

Wintermark

Albers

Broderick

. Acute stroke imaging research roadmap II. Stroke 2013; 44: 2628–39.

Albers

Thijs

Wechsler

. Magnetic resonance imaging profiles predict clinical response to early reperfusion: The diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol 2006; 60: 508–17.

De Silva

Fink

Christensen

. Assessing reperfusion and recanalization as markers of clinical outcomes after intravenous thrombolysis in the echoplanar imaging thrombolytic evaluation trial (EPITHET). Stroke 2009; 40: 2872–4.

Puetz

Dzialowski

Hill

. Intracranial thrombus extent predicts clinical outcome, final infarct size and hemorrhagic transformation in ischemic stroke: The clot burden score. Int J Stroke 2008; 3: 230–6.

Riedel

Zimmermann

Jensen-Kondering

Stingele

Deuschl

Jansen

. The importance of size: Successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 2011; 42: 1775–7.

Fiebach

Al-Rawi

Wintermark

. Vascular occlusion enables selecting acute ischemic stroke patients for treatment with desmoteplase. Stroke 2012; 43: 1561–6.

Jovin

Yonas

Gebel

. The cortical ischemic core and not the consistently present penumbra is a determinant of clinical outcome in acute middle cerebral artery occlusion. Stroke 2003; 34: 2426–33.

Yoo

Barak

Copen

. Combining acute diffusion-weighted imaging and mean transmit time lesion volumes with National Institutes of Health Stroke Scale Score improves the prediction of acute stroke outcome. Stroke 2010; 41: 1728–35.

Mlynash

Lansberg

De Silva

. Refining the definition of the malignant profile: Insights from the DEFUSE-EPITHET pooled data set. Stroke 2011; 42: 1270–5.

10.

Zhu

Michel

Aghaebrahim

. Computed tomography workup of patients suspected of acute ischemic stroke: Perfusion computed tomography adds value compared with clinical evaluation, noncontrast computed tomography, and computed tomography angiogram in terms of predicting outcome. Stroke 2013; 44: 1049–55.

11.

Ntaios

Faouzi

Ferrari

Lang

Vemmos

Michel

. An integer-based score to predict functional outcome in acute ischemic stroke: The ASTRAL score. Neurology 2012; 78: 1916–22.

12.

Liu

Ntaios

Zheng

. External validation of the ASTRAL score to predict 3- and 12-month functional outcome in the China National Stroke Registry. Stroke 2013; 44: 1443–5.

13.

Papavasileiou

Milionis

Michel

. ASTRAL score predicts 5-year dependence and mortality in acute ischemic stroke. Stroke 2013; 44: 1616–20.

14.

O'Donnell

Fang

D'Uva

. The PLAN score: A bedside prediction rule for death and severe disability following acute ischemic stroke. Arch Intern Med 2012; 172: 1548–56.

15.

Saposnik

Raptis

Kapral

. The iScore predicts poor functional outcomes early after hospitalization for an acute ischemic stroke. Stroke 2011; 42: 3421–8.

16.

Counsell

Dennis

McDowall

Warlow

. Predicting outcome after acute and subacute stroke: Development and validation of new prognostic models. Stroke 2002; 33: 1041–7.

17.

Nabavi

Kloska

Nam

. MOSAIC: Multimodal stroke assessment using computed tomography: Novel diagnostic approach for the prediction of infarction size and clinical outcome. Stroke 2002; 33: 2819–26.

18.

Counsell

Dennis

. Systematic review of prognostic models in patients with acute stroke. Cerebrovasc Dis 2001; 12: 159–70.

19.

Weimar C, Konig IR, Kraywinkel K, Ziegler A, Diener HC; German Stroke Study C . Age and National Institutes of Health Stroke Scale Score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: Development and external validation of prognostic models. Stroke 2004; 35: 158–62.

20.

Weimar

Ziegler

Konig

Diener

. Predicting functional outcome and survival after acute ischemic stroke. J Neurol 2002; 249: 888–95.

21.

Muscari

Puddu

Santoro

Zoli

. A simple scoring system for outcome prediction of ischemic stroke. Acta Neurol Scand 2011; 124: 334–42.

22.

Smith

Shobha

Dai

. Risk score for in-hospital ischemic stroke mortality derived and validated within the Get With the Guidelines-Stroke Program. Circulation 2010; 122: 1496–504.

23.

Michel

Odier

Rutgers

. The Acute STroke Registry and Analysis of Lausanne (ASTRAL): Design and baseline analysis of an ischemic stroke registry including acute multimodal imaging. Stroke 2010; 41: 2491–8.

24.

Barber

Demchuk

Zhang

Buchan

. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355: 1670–4.

25.

Blennow

Wallin

Uhlemann

Gottfries

. White-matter lesions on CT in Alzheimer patients: Relation to clinical symptomatology and vascular factors. Acta Neurol Scand 1991; 83: 187–93.

26.

Wintermark

Flanders

Velthuis

. Perfusion-CT assessment of infarct core and penumbra: Receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 2006; 37: 979–85.

27.

Wintermark

Reichhart

Thiran

. Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients. Ann Neurol 2002; 51: 417–32.

28.

European Stroke Organisation Executive C, Committee ESOW . Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25: 457–507.

29.

DeLong

Clarke-Pearson

. Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach. Biometrics 1988; 44: 837–45.

30.

Heldner

Zubler

Mattle

. National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke 2013; 44: 1153–7.

31.

Derex

Nighoghossian

Hermier

. Influence of pretreatment MRI parameters on clinical outcome, recanalization and infarct size in 49 stroke patients treated by intravenous tissue plasminogen activator. J Neurol Sci 2004; 225: 3–9.

32.

Furtado

Smith

Koroshetz

. Perfusion CT imaging follows clinical severity in left hemispheric strokes. Eur Neurol 2008; 60: 244–52.

33.

Nezu

Koga

Kimura

. Pretreatment ASPECTS on DWI predicts 3-month outcome following rt-PA: SAMURAI rt-PA Registry. Neurology 2010; 75: 555–61.

34.

Dani

Thomas

Chappell

. Computed tomography and magnetic resonance perfusion imaging in ischemic stroke: Definitions and thresholds. Ann Neurol 2011; 70: 384–401.

35.

Puetz

Khomenko

Hill

. Extent of hypoattenuation on CT angiography source images in basilar artery occlusion: Prognostic value in the Basilar Artery International Cooperation Study. Stroke 2011; 42: 3454–9.

36.

Miteff

Levi

Bateman

Spratt

McElduff

Parsons

. The independent predictive utility of computed tomography angiographic collateral status in acute ischaemic stroke. Brain 2009; 132(Pt 8): 2231–8.

37.

Gonzalez

Lev

Goldmacher

. Improved outcome prediction using CT angiography in addition to standard ischemic stroke assessment: Results from the STOPStroke study. PLoS ONE 2012; 7: e30352.

38.

Zhu

Michel

Aghaebrahim

. Prediction of recanalization trumps prediction of tissue fate: The penumbra: A dual-edged sword. Stroke 2013; 44: 1014–9.

39.

Lansberg

Straka

Kemp

. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): A prospective cohort study. Lancet Neurol 2012; 11: 860–7.

40.

Nagakane

Christensen

Brekenfeld

. EPITHET: Positive result after reanalysis using baseline diffusion-weighted imaging/perfusion-weighted imaging co-registration. Stroke 2011; 42: 59–64.

41.

Ford

. Early changes of tissue perfusion after tissue plasminogen activator in hyperacute ischemic stroke. Stroke 2011; 42: 65–72.

42.

Maas

Lev

. Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 2009; 40: 3001–5.