Accuracy of National Institutes of Health Stroke Scale Score in Predicting the Site of Arterial Occlusion in Acute Stroke: A Transcranial Doppler Study

Relationship of Alberta Stroke Program Early CT Score (ASPECTS) with the outcome of ischemic stroke and the neurocognitive stroke biomarkers

Background

Reliable and acceptable biomarkers are needed to anticipate the outcome and cognitive impairment following ischemic stroke. The goal of this research is to examine the association of ASPECTS with cognitive decline, biomarkers of stroke, and acute ischemic stroke outcomes. This study included 120 patients with ischemic stroke in the middle cerebral artery region. The initial NIHSS, non-contrast CT brain assessed by ASPECTS, and the biomarkers of cognitive decline such as ESR, CRP, S100B, MMP9, and glutamate were investigated. The Montreal Cognitive Assessment and modified Rankin scale (mRS) were evaluated after 3 months. Correlations between ASPECTS, MoCA, biomarkers of cognitive impairment, and mRS were done by Spearman correlation.

Results

The incidence of cognitive impairment in our patients was 25.8%. Stroke biomarkers (ESR, CRP, S100B, MMP9, and glutamate) were significantly increased in cognitively disabled individuals with significantly lower mean MoCA scores than in cognitively intact patients. There was a strong direct correlation linking the initial ASPECTS and total MoCA test score after 3 months follow-up. Cases with unfavorable outcomes were older, more incidence of hypertension, and had higher average initial NIHSS (P < 0.05). While the average ASPECTS scores for the favorable outcome group of patients were significantly higher and there was a significant negative correlation between the initial ASPECTS and modified Rankin Scale score.

Conclusions

ASPECTS is a reliable scale to identify the extent of acute ischemic injury and could participate in assessing the outcome. ASPECTS and particular neurocognitive stroke biomarkers will enable the early detection of post-stroke cognitive impairment.

Trial registration Registration of Clinical Trial Research: ClinicalTrials.gov ID: NCT04235920

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

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.

Prediction of functional outcome using the novel asymmetric middle cerebral artery index in cryptogenic stroke patients

BACKGROUND

Etiology is unknown in approximately one-quarter of stroke patients after evaluation, which is termed cryptogenic stroke (CS). The prognosis of CS patients is largely undetermined. We created a novel index from transcranial Doppler parameters including mean flow velocity (MV) and pulsatility index (PI) and investigated whether the calculation of asymmetry in the novel parameter can predict functional outcomes in CS patients.

METHODS

We made the middle cerebral artery (MCA) index (%) as a novel parameter, which was calculated as 100 X (MCA MV + MCA PI X 10) / (MCA MV-MCA PI X 10). The MCA asymmetry index (%) was also calculated as 100 X (|Rt MCA index-Lt MCA index|) / (Rt MCA index + Lt MCA index) / 2. Poor functional outcomes were defined as modified Rankin Scale score (mRS) ≥3 at 3 months after stroke onset.

RESULTS

A total of 377 CS patients were included. Among them, 52 (13.8%) patients had a poor outcome. The overall MCA asymmetry index was two-fold higher in CS patients with a poor outcome (10.26%) compared to those with a good outcome (5.41%, p = 0.002). In multivariable analysis, the overall MCA asymmetry index (OR, 1.054, 95% CI, 1.013-1.096, p = 0.009) and the cutoff value of the overall MCA asymmetry index >9 were associated with poor outcomes at 3 months (OR, 3.737, 95% CI, 1.530-9.128, p = 0.004).

CONCLUSION

We demonstrated that the novel asymmetric MCA index can predict short-term functional outcomes in CS patients.

Alberta Stroke Program Early CT Score Infarct Location Predicts Outcome Following M2 Occlusion

Background

Although it is generally thought that patients with distal middle cerebral artery (M2) occlusion have a favorable outcome, it has previously been demonstrated that a substantial minority will have a poor outcome by 90 days. We sought to determine whether assessing the Alberta Stroke Program Early CT Score (ASPECTS) infarct location allows for identifying patients at risk for a poor 90-day outcome.

Methods

We retrospectively analyzed patients with isolated acute M2 occlusion admitted to a single academic center between January 2010 and August 2012. Infarct regions were defined according to ASPECTS system on the initial head computed tomography. Discriminant function analysis was used to define specific ASPECTS regions that are predictive of the 90-day functional outcome as defined as a modified Rankin Scale score of 3–6. In addition, logistic regression was used to model the relationship between each individual ASPECT region with poor outcome; for evaluation and comparison, odds ratios, c-statistics, and Akaike information criterion values were estimated for each region.

Results

Ninety patients with isolated M2 were included in the final analysis. ASPECTS score ≤6 predicted poor outcome in this cohort (sensitivity = 0.591, specificity = 0.838, p < 0.001). Using multiple approaches, we found that infarction in ASPECTS regions M3 and M6 were strongly associated with poor functional status by 90 days.

Conclusion

Infarction in ASPECTS regions M3 and M6 are key predictors of functional outcome following isolated distal M2 occlusion. These findings will be helpful in stratifying outcomes if validated in future studies.