Alberta Stroke Program Early Computed Tomography Score to Select Patients for Endovascular Treatment Interventional Management of Stroke (IMS)-III Trial

• Published in: Stroke (1970) Vol. 45; no. 2; pp. 444 - 449
• Main Authors: Hill, Michael D., Demchuk, Andrew M., Goyal, Mayank, Jovin, Tudor G., Foster, Lydia D., Tomsick, Thomas A., von Kummer, Rüdiger, Yeatts, Sharon D., Palesch, Yuko Y., Broderick, Joseph P.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 01.02.2014
• Subjects: Aged; Arterial Occlusive Diseases - diagnostic imaging; Arterial Occlusive Diseases - therapy; Biological and medical sciences; Brain Ischemia - diagnostic imaging; Brain Ischemia - therapy; Case Management; Cerebral Angiography; Comorbidity; Confidence Intervals; Endovascular Procedures - methods; Female; Fibrinolytic Agents - therapeutic use; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Humans; Male; Medical sciences; Middle Aged; Nervous system (semeiology, syndromes); Neurology; Patient Selection; Predictive Value of Tests; Reperfusion; Risk; Stroke - diagnostic imaging; Stroke - therapy; Thrombolytic Therapy; Tissue Plasminogen Activator - therapeutic use; Tomography, X-Ray Computed - methods; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; Human; Stroke; Nervous system diseases; Radiodiagnosis; x-ray; Cardiovascular disease; Endovascular route; Cerebral disorder; Vascular disease; therapeutic; Clinical management; Treatment; Central nervous system disease; thrombolysis; Medical imagery; Computerized axial tomography; computed tomography scanner; Cerebrovascular disease; stroke; computed tomography scanner, x-ray; thrombolysis, therapeutic
• ISSN: 0039-2499; 1524-4628; 1524-4628
• DOI: 10.1161/STROKEAHA.113.003580

The Interventional Management of Stroke (IMS)-III trial randomized patients with acute ischemic stroke to intravenous tissue-type plasminogen activator (tPA) plus endovascular therapy versus intravenous tPA therapy alone within 3 hours from symptom onset. A predefined secondary hypothesis was that subjects with significant early ischemic change on the baseline scan would not respond to endovascular therapy. The primary outcome was 90-day modified Rankin Scale score 0 to 2. The baseline and follow-up computed tomographic (CT) scan images were reviewed centrally and blinded to any clinical information. We assessed whether the baseline Alberta Stroke Program Early CT Score (ASPECTS) predicted outcome and interacted with study treatment. We analyzed subgroups defined by time from onset to intravenous tPA initiation and baseline occlusion status at a prespecified α=0.01. Baseline demographic and clinical characteristics of 656 randomized patients were similar between subjects with a baseline ASPECTS 8 to 10 (58% of the study sample) versus 0 to 7. Subjects with ASPECTS 8 to 10 were almost twice as likely (relative risk, 1.8; 99% confidence interval, 1.4-2.4) to achieve a favorable outcome. There was insufficient evidence of a treatment-by-ASPECTS interaction. In those treated with onset to intravenous tPA <120 minutes, in CT angiography-proven internal carotid artery or middle cerebral artery occlusion, and in both, results were similar. The probability of achieving recanalization (arterial occlusion lesion, 2-3) of the primary arterial occlusive lesion (relative risk, 1.3; 99% confidence interval, 1.0-1.8) or achieving thrombolysis in cerebral ischemia score 2b/3 reperfusion (relative risk 2.0; 99% confidence interval, 1.2-3.2) was higher among subjects with higher ASPECTS. ASPECTS is a strong predictor of outcome and a predictor of reperfusion. ASPECTS did not identify a subpopulation of subjects that particularly benefitted from endovascular therapy immediately after routine intravenous tPA. http://www.clinicaltrials.gov. Unique identifier: NCT00359424.