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Background

Comparison of various methods of assessment of intracranial collaterals on the pretreatment CT-Angiograms to predict outcomes in acute anterior circulation ischemic stroke. Background.

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  1. Comparison of various methods of assessment of intracranial collaterals on the pretreatment CT-Angiograms to predict outcomes in acute anterior circulation ischemic stroke

  2. Background Intravenous tissue plasminogen activator (IV-TPA) remains the only approved therapeutic agent for acute ischemic stroke (AIS). Wide variations in the rates and extent of neurological recovery are observed in thrombolyzed patients Differences in the circle of Willis and the intracranial collaterals may compensate for the reduced cerebral perfusion and influence response to IV-TPA.

  3. Cerebral blood flow threshold Astrup J, Siesjo B, Symon L. Thresholds in cerebral ischemia: theischemic penumbra. Stroke 1981; 12: 723–25.

  4. Background The presence of effective collateral blood flow patterns may influence response to intravenously administered tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). But current methods of assessment of collaterals are largely qualitative or semi-quantitative, with no clear indication which one is superior.

  5. Objective We compared various existing methods of scoring collaterals on the pre-treatment computed tomographic angiogram (CTA). We attempted to determine if collaterals scores can predict functional outcome in AIS patients.

  6. Subjects & Methods: • Consecutive Anterior circulation AIS patients treated with IV-tPA within 4.5 hours of symptom-onset during 2007-2011 were included. Data were collected for demographics, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and stroke subtypes • Data were collected for demographic characteristics, vascular risk factors, stroke subtypes and blood pressure levels before IV-TPA bolus. • National Institute of Health Stroke Scale (NIHSS) scores were obtained before IV-TPA bolus, at 2-hours and at 24-hours • Functional outcomes assessed by modified Rankin Scale (mRS) at 3-months were dichotomized as good (mRS 0-1) and poor (mRS 2-6)

  7. Modified grading system Intracranial collaterals were evaluated by 2 independent blinded neuroradiologists via 4 predefined criteria using pre-tPA CT-angiograms Functional outcomes at 3-months were determined by modified Rankin scale (mRS). Data were analysed by SPSS 20.0.

  8. Collateral circulation was assessed via the following methods: • Miteff et al grading system • Entire MCA distal to occlusion reconsituted with contrast (Good) • Some branches of MCA reconstituted in sylvian fissure (moderate) • Distal superficial branches reconstituted (poor) • Mass et al grading system ( for leptomeningeal vessels and sylvian fissure vessels) • Absent • Less than contralateral side • Equal to contralateral side • Greater than contralateral side • Exhuberant • ASPECTS based grading system • Divide brain into ASPECTS region and grade each region • 0 for poor collaterals • 1 for moderate collaterals • 2 for good collaterals • Calculate a score from 0 to 20 • Tan et al grading system (Modified) • Poor: absent or seen in less than 50% MCA territory • Good: more than 50% MCA territory • Maas MB, Lev MH, Ay H, et al. Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 2009; 40: 3001–05. • Miteff F, Levi CR, Bateman GA, et al. The independent predictive utility of computed tomography angiography collateral status in acute ischemic stroke. Brain 2009; 132: 2231–38. • A Shuaib, K Butcher, AA Mohammad, M Saqqur, DS LiebeskindCollateral blood vessels in acute ischaemic stroke: a potential therapeutic target. Lancet Neurol 2011; 10: 909–21 • Tan IYL, Demchuk AM, Hopyan M. CT angiography clot burden score and collateral score: correlation with clinical and radiological outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 2009; 30: 525–31

  9. Tan et al grading system • Poor: absent or seen in less than 50% MCA territory • Good: more than 50% MCA territory • Tan IYL, Demchuk AM, Hopyan M. CT angiography clot burden score and collateral score: correlation with clinical and radiological outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 2009; 30: 525–31

  10. Miteff et al grading system • Good - Entire MCA distal to occlusion reconstituted with contrast • Moderate - Some branches of MCA reconstituted in Sylvian fissure • Poor - Distal superficial branches reconstituted Miteff F, Levi CR, Bateman GA, et al. The independent predictive utility of computed tomography angiography collateral status in acute ischemic stroke. Brain 2009; 132: 2231–38.

  11. Mass et al grading system : • Less than contralateral side • Absent • Equal to contralateral side • Greater than contralateral side • Exuberant Maas MB, Lev MH, Ay H, et al. Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 2009; 40: 3001–05.

  12. ASPECTS based grading system: M1 M4 C L M2 M5 I IC M3 M6 • Tan IYL, Demchuk AM, Hopyan M. CT angiography clot burden score and collateral score: correlation with clinical and radiological outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 2009; 30: 525–31 • Divide brain into ASPECTS region and grade each region • 0 for poor collaterals • 1 for moderate collaterals • 2 for good collaterals • Calculate a score from 0 to 20

  13. Results Of the total of 2745 AIS patients admitted to our center, 293 (10.6%) eligible cases were treated with IV-TPA during the study period. CTA was performed in 120 patients with anterior circulation AIS before IV-tPA bolus.

  14. Baseline characteristics (N=120)

  15. TOAST classification (n=120)

  16. Determinants of functional outcome

  17. Results • Univariable analysis • younger age, lower pre-tPA NIHSS scores and good collaterals according to ASPECTS and Miteffmethodology as significantly associated with good functional outcomes • multivariable logistic regression • only lower NIHSS (OR 1.111 per NIHSS point; 95% CI 1.023-1.206, p=0.013) and good collaterals by ASPECTS methodology (OR 1.784 per point; 95%CI: 1.020- 7.761, p= 0.049 )

  18. CT angiography grading systems OR: 1.67, 95%CI: 0.944- 2.958 p = 0.078 Leptomeningeal OR: 0.749, 95%CI: 0.447- 1.256 p = 0.273 Sylvian fissure OR: 1.455, 95%CI: 0.947- 2.256 p = 0.088 OR: 1.784, 95%CI: 1.020- 7.761 p = 0.049 OR 0.591; 95%CI 0.206-1.697, p=0.328 • Miteff et al grading system • Entire MCA distal to occlusion reconsituted with contrast (Good) • Some branches of MCA reconstituted in sylvian fissure (moderate) • Distal superficial branches reconstituted (poor) • Mass et al grading system • Absent • Less than contralateral side • Equal to contralateral side • Greater than contralateral side • Exhuberant • ASPECTS based grading system • Divide brain into ASPECTS region and grade each region • 0 for poor collaterals • 1 for moderate collaterals • 2 for good collaterals • Calculate a score from 0 to 20 • Tan et al grading system (Modified) • Poor: absent or seen in less than 50% MCA territory • Good: more than 50% MCA territory • Maas MB, Lev MH, Ay H, et al. Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 2009; 40: 3001–05. • Miteff F, Levi CR, Bateman GA, et al. The independent predictive utility of computed tomography angiography collateral status in acute ischemic stroke. Brain 2009; 132: 2231–38. • A Shuaib, K Butcher, AA Mohammad, M Saqqur, DS LiebeskindCollateral blood vessels in acute ischaemic stroke: a potential therapeutic target. Lancet Neurol 2011; 10: 909–21 • Tan IYL, Demchuk AM, Hopyan M. CT angiography clot burden score and collateral score: correlation with clinical and radiological outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 2009; 30: 525–31

  19. Results Dividing score into ASPECTS ≤6 vs Aspects ≥7 patients with good collateral ≥ 7 have a sensitivity 85.7%, specificity 72.5% to predict show good outcomes at 3 months. (OR. 2.958; 95%CI: 1.020- 8.578 p=0.036)

  20. Conclusions Conclusion: Of the existing intracranial CT-A collaterals scoring systems, only the ASPECTS methodology serves as a reliable predictor of favorable outcomes at 3-months in patients with anterior circulation AIS.

  21. Thank you

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