on September 15, 2005
Published online before print September 15, 2005, doi: 10.1161/01.STR.0000181116.15426.58
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Submitted on March 29, 2005
From the Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada (A.M.D.); the University of Calgary, Calgary, Alberta, Canada (M.D.H., P.A.B.); Henry Ford Hospital, Detroit, Mich (B.S., S.P.); and Mount Sinai School of Medicine, New York, NY (S.R.L.). * To whom correspondence should be addressed. E-mail: ademchuk{at}ucalgary.ca.
Background and Purpose--The importance of early ischemic change (EIC) on baseline computed tomography (CT) in the decision to thrombolyze the patient with acute ischemic stroke has been controversial. ASPECTS is a semiquantitative scale that scores the extent of EIC within the middle cerebral artery territory. We examined whether ASPECTS could be a treatment modifier by systematically reviewing the CT scans in the NINDS rtPA Stroke Study. Methods--Six hundred eight of the 624 CT scans were available and of sufficient quality. One of 2 teams (n=3 each) of expert ASPECTS readers evaluated each scan for an ASPECTS value using a consensus score approach. Each team was blind to all clinical information except symptom side and blind to follow-up imaging and outcome information. ASPECTS values were stratified before analysis. Multivariable logistic regression was used to determine if an ASPECTS by treatment interaction existed on treatment response, outcome, and intracerebral hemorrhage risk. Results--A total of 57.2% (348 of 608) of scans showed EIC with an ASPECTS <10. ASPECTS dichotomized into 8 to 10 and <8 did not have a treatment-modifying effect on good outcome but showed a trend to lower mortality at 90 days with tPA (relative risk 0.67, 95% confidence interval 0.41 to 1.06, P=0.10). ASPECTS 8 to 10 were associated with a trend to larger benefit of tPA with a number needed to treat (NNT) of 5 versus ASPECTS 3 to 7 with a NNT of 8. Conclusion--There was no evidence of treatment effect modification by the baseline ASPECTS value in the NINDS rtPA Stroke Study. Therefore, exclusion of patients for thrombolysis within 3 hours of symptom onset based on EIC is not supported by our data. There is a trend to reduced mortality and increased benefit to rtPA if the baseline CT scan is favorable (ASPECTS >7).
Accepted on June 21, 2005
Importance of Early Ischemic Computed Tomography Changes Using ASPECTS in NINDS rtPA Stroke Study
Andrew M. Demchuk MD, FRCPC*;
Key words: computed tomography • diagnostic imaging • ischemia • thrombolytic therapy • stroke, acute
This article has been cited by other articles:
 |
|
 |
|
  V. Puetz, P.N. Sylaja, M.D. Hill, S.B. Coutts, I. Dzialowski, U. Becker, G. Gahn, R. von Kummer, and A.M. Demchuk CT Angiography Source Images Predict Final Infarct Extent in Patients with Basilar Artery Occlusion AJNR Am. J. Neuroradiol., November 1, 2009; 30(10): 1877 - 1883. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 O. C. Singer, W. Kurre, M. C. Humpich, M. W. Lorenz, A. Kastrup, D. S. Liebeskind, G. Thomalla, J. Fiehler, J. Berkefeld, T. Neumann-Haefelin, et al. Risk Assessment of Symptomatic Intracerebral Hemorrhage After Thrombolysis Using DWI-ASPECTS Stroke, August 1, 2009; 40(8): 2743 - 2748. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Kohrmann and P. D. Schellinger Acute Stroke Triage to Intravenous Thrombolysis and Other Therapies with Advanced CT or MR Imaging: Pro MR Imaging Radiology, June 1, 2009; 251(3): 627 - 633. [Full Text] [PDF]
|
|
|
|
|
|
A. Kobayashi, J. M. Wardlaw, R. I. Lindley, S. C. Lewis, P. A.G. Sandercock, A. Czlonkowska, and on behalf of the IST-3 Collaborative Group Oxfordshire Community Stroke Project Clinical Stroke Syndrome and Appearances of Tissue and Vascular Lesions on Pretreatment CT in Hyperacute Ischemic Stroke Among the First 510 Patients in the Third International Stroke Trial (IST-3) Stroke, March 1, 2009; 40(3): 743 - 748. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Saqqur, G. Tsivgoulis, C. A. Molina, A. M. Demchuk, M. Siddiqui, J. Alvarez-Sabin, K. Uchino, S. Calleja, A. V. Alexandrov, and For the CLOTBUST Investigators Symptomatic intracerebral hemorrhage and recanalization after IV rt-PA: A multicenter study Neurology, October 21, 2008; 71(17): 1304 - 1312. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. W. Albers, P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 630S - 669S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Lin, O. Rapalino, M. Law, J.S. Babb, K.A. Siller, and B.K. Pramanik Accuracy of the Alberta Stroke Program Early CT Score during the First 3 Hours of Middle Cerebral Artery Stroke: Comparison of Noncontrast CT, CT Angiography Source Images, and CT Perfusion AJNR Am. J. Neuroradiol., May 1, 2008; 29(5): 931 - 936. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. D. Schellinger, G. Thomalla, J. Fiehler, M. Kohrmann, C. A. Molina, T. Neumann-Haefelin, M. Ribo, O. C. Singer, O. Zaro-Weber, and J. Sobesky MRI-Based and CT-Based Thrombolytic Therapy in Acute Stroke Within and Beyond Established Time Windows: An Analysis of 1210 Patients Stroke, October 1, 2007; 38(10): 2640 - 2645. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. De Keyser, Z. Gdovinova, M. Uyttenboogaart, P. C. Vroomen, and G. J. Luijckx Intravenous Alteplase for Stroke: Beyond the Guidelines and in Particular Clinical Situations Stroke, September 1, 2007; 38(9): 2612 - 2618. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. W. Muir, J. Baird-Gunning, L. Walker, T. Baird, M. McCormick, and S. B. Coutts Can the Ischemic Penumbra Be Identified on Noncontrast CT of Acute Stroke? Stroke, September 1, 2007; 38(9): 2485 - 2490. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. C. S. Camargo, K. L. Furie, A. B. Singhal, L. Roccatagliata, M. E. Cunnane, E. F. Halpern, G. J. Harris, W. S. Smith, R. G. Gonzalez, W. J. Koroshetz, et al. Acute Brain Infarct: Detection and Delineation with CT Angiographic Source Images versus Nonenhanced CT Scans Radiology, August 1, 2007; 244(2): 541 - 548. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Dirks, L. W Niessen, P. J Koudstaal, C. L Franke, R. J van Oostenbrugge, D. W J Dippel, and the members of the Delphi panel on indications and Intravenous thrombolysis in acute ischaemic stroke: from trial exclusion criteria to clinical contraindications. An international Delphi study J. Neurol. Neurosurg. Psychiatry, July 1, 2007; 78(7): 685 - 689. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. R. Messe, S. E. Kasner, J. A. Chalela, B. Cucchiara, A. M. Demchuk, M. D. Hill, and S. Warach CT-NIHSS Mismatch Does Not Correlate With MRI Diffusion-Perfusion Mismatch Stroke, July 1, 2007; 38(7): 2079 - 2084. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, May 22, 2007; 115(20): e478 - e534. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists Stroke, May 1, 2007; 38(5): 1655 - 1711. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. S. Butcher, S. B. Lee, M. W. Parsons, L. Allport, J. Fink, B. Tress, G. Donnan, S. M. Davis, and for the EPITHET Investigators Differential Prognosis of Isolated Cortical Swelling and Hypoattenuation on CT in Acute Stroke Stroke, March 1, 2007; 38(3): 941 - 947. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Khatri, L. R. Wechsler, and J. P. Broderick Intracranial Hemorrhage Associated With Revascularization Therapies Stroke, February 1, 2007; 38(2): 431 - 440. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Neumann-Haefelin, S. Hoelig, J. Berkefeld, J. Fiehler, A. Gass, M. Humpich, A. Kastrup, T. Kucinski, O. Lecei, D. S. Liebeskind, et al. Leukoaraiosis Is a Risk Factor for Symptomatic Intracerebral Hemorrhage After Thrombolysis for Acute Stroke Stroke, October 1, 2006; 37(10): 2463 - 2466. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M.D. Hill, A.M. Demchuk, T.A. Tomsick, Y.Y. Palesch, J.P. Broderick, and on behalf of the IMS-1 Investigators Using the Baseline CT Scan to Select Acute Stroke Patients for IV-IA Therapy. AJNR Am. J. Neuroradiol., September 1, 2006; 27(8): 1612 - 1616. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. U. Weir, J. H. W. Pexman, M. D. Hill, A. M. Buchan, and on behalf of the CASES investigators How well does ASPECTS predict the outcome of acute stroke treated with IV tPA? Neurology, August 8, 2006; 67(3): 516 - 518. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. A. Barber and W. Powers MR DWI does not substitute for stroke severity scores in predicting stroke outcome Neurology, April 25, 2006; 66(8): 1138 - 1139. [Full Text] [PDF]
|
|
|
|
|
|
I. Dzialowski, M. D. Hill, S. B. Coutts, A. M. Demchuk, D. M. Kent, O. Wunderlich, and R. von Kummer Extent of Early Ischemic Changes on Computed Tomography (CT) Before Thrombolysis: Prognostic Value of the Alberta Stroke Program Early CT Score in ECASS II Stroke, April 1, 2006; 37(4): 973 - 978. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Warach and J. Wardlaw Advances in Imaging 2005 Stroke, February 1, 2006; 37(2): 297 - 298. [Full Text] [PDF]
|
|