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Original research
Baseline ASPECTS and hypoperfusion intensity ratio influence the impact of first pass reperfusion on functional outcomes
  1. Mahmoud H Mohammaden1,2,
  2. Diogo C Haussen1,2,
  3. Leonardo Pisani1,2,
  4. Alhamza R Al-Bayati1,2,
  5. Catarina Perry da Camara1,2,
  6. Nirav Bhatt1,2,
  7. Samir R Belagaje1,2,
  8. Bernardo Boaventura Liberato1,2,
  9. Nicolas Bianchi1,2,
  10. Aaron M Anderson1,2,
  11. Michael R Frankel1,2,
  12. Raul G Nogueira1,2
  1. 1 Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2 Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
  1. Correspondence to Dr Raul G Nogueira, Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA 30303, USA; raul.g.nogueira{at}


Background First pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.

Methods A prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c–3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR <0.3 versus ≥0.3. Univariable and multivariable analyses were performed to establish the predictors of 90-day functional independence (modified Rankin Scale (mRS) ≤2) in each subgroup.

Results A total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR <0.3 (62.9% vs 52.8%, adjusted OR 1.524; 95% CI 0.592 to 3.920, p=0.38).

Conclusions The impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

  • stroke
  • thrombectomy

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  • Contributors MHM: study conception, acquisition of data, interpretation of data, drafting of the manuscript. DCH, LP, ARA-B, CPdC, NB, SRB, BBL, NB, AMA, MRF: critical revision of the manuscript. RGN: study conception, design of the work, acquisition of data, interpretation of data, drafting of the manuscript. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests RGN: reports potential conflicts with Stryker Neurovascular (DAWN Trial Principal Investigator, no compensation, Trevo Retriever Registry Steering Committee, no compensation, Trevo-2 Trial Principal Investigator, modest; Consultant, modest), Medtronic (SWIFT [SOLITAIRE FR With the Intention for Thrombectomy] Trial Steering Committee, modest; SWIFT-Prime Trial Steering Committee, no compensation; STAR [Solitaire Flow Restoration Thrombectomy for Acute Revascularization] Trial Angiographic Core Lab, significant), Penumbra (3D Separator Trial Executive Committee, no compensation), Cerenovus/Neuravi (ENDOLOW Trial Principal Investigator, EXCELLENT Registry Principal Investigator, Analysis of Revascularization in Ischemic Stroke with EmboTrap (ARISE-2)-2 trial Steering Committee, no compensation, Physician Advisory Board, modest), Phenox (Physician Advisory Board, modest), Anaconda (Physician Advisory Board, modest), Genentech (Physician Advisory Board, modest), Biogen (Physician Advisory Board, modest), Prolong Pharmaceuticals (Physician Advisory Board, modest), Allm Inc (Physician Advisory Board, no compensation), IschemaView (Speaker, modest), Brainomix (Research Software Use, no compensation), Sensome (Research Device Use, no compensation), Viz.AI (Physician Advisory Board, stock options), Philips (Research Software Use, no compensation, Speaker, modest), Corindus Vascular Robotics (Physician Advisory Board, stock options), Vesalio (Physician Advisory Board, stock options), Ceretrieve (Physician Advisory Board, stock options), and Astrocyte (Physician Advisory Board, stock options). DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author on reasonable request.