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SNIS 9th annual meeting oral abstracts
O-001 Pre-treatment CTA ASPECTS as a predictor of clinical outcome in endovascular stroke therapy (EVT): results from the penumbra START trial
  1. D Frei1,
  2. A Yoo2,
  3. D Heck3,
  4. F Hellinger II4,
  5. V McCollom5,
  6. D Fiorella6,
  7. A Turk III7,
  8. T Malisch8,
  9. O Zaidat9,
  10. M Alexander10,
  11. T Devlin11,
  12. E Levy12,
  13. Q Shah13,
  14. F Hui14,
  15. M Goyal15,
  16. B Ghodke16,
  17. A Shaibani17,
  18. M Harrigan18,
  19. T Jovin19,
  20. M Madison20,
  21. Z Chaudhry2,
  22. R Gonzalez2,
  23. L Barraza21,
  24. S Sit21,
  25. A Bose21
  1. 1Neurointerventional Surgery, Radiology Imaging Associates, Denver, Colorado, USA
  2. 2Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3Forsyth Medical Center, Winston-Salem, North Carolina, USA
  4. 4Florida Hospital, Orlando, Florida, USA
  5. 5Mercy Health Center, Oklahoma City, Oklahoma, USA
  6. 6Stony Brook Medical Center, Stony Brook, New York, USA
  7. 7Medical University of South Carolina, Charleston, South Carolina, USA
  8. 8Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
  9. 9Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  10. 10Cedars-Sinai Medical Center, Los Angeles, California, USA
  11. 11Chattanooga Center for Neurologic Research, Chattanooga, Tennessee, USA
  12. 12Kaleida Health, Buffalo, New York, USA
  13. 13Abington Memorial Hospital, Abington, Pennsylvania, USA
  14. 14Cleveland Clinic, Cleveland, Ohio, USA
  15. 15Alberta Health Services, Calgary, Alberta, Canada
  16. 16Harborview Medical Center, Seattle, Washington, USA
  17. 17Northwest Community Hospital, Arlington Heights, Illinois, USA
  18. 18University of Alabama at Birmingham, Birmingham, Alabama, USA
  19. 19University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  20. 20St. Paul Radiology, St Paul, Minnesota, USA
  21. 21Penumbra, Inc., Alameda, California, USA


Introduction/purpose There is no standard imaging approach for EVT patient selection. CT remains the most widely used modality for stroke evaluation. Ischemic change on non-contrast CT (NCCT) quantified using ASPECTS has been demonstrated to predict clinical response to EVT. To date, definitive studies evaluating the impact of CTA source image (CTA-SI) pre-treatment ASPECTS (pre-ASPECTS) on outcomes following EVT are lacking. START was a prospective, multicenter study to evaluate the influence of pre-treatment core infarct size in patients undergoing endovascular stroke therapy using the Penumbra System.

Materials and Methods The imaging method was at each center's discretion and included NCCT, CTA-SI, CT perfusion, or MRI diffusion imaging. This study focused on the preliminary CTA-SI results. Results are reported from an interim analysis of the START trial data as adjudicated by a central Core Laboratory. Graded in a blinded fashion, ASPECTS was analyzed according to the a priori classification (0–4, 5–7, 8–10), as well as using the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale scores of 0–2 (good) vs 3–6. Univariate and multivariate analyses were performed to determine predictors of outcome.

Results Of the 147 patients enrolled, 77 met study criteria for this interim analysis. The mean age was 66.0±14.1 years; median NIHSS was 19 (14–24). Target vessel occlusions were in the ICA (22.1%), MCA (75.3%), and other (2.6%). The median pre-ASPECTS on CTA-SI was 6 (4–7). There were 20 (26%) patients with scores of 0–4, 43 (55.8%) with 5–7, 14 (18.2%) with 8–10. The rate of TIMI 2–3 revascularization was 85.3% (64/75). The median time from groin puncture to aspiration discontinuation was 71.5 (40–108) min. 37 (48.1%) patients achieved a good 90-day outcome. 22 (28.6%) died. Four (5.2%) patients suffered from symptomatic hemorrhage, and 11 (14.3%) suffered from asymptomatic hemorrhage. Higher pre-ASPECTS on CTA-SI was significantly associated with good outcomes (median 6 (IQR 5–7) vs 5 (IQR 3–7), p<0.05). The rate of good outcomes was 20.0% for ASPECTS 0–4, 55.8% for 5–7, and 64.3% for 8–10 (p=0.08). Adjusting for age and NIHSS and comparing ASPECTS 0–4 with 5–10, pre-ASPECTS 5–10 was an independent predictor of good outcome (OR 6.8, p=0.006). In ROC analysis, ASPECTS >4 was the optimal threshold for identifying good outcomes (89% sensitivity, 38% specificity). Other univariate predictors of good outcome were lower age (p=0.01), lower NIHSS (p=0.04), revascularization time (p<0.0001), and shorter time from groin puncture to aspiration cessation (p=0.0004).

Conclusion Higher pre-treatment ASPECTS on CTA source images are associated with better outcomes following EVT. Comparative studies with NCCT ASPECTS are required to evaluate relative accuracy for patient selection.

Competing interests D Frei: None. A Yoo: None. D Heck: None. F Hellinger II: None. V McCollom: None. D Fiorella: None. A Turk III: None. T Malisch: None. O Zaidat: None. M Alexander: None. T Devlin: None. E Levy: None. Q Shah: None. F Hui: None. M Goyal: None. B Ghodke: None. A Shaibani: None. M Harrigan: None. T Jovin: None. M Madison: None. Z Chaudhry: None. R Gonzalez: None. L Barraza: Penumbra, Inc. S Sit: Penumbra, Inc. A Bose: Penumbra, Inc.

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