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Original research
Effect of age and baseline ASPECTS on outcomes in large-vessel occlusion stroke: results from the HERMES collaboration
  1. Johanna Maria Ospel1,2,
  2. Manon Kappelhof3,
  3. Nima Kashani2,4,
  4. Bijoy K Menon2,4,
  5. Bruce C V Campbell5,6,
  6. Luis San Roman7,
  7. Andrew M Demchuk2,4,
  8. Diederik W J Dippel8,
  9. Jeffrey L Saver9,
  10. Tudor G Jovin10,
  11. Peter Mitchell11,
  12. Serge Bracard12,
  13. Keith Muir13,
  14. Phil White14,15,
  15. Francis Guillemin16,
  16. Charles B L M Majoie3,
  17. Michael D Hill2,4,
  18. Scott Brown17,
  19. Mayank Goyal2,4
  20. On behalf of the HERMES collaborators
  1. 1Neuroradiology, University Hospital Basel, Basel, Switzerland
  2. 2Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  3. 3Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
  4. 4Radiology, University of Calgary, Calgary, Alberta, Canada
  5. 5Medicine, University of Melbourne, Parkville, Victoria, Australia
  6. 6Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  7. 7Interventional Neuroradiology, Imaging Diagnostics Center, Hospital Clinic of Barcelona, Barcelona, Spain
  8. 8Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
  9. 9Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA
  10. 10Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
  11. 11Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
  12. 12Radiology, Université de Lorraine, Nancy, France
  13. 13Institute of Neuroscience and Psychiatry, University of Glasgow, Glasgow, UK
  14. 14Institute for Ageing & Health, Newcastle University, Newcastle upon Tyne, UK
  15. 15Neuroradiology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
  16. 16Clinical Epidemiology, Université de Lorraine and University Hospital of Nancy, Nancy, France
  17. 17Altair Biostatistics, St. Louis Park, Minnesota, United States
  1. Correspondence to Dr Mayank Goyal, Diagnostic Imaging, University of Calgary, Calgary, AB T2N 1N4, Canada; mgoyal2412{at}


Background Patient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the combined effect of age and ASEPCTS on clinical outcome in acute ischemic stroke patients with LVO with and without EVT, and EVT treatment effect in different age/ASPECTS subgroups.

Methods The HERMES collaboration pooled data of seven randomized controlled trials that tested the efficacy of EVT. Adjusted logistic regression was performed to test for multiplicative interaction of age and ASPECTS with the primary outcome (ordinal mRS) and secondary outcomes (mRS 0–2/0–1/0–3) in the EVT and control arms. Patients were then stratified by age (<75 vs ≥75 years) and ASPECTS (0–5/6–7/8–10), and adjusted effect-size estimates for the association of EVT were derived for the six age/ASPECTS subgroups.

Results 1735 patients were included in the analysis. There was no multiplicative interaction between age and ASPECTS on clinical outcomes. In the exploratory subgroup analysis, we found a nominally negative point estimate for the association of EVT with clinical outcome in the ASPECTS 0–5/age ≥75, subgroup (acOR 0.36, 95% CI 0.07 to 1.89). The point estimate for moderate outcome (mRS0-3) nominally favored EVT (aOR 1.24, 95% CI 0.16 to 9.84). In all other subgroups, effect size-estimates consistently favored EVT.

Conclusion There was no multiplicative interaction of age and ASPECTS on clinical outcomes in EVT or control arm patients. Outcomes in patients ≥75 years with ASPECTS 0–5 were poor, irrespective of treatment. Further investigation to define the role of EVT and range of acceptable outcomes in this subgroup is warranted.

  • stroke
  • CT
  • degenerative
  • brain
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  • Twitter @johanna_ospel, @nimakashani, @mihill68

  • Collaborators HERMES collaborators

  • Contributors MG: conceptualization, drafting, and critical revision of the manuscript. JMO, MK: data acquisition, drafting, and critical revision of the manuscript. SB: statistical analysis and critical revision of the manuscript. Remaining authors: data curation, critical revision of the manuscript.

  • 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 JMO is supported by the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation, and Freiwillige Akademische Gesellschaft Basel. Mayank Goyal is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, and Mentice.

  • Patient consent for publication Not required.

  • Ethics approval Approval from the University of Calgary’s ethics committee was obtained prior to the study.

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

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Raw data will be made available by the corresponding author upon reasonable request after approval by the HERMES Executive Committee.

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