You are here

  • Home
  • Online First
  • Follow-up ASPECTS improves prediction of potentially lethal malignant edema in patients with large middle cerebral artery stroke

Article Text

Article menu
Download PDFPDF
Ischemic stroke
Original research
Follow-up ASPECTS improves prediction of potentially lethal malignant edema in patients with large middle cerebral artery stroke
  1. Rebecca Stafford1,2,
  2. Stefanos Chatzidakis3,4,
  3. Ivy So Yeon Kim1,2,
  4. Yihan Zhang1,3,
  5. Andriani Rina3,4,
  6. Benjamin Brush5,
  7. Asim Mian2,6,
  8. Mohamad Abdalkader2,6,
  9. David M Greer1,2,
  10. Stelios M Smirnakis3,4,7,
  11. Steven K Feske1,2,
  12. Josée Dupuis8,9,
  13. Charlene J Ong1,2
  1. 1Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
  2. 2Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
  3. 3Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
  4. 4Harvard Medical School, Boston, Massachusetts, USA
  5. 5Department of Neurology, New York University Langone Medical Center, New York, New York, USA
  6. 6Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
  7. 7Department of Neurology, Jamaica Plain Veterans Administration Hospital, Boston, Massachusetts, USA
  8. 8Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
  9. 9Department of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
  1. Correspondence to Dr Charlene J Ong, 85 East Concord St, Department of Neurology, Suite 1116 Boston Medical Center, Boston, MA 02118, USA; Cjong{at}bu.edu

Abstract

Background Recent studies have shown that follow-up head CT is a strong predictor of functional outcomes in patients with middle cerebral artery stroke and mechanical thrombectomy. We sought to determine whether total and/or regional follow-up Alberta Stroke Program Early CT Score (ASPECTSfu) are associated with important clinical outcomes during hospitalization and improve the performance of clinical prediction models of potentially lethal malignant edema (PLME).

Methods We conducted a retrospective study of patients at three medical centers in a major North American metropolitan area with baseline and follow-up head CTs after large middle cerebral artery stroke between 2006 and 2022. We used multivariable logistic regression to test the association of total and regional ASPECTSfu with PLME (cerebral edema related death or surgery), adjusting for total baseline ASPECTS, age, sex, admission glucose, tissue plasminogen activator, and mechanical thrombectomy. We compared existing clinical risk models with and without total or regional ASPECTSfu using area under the curve.

Results In our 560 patient cohort, lower total ASPECTSfu was significantly associated with higher odds of PLME when adjusting for confounders (OR 1.69, 95% CI 1.49 to 2.0), and improved model discrimination compared with existing models and models using baseline ASPECTS. Deep territory involvement (OR 2.46, 95% CI 1.53 to 4.01) and anterior territory involvement (OR 3.23, 95% CI 1.88 to 5.71) were significantly associated with PLME.

Conclusions Lower ASPECTSfu and certain locations on regional ASPECTSfu, including deep and anterior areas, were significantly associated with PLME. Including ASPECTSfu information improved discrimination of established edema prediction models and could be used immediately to help facilitate clinical management decisions and prognostication.

  • Brain
  • CT
  • Stroke

Data availability statement

Data are available upon reasonable request. Deidentified data are available upon request and establishment of a data use agreement. Please email the corresponding author for access.

https://doi.org/10.1136/jnis-2023-021145

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    Data are available upon reasonable request. Deidentified data are available upon request and establishment of a data use agreement. Please email the corresponding author for access.

    View Full Text

    Footnotes

    • RS and SC are joint first authors.

    • Contributors CJO, SKF, and SMS conceived the idea of the presented analyses and designed the overall study. RS, SC, ISYK, YZ, and AR organized and collected the patient data for analysis. RS, ISYK, CJO, SC, and AR performed manual reviews of patient notes to extract various features, such as stroke onset times, medications, procedures, and outcomes. BB developed code for automated feature extraction from radiology reports. AM and MA provided oversight and guidance on radiographic image measurements. RS, SC, BB, and CJO manually reviewed the radiographic images to measure swelling and determine radiographic outcomes. RS and YZ performed statistical analysis and interpretation. BB, AM, MA, DMG, SMS, SKF, JD, and CJO provided oversight and review of the statistical analysis. RS, SC, and CJO drafted the manuscript. BB, AM, MA, SMS, SKF, JD, and DMG helped with reviews and revisions. CJO provided overall study direction and critical review. All authors contributed to the article and approved the submitted version. CJO is the guarantor.

    • Funding NIH/NINDS K23NS116033 supported this work. The study sponsor had no role in study design; collection, analysis, interpretation of the data; writing of this manuscript; or decision to submit the paper for publication.

    • Competing interests None declared.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.