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Original research
Development and validation of a SCORing systEm for pre-thrombectomy diagnosis of IntraCranial Atherosclerotic Disease (Score-ICAD)
  1. Mohamed A Tarek1,2,
  2. Mateus Damiani Monteiro3,4,
  3. Mahmoud H Mohammaden5,
  4. Pedro N Martins1,4,
  5. Sunil A Sheth6,
  6. Jaydevsinh Dolia1,7,
  7. Aqueel Pabaney8,
  8. Jonathan A Grossberg9,
  9. Michael Nahhas10,
  10. Carlos A De La Garza6,
  11. Sergio Salazar-Marioni11,
  12. Srikant Rangaraju12,
  13. Raul G Nogueira13,
  14. Diogo C Haussen9
    1. 1Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
    2. 2Department of Neurology and Psychological Medicine, Sohag University Faculty of Medicine, Sohag, Egypt
    3. 3Emory University School of Medicine, Atlanta, Georgia, USA
    4. 4Grady Health System Marcus Stroke and Neuroscience Center, Atlanta, Georgia, USA
    5. 5Department of Neurology, Emory University Atlanta, Atlanta, Georgia, USA
    6. 6Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
    7. 7Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
    8. 8Emory University, Atlanta, Georgia, USA
    9. 9Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
    10. 10Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
    11. 11Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
    12. 12Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
    13. 13Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
    1. Correspondence to Dr Diogo C Haussen, Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA; diogo.haussen{at}


    Background Early identification of intracranial atherosclerotic disease (ICAD) may impact the management of patients undergoing mechanical thrombectomy (MT). We sought to develop and validate a scoring system for pre-thrombectomy diagnosis of ICAD in anterior circulation large vessel/distal medium vessel occlusion strokes (LVOs/DMVOs).

    Methods Retrospective analysis of two prospectively maintained comprehensive stroke center databases including patients with anterior circulation occlusions spanning 2010–22 (development cohort) and 2018–22 (validation cohort). ICAD cases were matched for age and sex (1:1) to non-ICAD controls.

    Results Of 2870 MTs within the study period, 348 patients were included in the development cohort: 174 anterior circulation ICAD (6% of 2870 MTs) and 174 controls. Multivariable analysis β coefficients led to a 20 point scale: absence of atrial fibrillation (5); vascular risk factor burden (1) for each of hypertension, diabetes, smoking, and hyperlipidemia; multifocal single artery stenoses on CT angiography (3); absence of territorial cortical infarct (3); presence of borderzone infarct (3); or ipsilateral carotid siphon calcification (2). The validation cohort comprised 56 ICAD patients (4.1% of 1359 MTs): 56 controls. Area under the receiver operating characteristic curve was 0.88 (0.84–0.91) and 0.82 (0.73–0.89) in the development and validation cohorts, respectively. Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0, 95% CI −0.5 to –0.5; slope 0.8, 95% CI 0.5 to 1.1). In the full cohort (n=414), ≥11 points showed the best performance for distinguishing ICAD from non-ICAD, with 0.71 (95% CI 0.65 to 0.78) sensitivity and 0.82 (95% CI 0.77 to 0.87) specificity, and 3.92 (95% CI 2.92 to 5.28) positive and 0.35 (95% CI 0.28 to 0.44) negative likelihood ratio. Scores ≥12 showed 90% specificity and 63% sensitivity.

    Conclusion The proposed scoring system for preprocedural diagnosis of ICAD LVOs and DMVOs presented satisfactory discrimination and calibration based on clinical and non-invasive radiological data.

    • Stroke
    • Thrombectomy
    • Intracranial Thrombosis

    Data availability statement

    Data are available upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request.

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    • X @Mo_TarekNeuro, @mateusdamiani, @Mahmoudneuro, @JayDoliaMD, @JAGrossbergMD, @MichaelNahhas, @diogohaussen

    • Contributors Conceptualization and methodology: MAT, MDM, and DCH. Formal analysis: MAT, SR, PM, MHM, and DCH. Investigation: MAT, MDM, PNM, and MN. Data collection: MAT, MDM, MN, CAG, and SS-M. Data curation: all authors. Writing-original draft: MAT and DCH. Writing-review and editing: all authors. Visualization: MAT, PNM, and DCH. Project administration: MAT and DCH. Supervision: DCH. Guarantor: DCH. Other coauthors: critical revision 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: consultant for Anaconda, Biogen, Cerenovus, Genentech, Philips, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron; stock options in Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, and Perfuze; principal investigator of the ENDOLOW trial and DUSK trial; stock options in Viz-AI, Perfuze, Cerebrotech, Reist/Q’Apel Medical, Truvic, Tulavi Therapeutics, Vastrax, Piraeus Medical, Brain4Care, Quantanosis AI, and Viseon. SAS: grant from National Institutes of Health (R01NS121154); consultant for Penumbra and Imperative Care; ownership of Motif Neurosciences. DCH: consultant for Stryker Neurovascular, Cerenovus, Chiesi USA, Brainomix, Poseydon Medical; consulting/DSMB for Jacobs Institute/Medtronic, Vesalio, Rapid Pulse; stock options in VizAI and Motif Neurotech.

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

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