Arooshi Kumar, MD

Liebeskind DS, Saber H, Bhuva P, Xiang B, Yoo AJ, Jadhav AP, Haussen DC, Budzik RF, Bonafe A, Yavagal DR, et al. Serial ASPECTS in the DAWN Trial: Infarct Evolution and Clinical Impact. Stroke. 2021;52:3318–3324.

With the rapid adoption of endovascular therapy (EVT) for selected ischemic stroke patients, there remains a need to identify practical biomarkers to help predict treatment efficacy and clinical outcomes. The Alberta Stroke Program Early CT Score (ASPECTS) grading system is a well-accepted method to capture the degree of brain injury following stroke in the anterior circulation.1,2 While it has emerged as one standard method to quantify degree of ischemia and select candidates for endovascular treatment (EVT), the utility of post-intervention ASPECTS scores remains unclear.

To that end, a secondary SWIFT analysis demonstrated that post-treatment ASPECTS score was a reliable predictor of 90-day clinical function after stroke for presenting in the early intervention window (< 6hours).3 This study aimed at investigating the relevance of post-treatment ASPECTS score for later presenting window (6-24 hours) patients with ischemic stroke using the DAWN trial results. In this study, the ASPECTS score, initial and after 24 hours, was tabulated from 81 CT-CT pairs, 56 CT-MRI pairs, and 66 MRI-MRI pairs.

 A total of 206 patients (mean age, 70.0±13.7 years; 54.9% [N=113] female) were included in the DAWN trial. The initial median core infarct volume was 10 cc (IQR, 0–19), while the median 24-hour core infarct volume was 16 cc (IQR, 4–50). Multivariable logistic regression demonstrated that older age and dyslipidemia were independently associated with higher baseline ASPECTS, while endovascular treatment, baseline glucose <150 mg/dL, lower baseline NIHSS, and older age predicted higher 24-hour ASPECTS. Among the patients who received endovascular therapy, 24-hour ASPECTS emerged as an independent predictor of good outcomes (defined as mRS between 0-2) at day 90 (OR, 1.32 [95% CI, 1.04–1.67], p=0.023).

This is an exciting secondary analysis of the DAWN trial that supports that 24-hour post-EVT ASPECTS score could be an indicative biomarker available to clinicians to predict clinical outcome. The authors acknowledge some limitations of this study, namely the various combinations of imaging modalities used to capture baseline and 24-hour intervention ASPECTS. Moreover, the DAWN trial by study design enrolled late window patients, suggesting these were slow progressing patients favoring better outcomes, which may bias the outcomes. Revascularization techniques and technology continue to evolve, and thus further investigating ASPECTS as a relevant biomarker to predict outcome in patients who received more novel EVT therapies could be of consideration to further generalize its relevance.

References:

  1. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyper-acute stroke before thrombolytic therapy. ASPECTS study group. Alberta stroke programme early CT score. Lancet. 2000;355:1670–1674.
  2. Prakkamakul S, Yoo AJ. ASPECTS CT in acute ischemia: review of current data. Top Magn Reson Imaging. 2017;26:103–112.
  3. Liebeskind DS, Jahan R, Nogueira RG, Jovin TG, Lutsep HL, Saver JL; SWIFT Investigators. Serial Alberta Stroke Program early CT score from baseline to 24 hours in Solitaire Flow Restoration with the Intention for Thrombectomy study: a novel surrogate end point for revascularization in acute stroke. Stroke. 2014;45:723–727.