Automated scoring of collaterals, blood pressure, and clinical outcome after endovascular treatment in patients with acute ischemic stroke and large-vessel occlusion

You described something but provided no solution on how to increase collateral scores to get better recovery. That is a failing grade and requires firing everyone involved.  Also no creation of a blood pressure management protocol.

Automated scoring of collaterals, blood pressure, and clinical outcome after endovascular treatment in patients with acute ischemic stroke and large-vessel occlusion

Daniel Guisado-Alonso¹, Pol Camps-Renom^1*, Raquel Delgado-Mederos¹, Esther Granell², Luis Prats-Sánchez¹, Alejandro Martínez-Domeño¹, Marina Guasch-Jiménez¹, M. Victoria Acosta¹, Anna Ramos-Pachón¹ and Joan Martí-Fàbregas¹

• ¹Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Barcelona, Spain
• ²Department of Radiology, UDIAT Corporació Sanitària Parc Taulí, Sabadell, Spain

Introduction: We aimed to determine whether the degree of collateral circulation is associated with blood pressure at admission in acute ischemic stroke patients treated with endovascular treatment and to determine its prognostic value.

Methods: We evaluated patients with anterior large vessel occlusion treated with endovascular treatment in a single-center prospective registry. We collected clinical and radiological data. Automated and validated software (Brainomix Ltd., Oxford, UK) was used to generate the collateral score (CS) from the baseline single-phase CT angiography: 0, filling of ≤10% of the occluded MCA territory; 1, 11–50%; 2, 51–90%; 3, >90%. When dichotomized, we considered that CS was good (CS = 2–3), or poor (CS = 0–1). We performed bivariate and multivariable ordinal logistic regression analysis to predict CS categories in our population. The secondary outcome was to determine the influence of automated CS on functional outcome at 3 months. We defined favorable functional outcomes as mRS 0–2 at 3 months.

Results: We included 101 patients with a mean age of 72.1 ± 13.1 years and 57 (56.4%) of them were women. We classified patients into 4 groups according to the CS: 7 patients (6.9%) as CS = 0, 15 (14.9%) as CS = 1, 43 (42.6%) as CS = 2 and 36 (35.6%) as CS = 3. Admission systolic blood pressure [aOR per 10 mmHg increase 0.79 (95% CI 0.68–0.92)] and higher baseline NIHSS [aOR 0.90 (95% CI, 0.84–0.96)] were associated with a worse CS. The OR of improving 1 point on the 3-month mRS was 1.63 (95% CI, 1.10–2.44) favoring a better CS (p = 0.016).

Conclusion: In acute ischemic stroke patients with anterior large vessel occlusion treated with endovascular treatment, admission systolic blood pressure was inversely associated with the automated scoring of CS on baseline CT angiography. Moreover, a good CS was associated with a favorable outcome.

Introduction

Endovascular treatment (EVT) is the standard of care for acute ischemic stroke (AIS) in selected patients with large intracranial vessel occlusion (LVO) (1, 2). However, only around 46% of the patients treated with EVT achieve functional independence at 3 months (3). Therefore, there is still room for improvement in EVT clinical outcomes.

Pre-treatment degree of collateral circulation (CC) has been reported as an important determinant for successful reperfusion (4) and clinical outcome (3) after EVT. The effects of the CC are crucial in maintaining perfusion to penumbral regions and also in facilitating the clearance of fragmented thrombus (5). In some studies, a higher admission blood pressure (BP) (6) and BP drops during EVT (7) are associated with a poorer clinical outcome after EVT. However, there are scarce and contradictory data evaluating the effect of admission BP on CC in AIS (8, 9). A better understanding of this relationship could lead to an optimisation of CC by a better management of pre-procedural and intra-procedural BP.

Multiple scores are available to measure CC in AIS, but the intra- and inter-observer agreement for all of them is modest (10, 11). Automated quantitative CC scoring in patients with AIS is a reliable, quick, and user-independent measure of the CC degree on baseline Computed Tomography Angiography (CTA) (12). Although there is no gold standard, one of the most widely used CC scales on CTA is the one described by Tan et al. (13). For this scale, there is a validated software to get a fully automated collateral score (CS) (14), that provides an objective quantification that is much more reproducible by other researchers.

The aim of the current study was to determine the association of admission BP with the degree of CC using an automated CS and to determine the prognostic value of CC in patients with AIS treated with EVT.

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