Serial ASPECTS to predict stroke-associated pneumonia after thrombolysis in patients with acute ischemic stroke

 You are uselessly predicting a problem and not solving it! I'd have you all fired!

Here for your edification:

Just maybe this vaccine!

• Pneumonia Vaccine (3 posts to July 2020)

 

• 11% Stroke-associated pneumonia (2 posts to October 2020)

Serial ASPECTS to predict stroke-associated pneumonia after thrombolysis in patients with acute ischemic stroke

Sarawut Krongsut^1*Atiwat Soontornpun²Niyada Anusasnee³

• ¹Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saraburi Hospital, Saraburi, Thailand
• ²Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
• ³Division of Radiology, Saraburi Hospital, Saraburi, Thailand

Background: Stroke-associated pneumonia (SAP) is a serious complication in stroke patients, significantly increasing mortality. The Alberta Stroke Program Early CT Score (ASPECTS) is a recognized predictor of acute ischemic stroke outcomes. We aimed to investigate the performance of serial ASPECTS assessments (baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS) for predicting SAP in patients with thrombolyzed acute anterior circulation ischemic stroke (AACIS).

Materials: A retrospective observational cohort study of adult patients with thrombolyzed AACIS was conducted. Baseline and 24-h ASPECTS using non-contrast computed tomography (NCCT), complications of stroke, including SAP and swallowing dysfunction using the Modified Water Swallowing test, were collected. Baseline and 24-h ASPECTS were evaluated by a certified neurologist and neuroradiologist. The predictive performance was determined based on the receiver operating characteristic curve (ROC). Multivariable logistic regression analyses were employed to assess the impact of serial ASPECTS assessment on predicting SAP.

Results: Of the 345 patients with thrombolyzed AACIS in our study, 18.4% (64/345) experienced SAP. The patients’ median age was 62 years [interquartile range (IQR): 52–73], with 53.4% being male. The median NIHSS score was 11 points (IQR: 8–17). The ROC analysis revealed areas under the curve for predicting SAP with baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS were 0.75 (95% CI, 0.69–0.82), 0.84 (95% CI, 0.79–0.89), and 0.82 (95% CI, 0.76–0.87), respectively. Of the three measures, 24-h ASPECTS was a better predictor of SAP (odds ratio: 5.33, 95%CI: 2.08–13.67, p < 0.001) and had a higher sensitivity (0.84 [95%CI, 0.74–0.92]) and specificity (0.79 [95%CI, 0.74–0.84]) than both baseline ASPECTS and change in ASPECTS.

Conclusion: 24-h NCCT-ASPECTS outperformed both baseline ASPECTS and change in ASPECTS for predicting SAP. Notably, 24-h ASPECTS, with a cut-off value of ≤6, exhibited good predictive performance and emerged as the better predictor for SAP.

1 Introduction

Stroke represents a substantial global public health challenge, being a leading cause of both mortality and disability (1). In Thailand, it ranks as the primary cause of death for females and the third most common for males, with a mortality rate of 10% and a 50% prevalence of disabilities among survivors (1). The incidence of ischemic stroke in Thailand is increasing as the average age of the population continues to rise. Intravenous recombinant tissue plasminogen activator (IV-tPA) is the standard treatment for patients with acute ischemic stroke (AIS) (2). Complications after stroke are associated with increased mortality and length of hospital stay. Most of these complications appear within the first week after AIS (3). Disability and mortality increase with the number of complications, particularly stroke-associated pneumonia (SAP) and other infections (4). SAP is a commonly encountered complication in clinical practice. The incidence of SAP as reported in previous studies varies depending on the hospital treatment facility, ranging from 10% to 57% for patients treated in intensive care units to 4%–12% for patients treated in stroke units (4, 5). This demonstrates that it is crucial to prioritize early detection and thorough monitoring of patients at high-risk for SAP. This proactive approach is designed to support physicians in treatment decision-making and ultimately to lead to reduced mortality rates and improved prognosis among patients with AIS receiving thrombolytic therapy.

Due to the lack of specific clinical symptoms and neuro-radiographic information that can aid in the early prediction of SAP, the appearance of complications often indicates a severe SAP that frequently results in mortality. In response to that situation, development of a prediction model was undertaken to identify patients at high risk for SAP (6, 7). Known risk factors for SAP include older age, male gender, diabetes, hypertension, atrial fibrillation (AF), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pre-existing dependency, various stroke subtypes, dysphagia, and greater stroke severity (8). The Alberta Stroke Program Early CT Score (ASPECTS) is a 10-point quantitative topographic CT scan score in patients with middle cerebral artery (MCA) stroke to assess early ischemic changes and cytotoxic edema (9). A previous study reported that ASPECTS and the National Institute of Health Stroke Score (NIHSS) had a strong negative correlation coefficient of −0.680 (p < 0.001) (10). Previous studies have also shown that 24-h NIHSS can predict long-term stroke outcomes more accurately than change in NIHSS and baseline NIHSS in patients treated with IV-tPA and mechanical thrombectomy (11, 12). Patients receiving IV-tPA typically undergo a 24-h follow-up using non-contrast computed tomography (NCCT). This period before the follow-up is of clinical significance as it provides a window of opportunity for re-evaluation of brain NCCT to exclude the presence of hemorrhagic transformation, a condition which is closely associated with stroke prognosis and which aids in assessing the size and location of cerebral ischemia. Thus, the assessment of serial ASPECTS (baseline ASPECTS, 24-h ASPECTS, and change ASPECTS) could serve as a crucial predictor for SAP in patients with AIS undergoing thrombolytic treatment.

Several studies have generally reported that ASPECTS was a useful tool in predicting functional outcome and intracerebral hemorrhage (ICH) (13, 14). In light of the current insufficiency of and lack of clarity in the available data including the lack of knowledge regarding the prognostic value of serial ASPECTS assessment, 24-h ASPECTS assessment could potentially serve as an important tool in predicting SAP. To investigate that possibility, the present study was designed to compare the prognostic value and assess the potential impact of baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS on NCCT for predicting SAP in patients with thrombolyzed acute anterior circulation ischemic stroke (AACIS).

More at link.