Abstract TP165: Computed-Tomography (CT) Based Imaging Scores in Basilar Artery Occlusions – A Comparison of Predictive Abilities for Functional Outcomes

IntroductionEndovascular thrombectomy (EVT) dramatically improves clinical outcomes, but the reduction in final infarct volume only accounts for 10‐15% of the treatment benefit. There is a clear need for imaging biomarkers that are strongly associated with long‐term functional outcome after EVT, both in clinical practice and clinical trial design (surrogate outcome measure). Here we aimed to quantify the relationship between functional outcome and a range of ADC thresholds on post‐EVT MRI.MethodsA single‐center cohort of consecutive acute stroke patients with anterior circulation large vessel occlusion, successful recanalization via EVT (mTICI ≥ 2b), and MRI of the brain between 12 hours and 7 days after EVT was evaluated. Imaging was processed via RAPID software. Final infarct volume was based on the traditional ADC <620 threshold. Logistic regression quantified the association of lesion volumes and good functional outcome (90‐day modified Rankin Scale ≤ 2) at a range of lower ADC thresholds (<570, <520, and <470). Infarct density was calculated as the percentage of the final infarct volume below the ADC threshold with the greatest effect size. Univariate and multivariate logistic regression quantified the association between clinical/imaging variables and functional outcome. A receiver operating characteristics (ROC) analysis was used to calculated areas under the curve (AUC) with 95% confidence intervals for the final model. The Delong test compared this AUC with two additional models: (1) the final multivariate model without infarct density and (2) the final model without infarct density and final infarct volume.ResultsOf the 120 patients who underwent MRI after successful EVT, lesion volume based on the ADC threshold <470 had the strongest association with good outcome (OR: 0.81 per 10mL; 95% CI: 0.66–0.99). In a multivariate model, infarct density (volume <470/volume <620 * 100) was independently associated with good outcome (aOR 0.68 per 10%; 95% CI: 0.49–0.95). In the multivariate model, final infarct volume was no longer associated with outcome (aOR 0.98 per 10mL; 95% CI: 0.85–1.14). The ROC analysis of the multivariate model with only clinical variables (age, sex, and NIHSS) yielded a good ability to distinguish patients with good and bad outcome (AUC = 0.77; 95% CI: 0.69 – 0.84). Adding infarct volume improved classification performance (AUC = 0.82; 95% CI: 0.75 – 0.88), but this was further improved by adding infarct density (AUC = 0.84, 95% CI: 0.78 – 0.91); p=0.02 comparing all three AUCs (Figure 1).ConclusionThe degree of tissue injury after EVT is topographically heterogeneous, and more profound tissue injury manifests as lower ADC values. Here, we operationalized the severity of infarct as infarct density, which is independently associated with long‐term clinical outcome and provides greater prognostic information than final infarct volume. This technique may hold value as a surrogate outcome measure in early phased clinical trials.

Frailty Predicts Postoperative Functional Outcomes After Microsurgical Resection of Ruptured Brain Arteriovenous Malformations in Older Patients

Several scores estimate the prognosis for gunshot wounds to the head (GSWH) at the point of hospital admission. However, prognosis may change over the course of the hospital stay. This study measures the accuracy of the Baylor score among patients who have already survived the acute phase of hospitalization and generates conditional outcome curves for the duration of hospital stay for patients with GSWH. Patients in whom GSWH with dural penetration occurred between January 2009 and June 2019 were identified from a trauma registry at a level I trauma center in the southeastern US. The Baylor score was calculated using component variables. Conditional overall survival and good functional outcome (Glasgow Outcome Scale score of 4 or 5) curves were generated. The accuracy of the Baylor score in predicting mortality and functional outcome among acute-phase survivors (survival > 48 hours) was assessed using receiver operating characteristic curves and the area under the curve (AUC). A total of 297 patients were included (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male), and 129 patients survived the initial 48 hours of admission. These acute-phase survivors had a decreased mortality rate of 32.6% (n = 42) compared to 68.4% (n = 203) for all patients, and an increased rate of good functional outcome (48.1%; n = 62) compared to the rate for all patients (23.2%; n = 69). Among acute-phase survivors, the Baylor score accurately predicted mortality (AUC = 0.807) and functional outcome (AUC = 0.837). However, the Baylor score generally overestimated true mortality rates and underestimated good functional outcome. Additionally, hospital day 18 represented an inflection point of decreasing probability of good functional outcome. During admission for GSWH, surviving beyond the acute phase of 48 hours doubles the rates of survival and good functional outcome. The Baylor score maintains reasonable accuracy in predicting these outcomes for acute-phase survivors, but generally overestimates mortality and underestimates good functional outcome. Future prognostic models should incorporate conditional survival to improve the accuracy of prognostication after the acute phase.

O21. First trimester serum placental growth factor and hyperglycosylated human chorionic gonadotropin are associated with later pre-eclampsia

In patients with large vessel occlusion stroke of the anterior circulation, underlying cause is a determinant of outcome. Whether this is the case for posterior circulation large vessel occlusion stroke has yet to be determined. We aimed to report on cause in patients with posterior circulation stroke treated with endovascular thrombectomy and to analyze the association with functional outcome. We used data of patients with posterior circulation stroke included in the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, a prospective multicenter observational study, between 2014 and 2018. Stroke cause was categorized into large artery atherosclerosis (LAA), cardioembolism, arterial dissection, embolic stroke of undetermined source (ESUS), other determined cause, or undetermined cause. For primary analysis on the association between cause and outcome, we used multivariable ordinal logistic regression analysis to estimate the adjusted common odds ratio for a shift towards a better functional outcome on the modified Rankin Scale at 90 days with LAA as a reference group. Secondary outcomes included favorable functional outcome (modified Rankin Scale score 0-3), National Institutes of Health Stroke Scale score at 24 to 48 hours, reperfusion on digital subtraction angiography, and stroke progression. Of 264 patients with posterior circulation stroke, 84 (32%) had LAA, 48 (18%) cardioembolism, 31 (12%) dissection, and 14 (5%) ESUS. Patients with a dissection were younger (48 [interquartile range, 43-60] years) and had a lower National Institutes of Health Stroke Scale at baseline (12 [interquartile range, 6-31]) than patients with other cause. Functional outcome was better for patients with cardioembolism and ESUS compared to LAA (modified Rankin Scale adjusted common odds ratio, 2.4 [95% CI, 1.1-5.2], respectively adjusted common odds ratio, 3.1 [95% CI, 1.0-9.3]). Patients with a dissection had a lower chance of successful reperfusion compared with LAA (adjusted odds ratio, 0.20 [95% CI, 0.06-0.70]). Unlike the anterior circulation, most frequent cause in our posterior large vessel occlusion stroke cohort is LAA followed by cardioembolism, dissection, and ESUS. Patients with cardioembolism and ESUS have a better prognosis for functional outcome after endovascular thrombectomy than patients with LAA.

BackgroundEndovascular therapy seems to benefit a subset of patients with large vessel occlusion strokes. We aimed to develop a clinically useful tool to identify patients who are likely to benefit...

BackgroundMechanical thrombectomy (MT) is the standard of care for anterior circulation proximal large vessel occlusion (LVO) stroke with salvageable tissue. Here, the National Institutes of Health Stroke Scale (NIHSS) 24...

Gunshot wounds to the head (GSWH) are devastating injuries associated with high rates of morbidity and mortality. Poor outcomes in these patients necessitate identifying which patients may benefit the most from aggressive clinical and surgical management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale (GCS) score, and bullet trajectory at initial presentation to prognosticate mortality and Glasgow Outcome Scale (GOS) score at 6 months. In this cohort of patients with GSWH, the authors aimed to demonstrate internal validation of the Baylor score, which was recently externally validated by a distinct patient cohort at a different level I trauma center. Data were obtained from the trauma registry at a high-volume level I trauma center. Patients with penetrating cranial gunshot wounds from January 2008 to May 2022 were identified and retrospectively analyzed. Patient demographics, GCS score, pupillary response, and bullet trajectory on CT scan were reviewed, and the Baylor score was calculated for each patient. GOS score was determined for each patient at last follow-up. The validity of the Baylor score to predict mortality and good functional outcomes was assessed using receiver operating characteristic curves and areas under the curve (AUCs) as performance measures. Over the 14-year study period, 404 patients met the inclusion criteria (mean age 31.5 [SD 12.9] years, 88.9% male). A total of 227 (56.2%) patients died, while 139 (34.4%) had good functional outcomes defined as GOS score 4 or 5 (moderate disability or good recovery, respectively). The Baylor score demonstrated good prognostication of both mortality (AUC 0.91) and good functional outcomes (AUC 0.93). Baylor scores of 0-2 underestimated good functional outcomes, and scores of 3-5 underestimated mortality. Patients older than 35 years with nonreactive pupils and low GCS score (3 or 4) had 100% mortality. The Baylor score is a useful and accurate tool for clinicians to estimate mortality and functional outcomes in patients with GSWH. The score may be valuable in guiding patient- and family-centered discussions regarding prognosis early in the treatment course.

PurposeHaemorrhagic transformation (HT) is an unpredictable complication of acute ischaemic stroke with large vessel occlusion following endovascular thrombectomy (EVT), and imaging parameters that are correlated with haemorrhage are unknown. We developed a modified version of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) by adding a periventricular region to assess cerebral contrast extravasation (CE) on dual-energy computed tomography (DECT) and assessed its predictive value for HT.MethodsIn total, 101 patients who underwent DECT immediately after EVT were prospectively enrolled. CE was defined as incident hyperdensity on iodine overlay maps. We quantified the CT attenuation in Hounsfield units (HU) and iodine concentration within the CE regions. The modified ASPECTS divided the middle cerebral artery vascular territory into 11 regions and added one region (paraventricular) to the original score. CE was scored as 1 point for each region, and the cumulative score was determined. Follow-up imaging was performed within 7 days postoperatively to confirm the occurrence of HT. A receiver operating characteristic (ROC) curve was constructed to assess the predictive value of various DECT-measured parameters for HT.ResultsOverall, 75/101 (74.3%) patients exhibited CE following EVT, and 47/101 (46.5%) patients exhibited HT. In the ROC curve analysis, the DECT parameter with the maximal area under the curve (AUC) for HT was the modified ASPECTS (AUC=0.87), indicating that patients with a modified ASPECTS >2 were more likely to develop HT (sensitivity: 83.0%, specificity: 83.3%). The maximum iodine concentration (AUC=0.76) and maximum CT attenuation (AUC=0.68) in the hyperdense region were also predictors of postoperative HT.ConclusionThe modified ASPECTS is a practical and sensitive method for assessing postoperative HT risk in patients following EVT.

To investigate the value of baseline CT imaging for the prediction of functional outcome and benefit of endovascular thrombectomy (EVT) for anterior large vessel occlusion (LVO). We used individual patient data from seven randomized EVT trials and included patients with available baseline CT imaging and outcome data. We developed a model to predict functional outcome and benefit of EVT, including baseline stroke-related and brain frailty CT imaging features alone. We compared the discriminative performance of our model for predicting good functional outcome (modified Rankin Scale [mRS] 0-2) and treatment benefit (difference between the probability of mRS 0-2 with vs without EVT) with MR PREDICTS by calculating the difference in C-statistics (delta C and delta C-for-benefit). We included 1391 patients (median age, 67 years, interquartile range 59-76; 53% male). Discrimination of the model based on CT imaging alone was substantial for the prediction of good functional outcome (C-statistic 0.700, 95% CI: 0.666-0.731) and treatment benefit (C-for-benefit 0.640, 95% CI: 0.586-0.690). After adding the known strongest clinical predictors namely age and National Institutes of Health Stroke Scale score, discrimination improved to slightly lower than MR PREDICTS for prediction of good functional outcome (C-statistic 0.733 vs 0.750; delta C, -0.017 [95% CI: -0.037 to 0.003]) and treatment benefit (C-for-benefit 0.675 vs 0.692; delta C-for-benefit -0.017 [95% CI: -0.084 to 0.050]). Baseline CT imaging holds considerable predictive value with regard to functional outcome and treatment benefit, but a combination of clinical and imaging features offers the best predictive performance. Question The predictive value of baseline CT imaging for the prediction of functional outcome and benefit of EVT for anterior LVO stroke is uncertain. Findings Discrimination of a model based on CT imaging alone is substantial, but can further be improved by the addition of limited clinical characteristics. Clinical relevance Baseline CT imaging holds considerable predictive value with regard to functional outcome and treatment benefit. The addition of limited clinical information is needed to achieve predictive performance similar to an established prediction model.

BackgroundComputed tomography perfusion (CTP) parameters have been shown to have predictive value for functional outcomes of patients with basilar artery occlusion (BAO). We report the predictive value of CTP-based software...

To establish a safe and effective usage of oral tacrolimus (FK506) in small bowel transplantation (SBTx) recipients, trough levels and area under the curve (AUC) values of FK506 were assessed using swine models of SBTx and short bowel. Thirty-eight Landrace male piglets were divided into four groups as follows: Group 1, controls (n=13); Group 2, a one-third small bowel model (n=5); Group 3, a short bowel model (n=10); and Group 4, a one-third small bowel allograft model (n=10; five donors and five recipients). Piglets of Groups 1 and 3 were further divided into two sub-groups, according to the route of drug administration: Groups 1a (n=10) and 3a (n=7) received FK506 orally, and Groups 1b (n=3) and 3b (n=3) received FK506 intravenously. Oral or intravenous FK506 was started on post-operative day 3 and continued until day 7 in each group. On day 7, trough levels and AUC values were measured. In Groups 1a, 2, 3a and 4, trough levels of FK506 were 2.1+/-1.2 (p<0.01 vs. Group 2, 3a or 4), 11.2+/-2.1, 23.3+/-4.8 (p<0.05 vs. Group 2 or 4) and 14.6+/-3.0 ng/mL, and AUC values were 101+/-90 (p<0.01 vs. Group 3a or 4), 319&+/-155, 808+/-200, and 531+/-113 ng.h/mL, respectively. Both trough levels and AUC values were lowest in Group 1a and highest in Group 3a. Between Groups 1b and 3b, there was no significant difference in the blood levels of intravenous FK506. The shorter the functioning residual small intestine was, the higher the trough level of oral FK506 was, while the presence or absence of small intestine did not affect blood levels of intravenous FK506. These results suggest that oral FK506 is metabolized in the functioning small intestine during its absorption. Therefore, events which cause intestinal malfunction, such as graft rejection in SBTx, inflammation and loss of small intestine, may adversely raise the trough level of oral FK506.

Evaluation of a glucose meter for determining the glycemic responses of foods

Background and purposeEndovascular therapy is associated with improved clinical outcomes in patients presenting with large vessel occlusions (LVO) however outcomes are typically worse in patients presenting as inter-facility transfers. A...

Background The clinical benefit of endovascular thrombectomy (EVT) for acute basilar artery occlusion (BAO) in patients with mild symptoms remains controversial. Purpose To evaluate the efficacy and safety of EVT versus intravenous thrombolysis (IVT) in patients with BAO with National Institutes of Health Stroke Scale (NIHSS) scores of 0-9 or 0-5. Materials and Methods In a multicenter retrospective study between January 2018 and January 2024, outcomes in patients with BAO with NIHSS scores of 0-9 or 0-5 who underwent EVT or IVT were compared using inverse probability weighting (IPW) methods. In a meta-analysis, studies (published until April 1, 2025) comparing EVT and medical management (ie, control treatment) in BAO were identified. Results The retrospective study included 200 patients (median age, 69 years [IQR, 60-76 years]; 137 men), and the meta-analysis included six studies encompassing 3014 patients. Among patients with NIHSS scores of 0-9, after IPW, EVT was associated with a higher likelihood of excellent functional outcome (modified Rankin Scale [mRS] score of 0-1) compared with IVT (adjusted odds ratio [OR], 2.02 [95% CI: 1.05, 3.86]; P = .04). In contrast, among patients with NIHSS scores of 0-5 (n = 52), EVT was associated with a lower likelihood of independent ambulation (mRS score of 0-3) than IVT (adjusted OR, 0.19 [95% CI: 0.05, 0.80]; P = .02). Meta-analysis indicated that in patients with NIHSS scores of 0-9, EVT was associated with a higher likelihood of excellent functional outcome compared with control treatment (adjusted OR, 2.15 [95% CI: 1.60, 2.91]; P < .001). However, among patients with NIHSS scores of 0-5, EVT was associated with a reduced likelihood of independent ambulation compared with control treatment (adjusted OR, 0.23 [95% CI: 0.09, 0.59]; P = .002). Conclusion Compared with IVT, EVT was associated with a higher likelihood of excellent functional outcome in patients with BAO with NIHSS scores of 0-9 but a lower likelihood of independent ambulation in patients with NIHSS scores of 0-5. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Kallmes and Rabinstein in this issue.