From the Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth (P.B., A.J.Y.).
The Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA (A.P.J.).
Stroke. 2019 Sep;50(9):2404-2412. doi: 10.1161/STROKEAHA.118.024583. Epub 2019 Jul 26.
Background and Purpose- It is unknown whether noncontrast computed tomography (NCCT) can identify patients who will benefit from intra-arterial treatment (IAT) in the extended time window. We sought to characterize baseline Alberta Stroke Program Early CT Score (ASPECTS) in DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and to assess whether ASPECTS modified IAT effect. Methods- Core lab adjudicated ASPECTS scores were analyzed. The trial cohort was divided into 2 groups by qualifying imaging (computed tomography versus magnetic resonance imaging). ASPECTS-by-treatment interaction was tested for the trial coprimary end points (90-day utility-weighted modified Rankin Scale (mRS) score and mRS, 0-2), mRS 0 to 3, and ordinal mRS. ASPECTS was evaluated separately as an ordinal and a dichotomized (0-6 versus 7-10) variable. Results- Of 205 DAWN subjects, 123 (60%) had NCCT ASPECTS, and 82 (40%) had diffusion weighted imaging ASPECTS. There was a significant ordinal NCCT ASPECTS-by-treatment interaction for 90-day utility-weighted mRS (interaction P=0.04) and mRS 0 to 2 (interaction P=0.02). For both end points, IAT effect was more pronounced at higher NCCT ASPECTS. The dichotomized NCCT ASPECTS-by-treatment interaction was significant only for mRS 0 to 2 (interaction P=0.04), where greater treatment benefit was seen in the ASPECTS 7 to 10 group (odds ratio, 7.50 [2.71-20.77] versus odds ratio, 0.48 [0.04-5.40]). A bidirectional treatment effect was observed in the NCCT ASPECTS 0 to 6 group, with treatment associated with not only more mRS 0 to 3 outcomes (50% versus 25%) but also more mRS 5 to 6 outcomes (40% versus 25%). There was no significant modification of IAT effect by diffusion weighted imaging ASPECTS. Conclusions- Baseline NCCT ASPECTS appears to modify IAT effect in DAWN. Higher NCCT ASPECTS was associated with greater benefit from IAT. No treatment interaction was observed for diffusion weighted imaging ASPECTS.
目前尚不清楚非对比增强计算机断层扫描（NCCT）是否可以识别出在扩展时间窗内将从动脉内治疗（IAT）中获益的患者。我们试图描述 DAWN（在接受神经介入治疗的觉醒和延迟出现的中风中，通过 DWI 或 CTP 评估与临床不匹配进行的治疗选择）中的基线阿尔伯塔卒中项目早期 CT 评分（ASPECTS），并评估 ASPECTS 是否改变了 IAT 的效果。
对核心实验室裁定的 ASPECTS 评分进行了分析。根据合格的影像学（计算机断层扫描与磁共振成像）将试验队列分为 2 组。对试验的主要终点（90 天效用加权改良 Rankin 量表（mRS）评分和 mRS0-2、mRS0-3 和有序 mRS）进行了 ASPECTS-治疗的交互作用检验。分别评估 ASPECTS 作为有序和二分类（0-6 与 7-10）变量。
在 205 例 DAWN 患者中，123 例（60%）有 NCCT ASPECTS，82 例（40%）有弥散加权成像 ASPECTS。90 天效用加权 mRS 的 NCCT ASPECTS-治疗交互作用具有显著的有序性（交互 P=0.04）和 mRS0-2（交互 P=0.02）。对于这两个终点，NCCT ASPECTS 较高时 IAT 的效果更为明显。二分类的 NCCT ASPECTS-治疗交互作用仅在 mRS0-2 时具有统计学意义（交互 P=0.04），在 ASPECTS7-10 组中观察到更大的治疗获益（优势比，7.50[2.71-20.77]与优势比，0.48[0.04-5.40]）。在 NCCT ASPECTS0-6 组中观察到双向治疗效果，治疗不仅与更多的 mRS0-3 结局相关（50%比 25%），而且与更多的 mRS5-6 结局相关（40%比 25%）。扩散加权成像 ASPECTS 对 IAT 效果没有明显的修饰作用。
基线 NCCT ASPECTS 似乎改变了 DAWN 中的 IAT 效果。较高的 NCCT ASPECTS 与 IAT 的获益更大相关。未观察到扩散加权成像 ASPECTS 的治疗交互作用。
