The charlotte large artery occlusion endovascular therapy outcome score compares favorably to the critical area perfusion score for prognostication before basilar thrombectomy.

INTRODUCTION: The Critical Area Perfusion Score (CAPS) predicts functional outcomes in vertebrobasilar thrombectomy patients based on computed tomography perfusion (CTP) hypoperfusion. We compared CAPS to the clinical-radiographic Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS). METHODS: Acute basilar thrombosis patients from January 2017-December 2021 were included in this retrospective analysis from a health system's stroke registry. Inter-rater reliability was assessed for 6 CAPS raters. A logistic regression with CAPS and CLEOS as predictors was performed to predict 90-day modified Rankin Scale (mRS) score 4-6. Area under the curve (AUC) analyses were performed to evaluate prognostic ability. RESULTS: 55 patients, mean age 65.8 (± 13.1) years and median NIHSS score 15.55-24, were included. Light's kappa among 6 raters for favorable versus unfavorable CAPS was 0.633 (95% CI 0.497-0.785). Increased CLEOS was associated with elevated odds of a poor outcome (odds ratio (OR) 1.0010, 95% CI 1.0007-1.0014, p<0.01), though CAPS was not (OR 1.0028, 95% CI 0.9420-1.0676, p=0.93). An overall favorable trend was observed for CLEOS (AUC 0.69, 95% CI 0.54-0.84) versus CAPS (AUC 0.49, 95% CI 0.34-0.64; p=0.051). Among 85.5% of patients with endovascular reperfusion, CLEOS had a statistically higher sensitivity than CAPS at identifying poor 90-day outcomes (71% versus 21%, p=0.003). CONCLUSIONS: CLEOS demonstrated better predictive ability than CAPS for poor outcomes overall and in patients achieving reperfusion after basilar thrombectomy.

Neurological outcomes for patients meeting radiographic criteria for DEFUSE 3 and SELECT2.

BACKGROUND: The DEFUSE 3 and SELECT2 thrombectomy trials included some patients with similar radiographic profiles, although the rates of good functional outcomes differed widely between the studies. OBJECTIVE: To report neurological outcomes for patients who meet CT and CT perfusion (CTP) inclusion criteria common to both DEFUSE 3 and SELECT2. METHODS: Retrospective study of thrombectomy patients, presenting between November 2016 and December 2023 to a large health system, with Alberta Stroke Program Early CT score ≥6, core infarction 50-69 mL, mismatch ratio ≥1.8, and mismatch volume ≥15 mL. The primary outcome was 90-day modified Rankin Scale score 0-2. A logistic regression analysis was performed to identify independent predictors of the primary outcome. RESULTS: 85 patients, with mean age 64.6 (16.6) years and median National Institutes of Health Stroke Scale score 18 (15-23), were included. Thirty-eight of 85 patients (44.7%) were functionally independent at 90 days. Predictors of functional independence included age (OR=0.943, 95% CI 0.908 to 0.980; P=0.003), initial glucose (OR=0.989, 95% CI 0.978 to 1.000; P=0.044), and time last known well to skin puncture (OR=0.997, 95% CI 0.994 to 1.000; P=0.028). The area under the curve for the multivariable model predicting the primary outcome was 0.82 (95% CI 0.73 to 0.92). CONCLUSION: Nearly half of patients meeting radiographic criteria common to DEFUSE 3 and SELECT2 are functionally independent at 90 days, similar to rates reported for the treated DEFUSE 3 cohort. This might be due to their moderate core volumes and large ischemic penumbra.

Validation of the Charlotte large artery occlusion endovascular therapy outcome score using Viz.ai-derived cerebral blood volume index.

BACKGROUND: The Charlotte large artery occlusion endovascular therapy outcome score (CLEOS) predicts poor 90-day outcomes for patients presenting with internal carotid artery (ICA) or middle cerebral artery (MCA) occlusions. It incorporates RAPID-derived cerebral blood volume (CBV) index, a marker of collateral circulation. We validated the predictive ability of CLEOS with Viz.ai-processed computed tomography perfusion (CTP) imaging. METHODS: The original CLEOS derivation cohort was compared to a validation cohort consisting of all ICA and MCA thrombectomy patients treated at a large health system with Viz.ai-processed CTP. Rates of poor 90-day outcome (mRS 4-6) were compared in the derivation and validation cohorts, stratified by CLEOS. CLEOS was compared to previously described prediction models using area under the curve (AUC) analyses. Calibration of CLEOS was performed to compare predicted risk of poor outcomes with observed outcomes. RESULTS: One-hundred eighty-one patients (mean age 66.4 years, median NIHSS 16) in the validation cohort were included. The validation cohort had higher median CTP core volumes (24 vs 8 ml) and smaller median mismatch volumes (81 vs 101 ml) than the derivation cohort. CLEOS-predicted poor outcomes strongly correlated with observed outcomes (R2 = 0.82). AUC for CLEOS in the validation cohort (0.72, 95% CI 0.64-0.80) was similar to the derivation cohort (AUC 0.75, 95% CI 0.70-0.80) and was comparable or superior to previously described prognostic models. CONCLUSIONS: CLEOS can predict risk of poor 90-day outcomes in ICA and MCA thrombectomy patients evaluated with pre-intervention, Viz.ai-processed CTP.

Automated detection of intracranial large vessel occlusions using Viz.ai software: Experience in a large, integrated stroke network.

BACKGROUND AND PURPOSE: Endovascular thrombectomy is an evidence-based treatment for large vessel occlusion (LVO) stroke. Commercially available artificial intelligence has been designed to detect the presence of an LVO on computed tomography angiogram (CTA). We compared Viz.ai-LVO (San Francisco, CA, USA) to CTA interpretation by board-certified neuroradiologists (NRs) in a large, integrated stroke network. METHODS: From January 2021 to December 2021, we compared Viz.ai detection of an internal carotid artery (ICA) or middle cerebral artery first segment (MCA-M1) occlusion to the gold standard of CTA interpretation by board-certified NRs for all code stroke CTAs. On a monthly basis, sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Trend analyses were conducted to evaluate for any improvement of LVO detection by the software over time. RESULTS: 3851 patients met study inclusion criteria, of whom 220 (5.7%) had an ICA or MCA-M1 occlusion per NR. Sensitivity and specificity were 78.2% (95% CI 72%-83%) and 97% (95% CI 96%-98%), respectively. PPV was 61% (95% CI 55%-67%), NPV 99% (95% CI 98%-99%), and accuracy was 95.9% (95% CI 95.3%-96.5%). Neither specificity or sensitivity improved over time in the trend analysis. CONCLUSIONS: Viz.ai-LVO has high specificity and moderately high sensitivity to detect an ICA or proximal MCA occlusion. The software has the potential to streamline code stroke workflows and may be particularly impactful when emergency access to NRs or vascular neurologists is limited.

The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Predicts Poor Outcomes 1 Year After Endovascular Thrombectomy.

OBJECTIVE: We evaluated the ability of several outcome prognostic scales to predict poor 1-year outcomes and mortality after endovascular thrombectomy. METHODS: In this retrospective analysis from the stroke registry of a large integrated health system, consecutive patients presenting from August 2020 to September 2021 with an anterior circulation large-vessel occlusion stroke treated with endovascular thrombectomy were included. Multivariable logistic regression was performed to determine the ability of each scale to predict the primary outcome (1-year modified Rankin Scale [mRS] score of 4-6) and the secondary outcome (1-year mortality). Area under the curve analyses were performed for each scale. RESULTS: In 237 included patients (mean age 68 [±15] years; median National Institutes of Health Stroke Scale score 16 [11-21]), poor 1-year outcomes were present in 116 patients (49%) and 1-year mortality was 34%. The CLEOS (Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score), which incorporates age, baseline National Institutes of Health Stroke Scale score, initial glucose level, and computed tomography perfusion cerebral blood volume index, had a significant association with poor 1-year outcomes (per 25-point increase; odds ratio, 1.0134; P = 0.02). CLEOS and PRE (Pittsburgh Response to Endovascular Therapy) were both significantly associated with 1-year mortality. Area under the curve values were comparable for CLEOS, PRE, Houston Intra-Arterial Therapy 2, and Totaled Health Risks in Vascular Events to predict 1-year mRS score 4-6 and mortality. Only 1 of 18 patients with CLEOS ≥690 had a 1-year mRS score of 0-3. CONCLUSIONS: CLEOS can predict poor 1-year outcomes and mortality for patients with anterior circulation large-vessel occlusion using prethrombectomy variables.

Predicting severe disability or death in endovascular thrombectomy with large computed tomography perfusion core infarction and limited penumbra.

BACKGROUND: Patients presenting with large core infarctions benefit from treatment with endovascular thrombectomy (EVT), with a notable 50% reduction in rates of severe disability (modified Rankin Scale [mRS] 5) at 90 days. We studied the ability of previously reported prognostic scales to predict devastating outcomes in patients with a large ischemic core and limited salvageable brain tissue. METHODS: Retrospective analysis from a health system's code stroke registry, including consecutive thrombectomy patients from November 2017 to December 2022 with an anterior circulation large vessel occlusion, computed tomography perfusion core infarct ≥ 50 ml, and mismatch volume < 15 ml or mismatch ratio < 1.8. Previously reported scales were compared using logistic regression and area under the curve (AUC) analyses to predict 90-day mRS 5-6. RESULTS: Sixty patients (mean age 62.38 ± 14.25 years, median core volume 103 ml [74.75-153]) met inclusion criteria, of whom 27 (45%) had 90-day mRS 5-6. The Charlotte Large artery occlusion endovascular therapy Outcome Score (CLEOS) (odds ratio [OR] 1.35, 95% CI [1.14-1.60], p = 0.0005), Houston Intra-Arterial Therapy-2 (OR 1.35, 95% CI [1.00-1.83], p = 0.0470), and Totaled Health Risks in Vascular Events (OR 1.53, 95% CI [1.07-2.18], p = 0.0199) predicted the primary outcome in the logistic regression analysis. CLEOS performed best in the AUC analysis (AUC 0.83, 95% CI [0.72-0.94]). CONCLUSION: CLEOS predicts devastating outcomes after EVT in patients with large core infarctions and small volumes of ischemic penumbra.

The Charlotte Large artery occlusion Endovascular therapy Outcome Score predicts independent outcome after thrombectomy.

BACKGROUND AND PURPOSE: Predicting functional outcomes after endovascular thrombectomy (EVT) is of interest to patients and families as they navigate hospital and post-acute care decision-making. We evaluated the prognostic ability of several scales to predict good neurological function after EVT. METHODS: We retrospectively analyzed records from a health system's code stroke registry, including consecutive successful thrombectomy patients from August 2020 to February 2023 presenting with an anterior circulation large vessel occlusion who were evaluated with pre-EVT CT perfusion. Primary and secondary outcomes were 90-day modified Rankin Scale (mRS) scores 0-2 and 0-1, respectively. Logistic regression was performed to evaluate the ability of each scale to predict the outcomes. Scales were compared by calculating the area under the curve (AUC). RESULTS: A total of 465 patients (mean age 68.1 [±14.9] years, median National Institutes of Health Stroke Scale [NIHSS] 16 [11-21]) met inclusion criteria. In the logistic regression, the Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS), Totaled Health Risks in Vascular Events, Houston Intra-Arterial Therapy-2, Pittsburgh Response to Endovascular therapy, and Stroke Prognostication using Age and NIHSS were significant in predicting the primary and secondary outcomes. CLEOS was superior to all other scales in predicting 90-day mRS 0-2 (AUC .75, 95% confidence interval [CI] .70-.80) and mRS 0-1 (AUC .74, 95% CI .69-.78). Twenty of 22 patients (90.9%) with CLEOS <315 had 90-day mRS 0-2. CONCLUSIONS: CLEOS predicts independent and excellent neurological function after anterior circulation EVT.

Predictors of devastating functional outcome despite successful basilar thrombectomy.

BACKGROUND: Basilar thrombosis frequently leads to poor functional outcomes, even with good endovascular reperfusion. We studied factors associated with severe disability or death in basilar thrombectomy patients achieving revascularization. METHODS: We retrospectively analyzed records from a health system's code stroke registry, including successful basilar thrombectomy patients from January 2017 to May 2023 who were evaluated with pretreatment computed tomography perfusion. The primary outcome was devastating functional outcome (90-day modified Rankin Scale [mRS] score 5-6). A multivariable logistic regression model was constructed to determine independent predictors of the primary outcome. The area under the receiver operator characteristics curve (AUC) was calculated for the model distinguishing good from devastating outcome. RESULTS: Among 64 included subjects, with mean (standard deviation) age 65.6 (14.1) years and median (interquartile range) National Institutes of Health Stroke Scale (NIHSS) 18 (5.75-24.5), the primary outcome occurred in 28 of 64 (43.8%) subjects. Presenting NIHSS (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.14, p = 0.02), initial glucose (OR 0.99, 95% CI 0.97-1.00, p < 0.05), and proximal occlusion site (OR 7.38, 95% CI 1.84-29.60, p < 0.01) were independently associated with 90-day mRS 5-6. The AUC for the multivariable model distinguishing outcomes was 0.81 (95% CI 0.70-0.92). CONCLUSION: We have identified presenting stroke severity, lower glucose, and proximal basilar occlusion as predictors of devastating neurological outcome in successful basilar thrombectomy patients. These factors may be used in medical decision making or for patient selection in future clinical trials.

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy.

BACKGROUND AND PURPOSE: The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) and Totaled Health Risks in Vascular Events (THRIVE) predict functional outcomes after anterior circulation endovascular thrombectomy (EVT). We evaluated the performance of CLEOS and THRIVE in patients presenting with an acute basilar artery occlusion (BAO) treated with EVT. METHODS: We conducted a retrospective analysis of a health system's stroke registry. Patients presenting with an acute BAO treated with EVT and evaluated with pre-thrombectomy CT perfusion (CTP) from January 2017 to December 2021 were included. CLEOS = (5 × age) + (10 × National Institutes of Health Stroke Scale [NIHSS]) + Glucose - (150 × CTP cerebral blood volume index) and THRIVE (0-9 points) = age 60-79 years, 1 point; age ≥ 80 years, 2 points; NIHSS 11-20, 2 points; NIHSS ≥ 21, 4 points; hypertension, diabetes mellitus, atrial fibrillation, 1 point each. Multivariable logistic regression was performed for the ability of CLEOS and THRIVE to predict the primary outcome, modified Rankin Scale score 3-6. RESULTS: Fifty-seven patients had mean age 66.6 (± 14.9) years and median NIHSS 15.5 (5-24). In the multivariable regression analysis, increased CLEOS was associated with significantly higher odds of a poor functional outcome (odds ratio [OR] = 1.0011, 95% confidence interval [CI]: 1.0003-1.0019, p = .008), whereas THRIVE was not (OR = 1.0326, 95% CI: 0.9478-1.1250, p = .466). CLEOS > 503 best predicted poor outcomes. CONCLUSIONS: A higher CLEOS score was associated with elevated odds of a poor 90-day functional outcome in our cohort of acute BAO patients treated with EVT.