title: ASTRAL-R score predicts non-recanalisation after intravenous thrombolysis in acute ischaemic stroke.
abstract: Intravenous thrombolysis (IVT) as treatment in acute ischaemic strokes may be insufficient to achieve recanalisation in certain patients. Predicting probability of non-recanalisation after IVT may have the potential to influence patient selection to more aggressive management strategies. We aimed at deriving and internally validating a predictive score for post-thrombolytic non-recanalisation, using clinical and radiological variables. In thrombolysis registries from four Swiss academic stroke centres (Lausanne, Bern, Basel and Geneva), patients were selected with large arterial occlusion on acute imaging and with repeated arterial assessment at 24 hours. Based on a logistic regression analysis, an integer-based score for each covariate of the fitted multivariate model was generated. Performance of integer-based predictive model was assessed by bootstrapping available data and cross validation (delete-d method). In 599 thrombolysed strokes, five variables were identified as independent predictors of absence of recanalisation: Acute glucose > 7 mmol/l (A), significant extracranial vessel STenosis (ST), decreased Range of visual fields (R), large Arterial occlusion (A) and decreased Level of consciousness (L). All variables were weighted 1, except for (L) which obtained 2 points based on β-coefficients on the logistic scale. ASTRAL-R scores 0, 3 and 6 corresponded to non-recanalisation probabilities of 18, 44 and 74 % respectively. Predictive ability showed AUC of 0.66 (95 %CI, 0.61-0.70) when using bootstrap and 0.66 (0.63-0.68) when using delete-d cross validation. In conclusion, the 5-item ASTRAL-R score moderately predicts non-recanalisation at 24 hours in thrombolysed ischaemic strokes. If its performance can be confirmed by external validation and its clinical usefulness can be proven, the score may influence patient selection for more aggressive revascularisation strategies in routine clinical practice.
authors.affiliation: Peter Vanacker, Centre Hospitalier Universitaire Vaudois, 46, Rue de Bugnon, 1011 Lausanne, Switzerland, E-mail: peter.vanacker@chuv.ch.
authors.forename: Peter
authors.initials: P
authors.lastname: Vanacker
authors.forename: Mirjam R
authors.initials: MR
authors.lastname: Heldner
authors.forename: David
authors.initials: D
authors.lastname: Seiffge
authors.forename: Hubertus
authors.initials: H
authors.lastname: Mueller
authors.forename: Ashraf
authors.initials: A
authors.lastname: Eskandari
authors.forename: Christopher
authors.initials: C
authors.lastname: Traenka
authors.forename: George
authors.initials: G
authors.lastname: Ntaios
authors.forename: Pascal J
authors.initials: PJ
authors.lastname: Mosimann
authors.forename: Roman
authors.initials: R
authors.lastname: Sztajzel
authors.forename: Vitor
authors.initials: V
authors.lastname: Mendes Pereira
authors.forename: Patrick
authors.initials: P
authors.lastname: Cras
authors.forename: Stefan
authors.initials: S
authors.lastname: Engelter
authors.forename: Philippe
authors.initials: P
authors.lastname: Lyrer
authors.forename: Urs
authors.initials: U
authors.lastname: Fischer
authors.forename: Dimitris
authors.initials: D
authors.lastname: Lambrou
authors.forename: Marcel
authors.initials: M
authors.lastname: Arnold
authors.forename: Patrik
authors.initials: P
authors.lastname: Michel
mesh_terms: D000465:Algorithms; D019540:Area Under Curve; D002545:Brain Ischemia / Q000188:drug therapy*; D020000:Decision Support Systems, Clinical; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012044:Regression Analysis; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000009:adverse effects* / Q000379:methods; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents
keywords: Cerebral infarction; cerebral revascularisation; cerebrovascular occlusion; decision support techniques; thrombolytic therapy