title: Good Intracranial Collaterals Trump Poor ASPECTS (Alberta Stroke Program Early CT Score) for Intravenous Thrombolysis in Anterior Circulation Acute Ischemic Stroke.
abstract: In acute ischemic stroke, large early infarct size estimated by the Alberta Stroke Program Early CT Score (ASPECTS) is associated with poorer outcomes and is a relative contraindication for recanalization therapies. The state of the intracranial collateral circulation influences the functional outcome and may be a variable to consider before thrombolysis. We evaluated the prognostic effect of the collateral circulation in patients with thrombolyzed acute ischemic stroke who have large early infarct sizes as indicated by low ASPECTS.
  
  
  
  Patients with anterior circulation acute ischemic stroke who received a computed tomographic angiogram and subsequent treatment with intravenous tissue-type plasminogen activator from 2010 to 2013 were studied. Two independent neuroradiologists determined their ASPECTS. We stratified patients using ASPECTS into 2 groups: large volume infarcts (ASPECTS≤7 points) and small volume infarcts (ASPECTS 8-10). In addition, we evaluated a third group with very large volume infarcts (ASPECTS≤5 points). We then analyzed the 3 subgroups using the Maas, Tan, and ASPECTS-collaterals grading systems of the computed tomographic angiogram intracranial collaterals. Good outcomes were defined by modified Rankin Scale score of 0 to 2 at 3 months.
  
  
  
  A total of 300 patients were included in the final analysis. For patients with very large volume infarcts (ASPECTS≤5 points), univariable analysis showed that younger age, male sex, lower National Institute of Health Stroke Scale (NIHSS), lower systolic blood pressure, and good collaterals by Maas, Tan, or ASPECTS-collaterals grading were predictors of good outcomes. On multivariate analysis, younger age (odds ratio, 0.93; 95% confidence interval, 0.89-0.97; P=0.002) and good collaterals by ASPECTS-collaterals system (odds ratio, 1.34; 95% confidence interval, 1.15-1.57; P<0.001) were associated with good outcomes.
  
  
  
  In patients with large and very large volume infarcts, good collaterals as measured by the ASPECTS-collaterals system is associated with improved outcomes and can help select patients for intravenous thrombolysis.
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Benjamin Y Q
authors: BY
authors: Tan
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Kong
authors: K
authors: Wan-Yee
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Prakash
authors: P
authors: Paliwal
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Anil
authors: A
authors: Gopinathan
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Mahendran
authors: M
authors: Nadarajah
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Eric
authors: E
authors: Ting
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Narayanaswamy
authors: N
authors: Venketasubramanian
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Raymond C S
authors: RC
authors: Seet
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Bernard P L
authors: BP
authors: Chan
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Hock L
authors: HL
authors: Teoh
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Rahul
authors: R
authors: Rathakrishnan
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
authors: Vijay K
authors: VK
authors: Sharma
authors: From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.). leonard_ll_yeo@nuhs.edu.sg.
authors: Leonard L L
authors: LL
authors: Yeo
mesh_terms: D000367:Age Factors; D000368:Aged; D015901:Angiography, Digital Subtraction; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000188:drug therapy; D003097:Collateral Circulation / Q000502:physiology*; D000072226:Computed Tomography Angiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012737:Sex Factors; D020521:Stroke / Q000000981:diagnostic imaging* / Q000188:drug therapy; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: collateral circulation; male; multivariate analysis; stroke