e-ASPECTS software is non-inferior to neuroradiologists in applying the ASPECT score to computed tomography scans of acute ischemic stroke patients.

Background The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is an established 10-point quantitative topographic computed tomography scan score to assess early ischemic changes. We performed a non-inferiority trial between the e-ASPECTS software and neuroradiologists in scoring ASPECTS on non-contrast enhanced computed tomography images of acute ischemic stroke patients. Methods In this multicenter study, e-ASPECTS and three independent neuroradiologists retrospectively and blindly assessed baseline non-contrast enhanced computed tomography images of 132 patients with acute anterior circulation ischemic stroke. Follow-up scans served as ground truth to determine the definite area of infarction. Sensitivity, specificity, and accuracy for region- and score-based analysis, receiver-operating characteristic curves, Bland-Altman plots and Matthews correlation coefficients relative to the ground truth were calculated and comparisons were made between neuroradiologists and different pre-specified e-ASPECTS operating points. The non-inferiority margin was set to 10% for both sensitivity and specificity on region-based analysis. Results In total 2640 (132 patients × 20 regions per patient) ASPECTS regions were scored. Mean time from onset to baseline computed tomography was 146 ± 124 min and median NIH Stroke Scale (NIHSS) was 11 (6-17, interquartile range). Median ASPECTS for ground truth on follow-up imaging was 8 (6.5-9, interquartile range). In the region-based analysis, two e-ASPECTS operating points (sensitivity, specificity, and accuracy of 44%, 93%, 87% and 44%, 91%, 85%) were statistically non-inferior to all three neuroradiologists (all p-values <0.003). Both Matthews correlation coefficients for e-ASPECTS were higher (0.36 and 0.34) than those of all neuroradiologists (0.32, 0.31, and 0.3). Conclusions e-ASPECTS was non-inferior to three neuroradiologists in scoring ASPECTS on non-contrast enhanced computed tomography images of acute stroke patients.

Intravenous thrombolysis in acute ischaemic stroke: a systematic review and meta-analysis to aid decision making in patients over 80 years of age.

Introduction Patients ≥ 80 years of age are increasingly receiving intravenous thrombolysis for acute ischaemic stroke (AIS) despite lack of firm evidence. This systematic review assesses the safety and efficacy of intravenous thrombolysis with alteplase in ≥ 80 versus < 80 year old patients with AIS. Methods The existing literature was systematically analysed for outcome measures of mortality, functional recovery by modified Rankin scale and symptomatic intracranial haemorrhage (SICH) at 3 months following intravenous thrombolysis with alteplase in <80 and ≥ 80 year old patients with AIS. Statistical tests were performed for heterogeneity and publication bias. A detailed sensitivity analysis was performed and Forest plot was constructed for each of the outcome measures. Results 13 studies were identified. The overall OR was 2.77 (95% CI 2.25 to 3.40) for death, 0.49 (95% CI 0.40 to 0.61) for achieving a favourable outcome and 1.31 (95% CI 0.93 to 1.84) for SICH in ≥ 80 year old patients compared with those < 80 years old. The total number of events contributing to the estimates of effect for each outcome was: death 199, favourable outcome 141 and SICH 49. Conclusion Patients ≥ 80 years of age appear to have a lower probability of gaining a favourable outcome and a higher mortality rate compared with patients < 80 years old; however, the rate of SICH was not significantly increased. This supports recruitment of patients aged ≥ 80 years into ongoing trials comparing thrombolysis with controls. For patients who refuse or cannot be randomised, it provides information on risks and benefits of using alteplase off-licence.