Serial ASPECTS to Predict Stroke-associated Pneumonia After Thrombolysis in Patients with Acute Ischemic Stroke

Overview

Journal Front Neurol

Specialty Neurology

Date 2024 May 7

PMID 38711555

Authors

Sarawut Krongsut

Atiwat Soontornpun

Niyada Anusasnee

Affiliations

Soon will be listed here.

Abstract

Background: Stroke-associated pneumonia (SAP) is a serious complication in stroke patients, significantly increasing mortality. The Alberta Stroke Program Early CT Score (ASPECTS) is a recognized predictor of acute ischemic stroke outcomes. We aimed to investigate the performance of serial ASPECTS assessments (baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS) for predicting SAP in patients with thrombolyzed acute anterior circulation ischemic stroke (AACIS).

Materials: A retrospective observational cohort study of adult patients with thrombolyzed AACIS was conducted. Baseline and 24-h ASPECTS using non-contrast computed tomography (NCCT), complications of stroke, including SAP and swallowing dysfunction using the Modified Water Swallowing test, were collected. Baseline and 24-h ASPECTS were evaluated by a certified neurologist and neuroradiologist. The predictive performance was determined based on the receiver operating characteristic curve (ROC). Multivariable logistic regression analyses were employed to assess the impact of serial ASPECTS assessment on predicting SAP.

Results: Of the 345 patients with thrombolyzed AACIS in our study, 18.4% (64/345) experienced SAP. The patients' median age was 62 years [interquartile range (IQR): 52-73], with 53.4% being male. The median NIHSS score was 11 points (IQR: 8-17). The ROC analysis revealed areas under the curve for predicting SAP with baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS were 0.75 (95% CI, 0.69-0.82), 0.84 (95% CI, 0.79-0.89), and 0.82 (95% CI, 0.76-0.87), respectively. Of the three measures, 24-h ASPECTS was a better predictor of SAP (odds ratio: 5.33, 95%CI: 2.08-13.67, < 0.001) and had a higher sensitivity (0.84 [95%CI, 0.74-0.92]) and specificity (0.79 [95%CI, 0.74-0.84]) than both baseline ASPECTS and change in ASPECTS.

Conclusion: 24-h NCCT-ASPECTS outperformed both baseline ASPECTS and change in ASPECTS for predicting SAP. Notably, 24-h ASPECTS, with a cut-off value of ≤6, exhibited good predictive performance and emerged as the better predictor for SAP.

Citing Articles

Integrating the ADS Score with 24-Hour ASPECTS and red cell distribution width for enhanced prediction of stroke-associated pneumonia following intravenous thrombolysis: model development and internal validation.

Krongsut S, Na-Ek N, Soontornpun A, Anusasnee N Eur J Med Res. 2025; 30(1):28.

PMID: 39810169 PMC: 11734527. DOI: 10.1186/s40001-025-02282-3.

References

Mann G, Hankey G, Cameron D . Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999; 30(4):744-8. DOI: 10.1161/01.str.30.4.744. View

Rangaraju S, Frankel M, Jovin T . Prognostic Value of the 24-Hour Neurological Examination in Anterior Circulation Ischemic Stroke: A post hoc Analysis of Two Randomized Controlled Stroke Trials. Interv Neurol. 2016; 4(3-4):120-9. PMC: 4817381. DOI: 10.1159/000443801. View

Kishore A, Vail A, Chamorro A, Garau J, Hopkins S, Di Napoli M . How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis. Stroke. 2015; 46(5):1202-9. DOI: 10.1161/STROKEAHA.114.007843. View

Walter U, Knoblich R, Steinhagen V, Donat M, Benecke R, Kloth A . Predictors of pneumonia in acute stroke patients admitted to a neurological intensive care unit. J Neurol. 2007; 254(10):1323-9. DOI: 10.1007/s00415-007-0520-0. View

Horan T, Andrus M, Dudeck M . CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008; 36(5):309-32. DOI: 10.1016/j.ajic.2008.03.002. View

Chamorro A, Urra X, Planas A . Infection after acute ischemic stroke: a manifestation of brain-induced immunodepression. Stroke. 2007; 38(3):1097-103. DOI: 10.1161/01.STR.0000258346.68966.9d. View

Li Y, Zhang Y, Ma L, Niu X, Chang J . Risk of stroke-associated pneumonia during hospitalization: predictive ability of combined ADS score and hyperglycemia. BMC Neurol. 2019; 19(1):298. PMC: 6876087. DOI: 10.1186/s12883-019-1497-x. View

Jantasri S, Tiamkao S, Sawanyawisuth K . A 2-point difference of NIHSS as a predictor of acute ischemic stroke outcome at 3 months after thrombolytic therapy. Clin Neurol Neurosurg. 2020; 198:106206. DOI: 10.1016/j.clineuro.2020.106206. View

Osawa A, Maeshima S, Tanahashi N . Water-swallowing test: screening for aspiration in stroke patients. Cerebrovasc Dis. 2013; 35(3):276-81. DOI: 10.1159/000348683. View

10.

Harms H, Reimnitz P, Bohner G, Werich T, Klingebiel R, Meisel C . Influence of stroke localization on autonomic activation, immunodepression, and post-stroke infection. Cerebrovasc Dis. 2011; 32(6):552-60. DOI: 10.1159/000331922. View

11.

Tao J, Hu Z, Lou F, Wu J, Wu Z, Yang S . Higher Stress Hyperglycemia Ratio Is Associated With a Higher Risk of Stroke-Associated Pneumonia. Front Nutr. 2022; 9:784114. PMC: 8902157. DOI: 10.3389/fnut.2022.784114. View

12.

Mokin M, Primiani C, Siddiqui A, Turk A . ASPECTS (Alberta Stroke Program Early CT Score) Measurement Using Hounsfield Unit Values When Selecting Patients for Stroke Thrombectomy. Stroke. 2017; 48(6):1574-1579. DOI: 10.1161/STROKEAHA.117.016745. View

13.

Warner J, Harrington R, Sacco R, Elkind M . Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019; 50(12):3331-3332. DOI: 10.1161/STROKEAHA.119.027708. View

14.

Mistry E, Yeatts S, de Havenon A, Mehta T, Arora N, De Los Rios La Rosa F . Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change. Stroke. 2021; 52(8):2547-2553. PMC: 11261999. DOI: 10.1161/STROKEAHA.120.032487. View

15.

von Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007; 147(8):573-7. DOI: 10.7326/0003-4819-147-8-200710160-00010. View

16.

JOHNSTON K, Li J, Lyden P, Hanson S, Feasby T, Adams R . Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. RANTTAS Investigators. Stroke. 1998; 29(2):447-53. DOI: 10.1161/01.str.29.2.447. View

17.

Barber P, Demchuk A, Zhang J, Buchan A . Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000; 355(9216):1670-4. DOI: 10.1016/s0140-6736(00)02237-6. View

18.

Puetz V, Dzialowski I, Hill M, Demchuk A . The Alberta Stroke Program Early CT Score in clinical practice: what have we learned?. Int J Stroke. 2009; 4(5):354-64. DOI: 10.1111/j.1747-4949.2009.00337.x. View

19.

Tanaka K, Matsumoto S, Furuta K, Yamada T, Nagano S, Takase K . Modified diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score including deep white matter lesions predicts symptomatic intracerebral hemorrhage following intravenous thrombolysis. J Thromb Thrombolysis. 2019; 50(1):174-180. PMC: 7293975. DOI: 10.1007/s11239-019-01979-7. View

20.

Ji R, Shen H, Pan Y, Wang P, Liu G, Wang Y . Novel risk score to predict pneumonia after acute ischemic stroke. Stroke. 2013; 44(5):1303-9. DOI: 10.1161/STROKEAHA.111.000598. View