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Modified Pediatric ASPECT Score Associated With Stroke Severity Outcomes

The association of modASPECTS and outcome persisted even after adjusting for stroke risk factors that may have independent associations with poor outcome and age at stroke ictus.

Recently published findings in Neurology demonstrated correlations between modified pediatric Alberta Stroke Program Early CT Score (modASPECTS) and Pediatric NIH Stroke Scale (PedNIHSS) scores, hemorrhagic transformation, and 12-month outcome in children with acute ischemic stroke (AIS) as well as acute hemorrhagic transformation.1

Lead author Lauren A. Beslow, MD, MSCE, FAHA, physician, Division of Neurology, Children’s Hospital of Philadelphia (CHOP), and colleagues evaluated modASPECTS, an abridged version of ASPECTS, a 10-point quantitative topographic CT scan score, in 131 children, aged 29 to 18 years, enrolled from 2 institutional prospective stroke registries. In the entire cohort, median modASPECTS was 4 (interquartile range [IQR], 3-7), and median number of days from stroke ictus to MRI was 1 (IQR, 0-1 day).

At the conclusion of the study, investigators found modASPECTS to be correlated with PedNIHSS among 89 children aged 2 years or older (ρ, 0.40; P = .0001).1 This was similar to the ρ of –0.31 in adult studies that compared ASPECTS and an electronic ASPECTS to NIHSS scores.2 ρ between modASPECTS and PedNIHSS score was 0.44 (P = .017) for those aged 2 years or older with isolated anterior circulation stroke and PedNIHSS score on the day of stroke ictus (n = 48). Among 29 children (31.9%) age 2 years or older who had both an MRI and a neurological examination on the day of stroke ictus, ρ between modASPECTS and PedNIHSS score was 0.47 (P = .0098).

"ModASPECTS should be investigated as a tool to identify children who would benefit from thrombectomy as low modASPECTS with high PedNIHSS could represent a child with a perfusion-diffusion mismatch,” Beslow et al wrote.1 "We also plan to validate the modASPECTS and its relationship to functional outcome in a broader international cohort with carefully collected data on time of stroke onset, time from stroke ictus to PedNIHSS and MRI, and with standardized outcomes at both 12-months post-stroke and long-term."

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Among those who had 12-month follow-up available (n = 128), children with poor outcomes had higher modASPECTS scores than those with good outcomes (median modASPECTS, 6 [IQR, 3-8] vs median modASPECTS, 3 [IQR, 2-5]; P = .0008). Notably, there was a correlation observed between modASPECTS and 12-month Pediatric Stroke Outcome Measure (PSOM; ρ = 0.35; P <.0001).

For every 1-point increase in modASPECTS, the common OR for an outcome in the following PSOM severity category was 1.14 (95% CI, 1.04-1.24; P = .0005). When adjusting for both age at stroke ictus and the presence of tumor or meningitis, 2 stroke risk factors that are independently associated with poor outcome, the common OR was 1.14 (95% CI, 1.03-1.24; P = .008).

ModASPECTS was also found to be associated with the presence of hemorrhagic transformation (OR, 1.1 [95% CI, 1.02-1.25]; P = .018); however, these associations were deemed not significant (OR, 0.82 [95% CI, 0.54-1.25]; P = .36) after limiting the analysis to only children aged 2 years or older with isolated anterior circulation infarction and PedNIHSS on the day of stroke ictus.

The value of the acute adult ASPECTS is to identify and quantify early ischemic changes that may reflect irreversibly damaged tissue or conversely, salvageable tissue. ASPECTS is determined from evaluation of 2 standardized regions of the MCA territory: the basal ganglia level and the supraganglionic level. In 2019, the American Heart Association released guidelines that suggested the use of ASPECTS for patients presenting within 6 hours of onset of large vessel occlusion when determining eligibility for mechanical thrombectomy without perfusion imaging.3

Beslow et al concluded, "future studies are also needed to evaluate the utility of modASPECTS in children who undergo acute stroke therapies to determine whether certain ranges of scores identify children who may derive the most benefit from therapy or who might be at highest risk for symptomatic intracranial hemorrhages."

1. Beslow LA, Vossough A, Ichord RN, et al. Association of pediatric ASPECTS and NIH stroke scale, hemorrhagic transformation, and 12-month outcome in children with acute ischemic stroke. Neurology. Published online August 13, 2021. doi: 10.1212/WNL.0000000000012558
2. Demchuk AM, Hill MD, Barber PA, et al. Importance of early ischemic computed tomography changes using ASPECTS in NINDS rtPA Stroke Study. Stroke 2005;36:2110-2115.
3. Powers WJ, Rabinstein AA, Ackerson T, et al. 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:e344-e418.