Development and validation of a SCORing systEm for pre-thrombectomy diagnosis of IntraCranial Atherosclerotic Disease (Score-ICAD)

Mohamed A Tarek; Mateus Damiani Monteiro; Mahmoud H Mohammaden; Pedro N Martins; Sunil A Sheth; Jaydevsinh Dolia; Aqueel Pabaney; Jonathan A Grossberg; Michael Nahhas; Carlos A De La Garza; Sergio Salazar-Marioni; Srikant Rangaraju; Raul G Nogueira; Diogo C Haussen

doi:10.1136/jnis-2024-021676

Development and validation of a SCORing systEm for pre-thrombectomy diagnosis of IntraCranial Atherosclerotic Disease (Score-ICAD)

J Neurointerv Surg. 2024 May 23:jnis-2024-021676. doi: 10.1136/jnis-2024-021676. Online ahead of print.

Authors

Mohamed A Tarek^{1

2}, Mateus Damiani Monteiro^{3

4}, Mahmoud H Mohammaden⁵, Pedro N Martins^{1

4}, Sunil A Sheth⁶, Jaydevsinh Dolia^{1

7}, Aqueel Pabaney⁸, Jonathan A Grossberg⁹, Michael Nahhas¹⁰, Carlos A De La Garza⁶, Sergio Salazar-Marioni¹¹, Srikant Rangaraju¹², Raul G Nogueira¹³, Diogo C Haussen¹⁴

Affiliations

¹ Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA.
² Department of Neurology and Psychological Medicine, Sohag University Faculty of Medicine, Sohag, Egypt.
³ Emory University School of Medicine, Atlanta, Georgia, USA.
⁴ Grady Health System Marcus Stroke and Neuroscience Center, Atlanta, Georgia, USA.
⁵ Department of Neurology, Emory University Atlanta, Atlanta, Georgia, USA.
⁶ Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA.
⁷ Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.
⁸ Emory University, Atlanta, Georgia, USA.
⁹ Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁰ Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA.
¹¹ Neurology, University of Texas McGovern Medical School, Houston, Texas, USA.
¹² Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA.
¹³ Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
¹⁴ Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA diogo.haussen@emory.edu.

PMID: 38782568
DOI: 10.1136/jnis-2024-021676

Abstract

Background: Early identification of intracranial atherosclerotic disease (ICAD) may impact the management of patients undergoing mechanical thrombectomy (MT). We sought to develop and validate a scoring system for pre-thrombectomy diagnosis of ICAD in anterior circulation large vessel/distal medium vessel occlusion strokes (LVOs/DMVOs).

Methods: Retrospective analysis of two prospectively maintained comprehensive stroke center databases including patients with anterior circulation occlusions spanning 2010-22 (development cohort) and 2018-22 (validation cohort). ICAD cases were matched for age and sex (1:1) to non-ICAD controls.

Results: Of 2870 MTs within the study period, 348 patients were included in the development cohort: 174 anterior circulation ICAD (6% of 2870 MTs) and 174 controls. Multivariable analysis β coefficients led to a 20 point scale: absence of atrial fibrillation (5); vascular risk factor burden (1) for each of hypertension, diabetes, smoking, and hyperlipidemia; multifocal single artery stenoses on CT angiography (3); absence of territorial cortical infarct (3); presence of borderzone infarct (3); or ipsilateral carotid siphon calcification (2). The validation cohort comprised 56 ICAD patients (4.1% of 1359 MTs): 56 controls. Area under the receiver operating characteristic curve was 0.88 (0.84-0.91) and 0.82 (0.73-0.89) in the development and validation cohorts, respectively. Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0, 95% CI -0.5 to -0.5; slope 0.8, 95% CI 0.5 to 1.1). In the full cohort (n=414), ≥11 points showed the best performance for distinguishing ICAD from non-ICAD, with 0.71 (95% CI 0.65 to 0.78) sensitivity and 0.82 (95% CI 0.77 to 0.87) specificity, and 3.92 (95% CI 2.92 to 5.28) positive and 0.35 (95% CI 0.28 to 0.44) negative likelihood ratio. Scores ≥12 showed 90% specificity and 63% sensitivity.

Conclusion: The proposed scoring system for preprocedural diagnosis of ICAD LVOs and DMVOs presented satisfactory discrimination and calibration based on clinical and non-invasive radiological data.

Keywords: Intracranial Thrombosis; Stroke; Thrombectomy.