Impact of ASPECTS on computed tomography angiography source images on outcome after thrombolysis or endovascular therapy in large vessel occlusions K. Wasser a,* , P. Papanagiotou b,* , F. Brunner c , H. Hildebrandt c , M. Winterhalter d , C. Roth b and A. Kastrup c a Department of Neurology, University of G€ ottingen, G€ ottingen; b Department of Neuroradiology, Klinikum Bremen-Mitte, Bremen; c Department of Neurology, Klinikum Bremen-Mitte, Bremen; and d Department of Anesthesiology, Klinikum Bremen-Mitte, Bremen, Germany Keywords: ASPECTS, endovascular treatment, outcome, stroke, symptomatic intracerebral hemorrhage, thrombectomy, thrombolysis Received 4 March 2016 Accepted 13 May 2016 European Journal of Neurology 2016, 0: 1–7 doi:10.1111/ene.13068 Background and purpose: Endovascular therapy (ET) is superior to intra- venous thrombolysis (IVT) in selected patients with anterior circulation large vessel occlusions. However, it is unclear if this positive effect also applies to patients with extensive early ischaemic changes. The aim of this study was to analyze the impact of the Alberta Stroke Program Early Computed Tomogra- phy Score (ASPECTS) on the CT angiography source images (SI) on outcome after ET or IVT. Methods: Using our prospectively obtained stroke database and the admis- sion SI-ASPECTS divided into three groups (0–5, 6–7 and 8–10), primarily the rates of good outcome [modified Rankin Scale (mRS) ≤2 at discharge] after either ET (n = 255) or IVT (n = 479) were compared. Results: A favorable SI-ASPECTS (8–10) was present in 501 patients, 132 patients had a moderately favorable SI-ASPECTS (6–7) and 101 patients had an unfavorable SI-ASPECTS (0–5). Irrespective of the treatment modality, no patient with an unfavorable SI-ASPECTS had a good outcome and 38% died during hospital stay. Whilst significantly more patients with a favorable SI- ASPECTS had a good outcome after ET than after IVT (51% vs. 35%, P < 0.01), there was only a non-significant trend towards a good outcome after ET than after IVT in patients with a moderately favorable ASPECTS (25% vs. 14%, P = 0.1). Conclusion: Patients with extensive early ischaemic changes on CT scans (SI- ASPECTS ≤5) might not profit from ET. The impact of ET on outcome in patients with moderately favorable SI-ASPECTS should be addressed in further trials. Introduction In several recently published landmark trials, endovas- cular treatment (ET) (with the use of third generation retrievable stents in the majority of patients) has been shown to be superior to systemic intravenous throm- bolysis (IVT) alone in acute ischaemic stroke patients with a proximal intracranial occlusion of the anterior circulation [1–6]. Based on these results, current guidelines highly rec- ommend ET, in addition to IVT within 4.5 h when eligible, in acute stroke patients with large artery occlusions in the anterior circulation up to 6 h after symptom onset [7]. However, against the background of several negative ET trials in 2013, the newer trials mainly focused on the presumably most promising patient cohorts using multimodal imaging [1–6]. In the majority of these trials patients with large ischaemic cores upon admission, for instance, were Correspondence: A. Kastrup, Department of Neurology, Klinikum Bremen-Mitte, St-J€ urgen-Strasse 1, 28177 Bremen, Germany (tel.: +49 421-4972645; fax: +49 421-4972646; e-mail: akastru@gwdg. de). *Both authors contributed equally to this paper. © 2016 EAN 1 ORIGINALARTICLE EUROPEANJOURNALOFNEUROLOGY