External Validation of the MRI-DRAGON Score: Early Prediction of Stroke Outcome after Intravenous Thrombolysis

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Abstract

Background and Purpose

The aim of our study was to validate in an independent cohort the MRI-DRAGON score, an adaptation of the (CT-) DRAGON score to predict 3-month outcome in acute ischemic stroke patients undergoing MRI before intravenous thrombolysis (IV-tPA).

Methods

We reviewed consecutive (2009–2013) anterior circulation stroke patients treated within 4.5 hours by IV-tPA in the Lille stroke unit (France), where MRI is the first-line pretherapeutic work-up. We assessed the discrimination and calibration of the MRI-DRAGON score to predict poor 3-month outcome, defined as modified Rankin Score >2, using c-statistic and the Hosmer-Lemeshow test, respectively.

Results

We included 230 patients (mean ±SD age 70.4±16.0 years, median [IQR] baseline NIHSS 8 [5]– [14]; poor outcome in 78(34%) patients). The c-statistic was 0.81 (95%CI 0.75–0.87), and the Hosmer-Lemeshow test was not significant (p = 0.54).

Conclusions

The MRI-DRAGON score showed good prognostic performance in the external validation cohort. It could therefore be used to inform the patient's relatives about long-term prognosis and help to identify poor responders to IV-tPA alone, who may be candidates for additional therapeutic strategies, if they are otherwise eligible for such procedures based on the institutional criteria.

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Most cited references 11

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Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging.

A Buchan, J H Pexman, D. Hill … (2005)

Controversy exists about the optimal imaging technique in acute stroke. It was hypothesised that CT is comparable with DWI, when both are read systematically using quantitative scoring. Ischaemic stroke patients who had CT within six hours and DWI within seven hours of onset were included. Five readers used a quantitative scoring system (ASPECTS) to read the baseline (b) and follow up CT and DWI. Use of MRI in acute stroke was also assessed in patients treated with tissue plasminogen activator (tPA) by prospectively recording reasons for exclusion. Patients were followed clinically at three months. bDWI and bCT were available for 100 consecutive patients (admission median NIHSS = 9). The mean bDWI and bCT ASPECTS were positively related (p<0.001). The level of interrater agreement ranged from good to excellent across all modalities and time periods. Bland-Altman plots showed more variability between bCT and bDWI than at 24 hours. The difference between bCT and bDWI was < or =2 ASPECTS points. Of bCT scans with ASPECTS 8-10, 81% had DWI ASPECTS 8-10. Patients with bCT ASPECTS of 8-10 were 1.9 times more likely to have a favourable outcome at 90 days than those with a score of 0-7 (95% CI 1.1 to 3.1, p = 0.002). The relative likelihood of favourable outcome with a bDWI ASPECTS 8-10 was 1.4 (95% CI 1.0 to 1.9, p = 0.10). Of patients receiving tPA 45% had contraindications to urgent MRI. The differences between CT and DWI in visualising early infarction are small when using ASPECTS. CT is faster and more accessible than MRI, and therefore is the better neuroimaging modality for the treatment of acute stroke.

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Predicting outcome of IV thrombolysis-treated ischemic stroke patients: the DRAGON score.

D Strbian, A Meretoja, F J Ahlhelm … (2012)

To develop a functional outcome prediction score, based on immediate pretreatment parameters, in ischemic stroke patients receiving IV alteplase. The derivation cohort consists of 1,319 ischemic stroke patients treated with IV alteplase at the Helsinki University Central Hospital, Helsinki, Finland. We evaluated the predictive value of parameters associated with the 3-month outcome and developed the score according to the magnitude of logistic regression coefficients. We assessed accuracy of the model with bootstrapping. External validation was performed in a cohort of 330 patients treated at the University Hospital Basel, Basel, Switzerland. We assessed the score performance with area under the receiver operating characteristic curve (AUC-ROC). The DRAGON score (0-10 points) consists of (hyper)Dense cerebral artery sign/early infarct signs on admission CT scan (both = 2, either = 1, none = 0), prestroke modified Rankin Scale (mRS) score >1 (yes = 1), Age (≥ 80 years = 2, 65-79 years = 1, 8 mmol/L [>144 mg/dL] = 1), Onset-to-treatment time (>90 minutes = 1), and baseline National Institutes of Health Stroke Scale score (>15 = 3, 10-15 = 2, 5-9 = 1, 0-4 = 0). AUC-ROC was 0.84 (0.80-0.87) in the derivation cohort and 0.80 (0.74-0.86) in the validation cohort. Proportions of patients with good outcome (mRS score 0-2) were 96%, 88%, 74%, and 0% for 0-1, 2, 3, and 8-10 points, respectively. Proportions of patients with miserable outcome (mRS score 5-6) were 0%, 2%, 5%, 70%, and 100% for 0-1, 2, 3, 8, and 9-10 points, respectively. External validation showed similar results. The DRAGON score is valid at our site and was reliable externally. It can support clinical decision-making, especially when invasive add-on strategies are considered. The score was not studied in patients with basilar artery occlusion. Further external validation is warranted.

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Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome.

Toru Usui, K. Ohara, Shinichiro Uchiyama … (2010)

There are few studies regarding functional outcome and lesion extent on diffusion-weighted MRI (DWI) in patients with posterior circulation (PC) infarction. The aim of our study was to assess whether a newly proposed posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) on DWI is useful for predicting functional outcome in PC patients. One hundred thirty-two patients with first-ever ischemic stroke in the posterior circulation within 24 h of onset who were admitted to our hospital were enrolled in the study. We compared background characteristics, vital signs, laboratory data, and MRI findings between favorable (F) and unfavorable (U) outcome groups at 3 months, according to the modified Rankin Scale (mRS). The F and U groups were defined as having a mRS of 0-2 and 3-6, respectively. pc-ASPECTS was scored by DWI obtained 12-36 h after onset. Ninety-eight patients (74.2%) were classified into the F group and 34 patients (25.8%) into the U group. On univariate analysis, F group patients were younger, had lower National Institutes of Health Stroke Scale (NIHSS) score at entry, and a lower rate of early neurological deterioration (END) and cardioembolic stroke than U group patients. On MRI, F group patients had lower leukoaraiosis and medial temporal atrophy score and higher pc-ASPECTS score on DWI compared to U group patients. Multiple logistic regression analysis revealed NIHSS (p < 0.001), END (p = 0.0057), pc-ASPECTS (p < 0.001), and leukoaraiosis (p = 0.0091) as independent predictors of functional outcome. pc-ASPECTS appears to be a powerful marker for predicting functional outcome, along with clinical severity and END. Leukoaraiosis may also be an independent predictor of functional outcome.

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Author and article information

Contributors

Mathias Gelderblom: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2014

Publication date (Electronic): 4 June 2014

Volume: 9

Issue: 6

Electronic Location Identifier: e99164

Affiliations

[1 ]Department of Neurology, Hôpital Sainte-Anne, Paris, France & Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894

[2 ]Department of Radiology, Hôpital Sainte-Anne, Paris, France & Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894

[3 ]Department of Neurology, Lille University Hospital, Lille, France & Université Lille Nord de France, UDSL, EA 1046

[4 ]Department of Radiology, Lille University Hospital, Lille, France & Université Lille Nord de France, UDSL, EA 1046

University Hospital-Eppendorf, Germany

Author notes

* E-mail: g.turc@ 123456ch-sainte-anne.fr

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: GT. Performed the experiments: GT PA NPD HH ON XL CC CO DL. Analyzed the data: GT PA CO ON XL. Contributed reagents/materials/analysis tools: JLM DL CO. Wrote the paper: GT CO JLM.

Article

Publisher ID: PONE-D-14-04560

DOI: 10.1371/journal.pone.0099164

PMC ID: 4045936

PubMed ID: 24896827

SO-VID: 5243cbf4-decd-49dc-bb55-05e2461257ac

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 24 February 2014

Date accepted : 12 May 2014

Page count

Pages: 5

Funding

The authors have no support or funding to report.

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External Validation of the MRI-DRAGON Score: Early Prediction of Stroke Outcome after Intravenous Thrombolysis

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Abstract

Background and Purpose

Methods

Results

Conclusions

Related collections

Stroke MRI

Most cited references 11

Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging.

Predicting outcome of IV thrombolysis-treated ischemic stroke patients: the DRAGON score.

Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome.

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