The Rapid Occluded MCA Vessel Etiology (ROME) Score - Identifying the Etiology of Large Vessel Occlusions of the Middle Cerebral Artery

Background Differentiating between intra-cerebral atherosclerotic disease (ICAD) and non-ICAD large vessel occlusion (LVO) is crucial for selecting the appropriate mechanical thrombectomy (MT) technique and device. We developed an algorithm to predict LVO etiology using clinical and radiographic features in the emergent setting.

We conducted a retrospective chart review of middle cerebral artery (MCA) occlusions treated with MT and confirmed as ICAD or non-ICAD. We recorded common risk factors and radiographic features from CT angiography to identify significant differences between groups. These factors were used in a multivariable logistic regression to create the algorithm. The ROME score was then tested against the ABC2D algorithm for predicting ICAD LVO in a prospective cohort.

The analysis included 33 ICAD and 327 non-ICAD LVO strokes. ICAD LVO patients were less likely to have atrial fibrillation (9.1% vs 53.8%; [points: 4]) or systolic heart failure with EF≤35% (9.1% vs 27.8%; [points: 1) and more likely to present with progressive or fluctuating symptoms (21.2% vs 4.6%; [points: 1). ICAD patients had a higher incidence of multi-vessel atherosclerotic disease (84.8% vs 37%; [points: 1]), tapered appearance of occlusion (60.6% vs 0.9%; [points: 6]), and extra-cranial ICA atherosclerotic plaque with high-risk features (plaques with lengths ≥1cm or thickness >3mm perpendicular to the long axis of the artery with associated ulceration or with soft plaque component (87.9% vs 37.6%; [points: 4]). AUC for the ROME score was 0.9666 with the highest sensitivity (97%) and specificity (88%) at a cut-off of 9. In the prospective cohort of 201 patients, the ROME score showed 81.3% sensitivity and 98.8% specificity, while the ABC2D score showed 90.6% sensitivity and 50.3% specificity.

Our scoring system effectively differentiates between ICAD and non-ICAD LVO, with greater specificity than the ABC2D score. Future steps will include validation in external databases and clinical trials. Competing Interest Statement The authors have declared no competing interest. Funding Statement No external funding was received. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Henry Ford IRB I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Data acquired in study will be available upon individual request.