Detection of large vessel occlusion stroke with electroencephalography in the emergency room: first results of the ELECTRA-STROKE study

Abstract Background Prehospital detection of large vessel occlusion stroke of the anterior circulation (LVO-a) would enable direct transportation of these patients to an endovascular thrombectomy (EVT) capable hospital. The ongoing ELECTRA-STROKE study investigates the diagnostic accuracy of dry electrode electroencephalography (EEG) for LVO-a stroke in the prehospital setting. To determine which EEG features are most useful for this purpose and assess EEG data quality, EEG recordings are also performed in the emergency room (ER). Here, we report data of the first 100 patients included in the ER. Methods Patients presented to the ER with a suspected stroke or known LVO-a stroke underwent a single EEG prior to EVT. Diagnostic accuracy for LVO-a stroke of frequency band power, brain symmetry and phase synchronization measures were evaluated by calculating receiver operating characteristic curves. Optimal cut-offs were determined as the highest sensitivity at a specificity of ≥ 80%. Results EEG data were of sufficient quality for analysis in 65/100 included patients. Of these, 35/65 (54%) had an acute ischemic stroke, of whom 9/65 (14%) had an LVO-a stroke. Median onset-to-EEG-time was 266 min (IQR 121–655) and median EEG-recording-time was 3 min (IQR 3–5). The EEG feature with the highest diagnostic accuracy for LVO-a stroke was theta–alpha ratio (AUC 0.83; sensitivity 75%; specificity 81%). Combined, weighted phase lag index and relative theta power best identified LVO-a stroke (sensitivity 100%; specificity 84%). Conclusion Dry electrode EEG is a promising tool for LVO-a stroke detection, but data quality needs to be improved and validation in the prehospital setting is necessary. (TRN: NCT03699397, registered October 9 2018).

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Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽

10.1161/strokeaha.120.033053 ◽

2021 ◽

Author(s):

Laura C.C. van Meenen ◽

Maritta N. van Stigt ◽

Arjen Siegers ◽

Martin D. Smeekes ◽

Joffry A.F. van Grondelle ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Stroke Care ◽

Prehospital Setting ◽

Large Vessel ◽

Large Vessel Occlusion ◽

User Friendliness ◽

Vessel Occlusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

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Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review

The Ultrasound Journal ◽

10.1186/s13089-019-0143-6 ◽

2019 ◽

Vol 11 (1) ◽

Cited By ~ 1

Author(s):

Daria Antipova ◽

Leila Eadie ◽

Ashish Stephen Macaden ◽

Philip Wilson

Keyword(s):

Systematic Review ◽

Diagnostic Accuracy ◽

Acute Stroke ◽

Clinical Assessment ◽

Assessment Tools ◽

Large Vessel ◽

Cochrane Library ◽

Direct Transfer ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Abstract Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

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Abstract WMP16: Artificial Intelligence Detection of Cerebrovascular Large Vessel Occlusion - Nine Month, 650 Patient Evaluation of the Diagnostic Accuracy and Performance of the Viz.ai LVO Algorithm

Stroke ◽

10.1161/str.50.suppl_1.wmp16 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Cited By ~ 5

Author(s):

Arindam Chatterjee ◽

Nayana R Somayaji ◽

Ismail M Kabakis

Keyword(s):

Artificial Intelligence ◽

Diagnostic Accuracy ◽

Large Vessel ◽

Patient Evaluation ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

And Performance

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Abstract WP119: Leukoaraiosis Attenuates Diagnostic Accuracy of Large Vessel Occlusion Scales

Stroke ◽

10.1161/str.49.suppl_1.wp119 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Yunis M Mayasi ◽

Brian Silver ◽

Richard P Goddeau ◽

Adalia Jun-O’connell ◽

Majaz Moonis ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

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Large Vessel Occlusion Stroke Detection in the Prehospital Environment

Current Emergency and Hospital Medicine Reports ◽

10.1007/s40138-021-00234-9 ◽

2021 ◽

Author(s):

Lauren Patrick ◽

Wade Smith ◽

Kevin J. Keenan

Keyword(s):

Endovascular Therapy ◽

Ease Of Use ◽

Prehospital Setting ◽

Large Vessel ◽

Published Data ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Units ◽

Suspected Stroke

Abstract Purpose of Review Endovascular therapy for acute ischemic stroke secondary to large vessel occlusion (LVO) is time-dependent. Prehospital patients with suspected LVO stroke should be triaged directly to specialized stroke centers for endovascular therapy. This review describes advances in LVO detection among prehospital suspected stroke patients. Recent Findings Clinical prehospital stroke severity tools have been validated in the prehospital setting. Devices including EEG, SSEPs, TCD, cranial accelerometry, and volumetric impedance phase-shift-spectroscopy have recently published data regarding LVO detection in hospital settings. Mobile stroke units bring thrombolysis and vessel imaging to patients. Summary The use of a prehospital stroke severity tool for LVO triage is now widely supported. Ease of use should be prioritized as there are no meaningful differences in diagnostic performance amongst tools. LVO diagnostic devices are promising, but none have been validated in the prehospital setting. Mobile stroke units improve patient outcomes and cost-effectiveness analyses are underway.

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Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016054 ◽

2020 ◽

pp. neurintsurg-2020-016054 ◽

Cited By ~ 1

Author(s):

Lee Birnbaum ◽

David Wampler ◽

Arash Shadman ◽

Mateja de Leonni Stanonik ◽

Michele Patterson ◽

...

Keyword(s):

Predictive Value ◽

Systems Of Care ◽

Prehospital Setting ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Intraparenchymal Hemorrhage ◽

Vessel Occlusion ◽

Statistical Measures ◽

Published Evidence

BackgroundNumerous stroke severity scales have been published, but few have been studied with emergency medical services (EMS) in the prehospital setting. We studied the Vision, Aphasia, Neglect (VAN) stroke assessment scale in the prehospital setting for its simplicity to both teach and perform. This prospective prehospital cohort study was designed to validate the use and efficacy of VAN within our stroke systems of care, which includes multiple comprehensive stroke centers (CSCs) and EMS agencies.MethodsThe performances of VAN and the National Institutes of Health Stroke Scale (NIHSS) ≥6 for the presence of both emergent large vessel occlusion (ELVO) alone and ELVO or any intracranial hemorrhage (ICH) combined were reported with positive predictive value, sensitivity, negative predictive value, specificity, and overall accuracy. For subjects with intraparenchymal hemorrhage, volume was calculated based on the ABC/2 formula and the presence of intraventricular hemorrhage was recorded.ResultsBoth VAN and NIHSS ≥6 were significantly associated with ELVO alone and with ELVO or any ICH combined using χ2 analysis. Overall, hospital NIHSS ≥6 performed better than prehospital VAN based on statistical measures. Of the 34 cases of intraparenchymal hemorrhage, mean±SD hemorrhage volumes were 2.5±4.0 mL for the five VAN-negative cases and 17.5±14.2 mL for the 29 VAN-positive cases.ConclusionsOur VAN study adds to the published evidence that prehospital EMS scales can be effectively taught and implemented in stroke systems with multiple EMS agencies and CSCs. In addition to ELVO, prehospital scales such as VAN may also serve as an effective ICH bypass tool.

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Abstract TP251: Pomona Large Vessel Occlusion Scale for Pre-hospital and Emergency Room Settings

Stroke ◽

10.1161/str.48.suppl_1.tp251 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kessarin Panichpisal ◽

Nazli Janjua ◽

Karen Tse-Chang ◽

Kimberly.A.Jones A Jones ◽

Katrina Woolfolk ◽

...

Keyword(s):

Emergency Room ◽

Acute Stroke ◽

High Sensitivity ◽

Screening Tools ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Historical Cohort ◽

Lower Accuracy

Background: Early detection of acute stroke with large vessel occlusion (LVO) in both pre-hospital and emergency room settings results in favorable clinical outcomes. There is still no universal guideline for LVO screening. Method: We proposed that the presence of any of the following signs (Pomona scale): gaze deviation, expressive aphasia or neglect has a high sensitivity and accuracy to predict LVO. We reviewed a historical cohort of all acute stroke activation patients at Pomona Valley Hospital during February 2014 to January 2016. We tested Pomona scale in both groups. The predictive performance of Pomona scale was compared with different NIHSS cutoffs ( ≥4, ≥6, ≥8, ≥10), Los Angeles Motor Scale (LAMS), Cincinnati Prehospital Stroke Severity (CPSS) scale, Vision Aphasia and Neglect scale (VAN) and Prehospital Acute Stroke Severity (PASS) scale. Results: LVO was detected in 129 of the 777 acute stroke activation (17%). Two hundred and forty-two patients had nonLVO stroke (31%). NIHSS ≥4 and Pomona scale had highest sensitivity (0.99 and 0.98 respectively) to predict LVO. LAM scale had lowest sensitivity (0.68). Pomona scale had moderate accuracy (0.61) which was comparable with VAN (0.66) and PASS (0.67). NIHSS ≥4 had the least accuracy (0.28). When Pomona scale was combined with arm weakness, it had highest accuracy (0.77) and high sensitivity (0.92) to predict LVO in acute ischemic stroke subgroup. Using various NIHSS cut off to screen for LVO had lower accuracy than using other LVO screening tools. Conclusion: Pomona scale is very sensitive to predict LVO. It may be used as a screening tool for LVO in emergency room setting. Combination of arm weakness and Pomona scale may be used as a Pre-hospital LVO screening with moderately high accuracy.

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Blood PREssure Augmentation in Large-vessel Occlusion Stroke Study

Case Medical Research ◽

10.31525/ct1-nct04218773 ◽

2020 ◽

Author(s):

Keyword(s):

Blood Pressure ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Study

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Abstract TP81: A Closer Look at MRI-Based Core in Patients With Large Vessel Occlusion Within 6 Hours From Onset

Stroke ◽

10.1161/str.51.suppl_1.tp81 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Marie Luby ◽

Yojan Shah ◽

Evan McCreedy ◽

Kyle Kern ◽

Lawrence L Latour ◽

...

Keyword(s):

Onset Time ◽

Large Vessel ◽

Mri Imaging ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Neurological Improvement ◽

Stroke Study ◽

Treatment Onset ◽

Core Volume

Introduction: Recent clinical trials including EXTEND-IA and SWIFT PRIME utilized CT and MRI imaging to exclude large core patients from endovascular therapy (EVT) presenting within 6 hours from onset. We hypothesize that patients with clinical-core mismatch, retrospectively defined as admit NIHSS ≥ 6 and core volume ≤20 mL, were more likely to have early neurological improvement versus those who did not. Methods: Patients included had confirmed large vessel occlusion in the anterior circulation, presented within 6 hours from last known normal, were screened pre-EVT with multimodal MRI, treated with EVT between January 2015 through July 2019, and consented to Natural History of Stroke Study. Core volumes were calculated using a fully automated algorithm, “coretool”, based on processed DWI and ADC maps thresholded at ≤620 μm 2 /sec. Perfusion deficit volumes were calculated by thresholding Tmax maps at >6 sec delay. Early neurological improvement (ENI) was defined as a decrease in NIHSS≥8 points or NIHSS of 0-1 at 24 hours. Results: Fifty-four patients met study criteria with median age 54 years, 59% female, admit NIHSS=19 [13-23], onset=117 min [59-155], onset to groin=212 min [171-265], core volume=9mL [4-31], Tmax volume=82mL [50-107], mismatch volume=51mL [30-86], mismatch ratio=7.5 [2.6-11.9], and 90 day mRS=3 [1-5]. Of the 54 patients, 61% (n=33) had clinical-core mismatch while 39% (n=21) did not. Patients with mismatch had smaller core volumes, median 6 versus 39mL (p<0.001) and larger mismatch ratios, median 8.9 versus 2.6, (p=0.003), but no differences in age, sex, IV tPA treatment, onset time, onset to groin time, admit NIHSS, complete recanalization rate, Tmax volume, mismatch volume, or day 90 mRS. Fifty-five percent (18/33) of patients with clinical-core mismatch had ENI at 24 hours versus 24% (5/21) without (p=0.026). Conclusions: Patients with clinical-core mismatch had a significantly higher rate of early neurological improvement at 24 hours post EVT. However, some patients without mismatch but with complete recanalization still did well. Alternative definitions of mismatch, outside of current guidelines, may identify patients that will benefit more from EVT.

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