Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die. 

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Teaching Impact on Telestroke Nurse Recognition of Large Vessel Occlusion Computerized Tomography Perfusion Patterns

Stroke ◽

10.1161/strokeaha.119.028757 ◽

2020 ◽

Vol 51 (6) ◽

pp. 1879-1882

Author(s):

Laura Williams ◽

Maria Helms ◽

Emily K. Snider ◽

Brenda Chang ◽

Sam Singh ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Computerized Tomography ◽

Good Accuracy ◽

Internal Carotid ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

The Impact

Background and Purpose— A distinguishing feature of our Stroke Network is telestroke nurses who remotely facilitate evaluations. To enable expeditious transfer of large vessel occlusion (LVO) acute ischemic stroke patients presenting to nonthrombectomy centers, the telestroke nurses must immediately identify color thresholded computerized tomography perfusion (CTP) patterns consistent with internal carotid artery (ICA), middle cerebral artery (MCA) segment 1(M1), and MCA segment 2 (M2) LVO acute ischemic stroke. Methods— We developed a 6-month series of tutorials and tests for 16 telestroke nurses, focusing on CTP pattern recognition consistent with ICA, M1, or M2 LVO acute ischemic stroke. We simultaneously conducted a prospective cohort study to evaluate the impact of this intervention. Results— Telestroke nurses demonstrated good accuracy in detecting ICA, M1, or M2 LVO during the first 3 months of teaching (83%–94% accurate). This significantly improved during the last 3 months (99%–100%), during which the likelihood of correctly identifying the presence of any one of these LVOs exceeded that of the first 3 months ( P <0.001). There was a higher probability of correctly identifying any CTP pattern as consistent with either an ICA, M1, or M2 occlusion versus other types of occlusions or nonocclusions (odds ratio, 5.22 [95% CI, 3.2–8.5]). Over time, confidence for recognizing CTP patterns consistent with an ICA, M1, or M2 LVO did not differ significantly. Conclusions— A series of tutorials and tests significantly increased the likelihood of telestroke nurses correctly identifying CTP patterns consistent with ICA, M1, or M2 LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at 4 months.

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Mechanical thrombectomy techniques for acute ischemic stroke

Romanian Neurosurgery ◽

10.33962/roneuro-2020-007 ◽

2020 ◽

pp. 46-51

Author(s):

A. Chiriac ◽

Georgiana Ion ◽

N. Dobrin ◽

Dana Turliuc ◽

I. Poeata

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Current Trends

Mechanical thrombectomy technique was introduced as an effective and secure method in acute ischemic stroke patients suffering from intracranial large vessel occlusion (LVO). In this article, we will review the main mechanical thrombectomy techniques and current trends in this type of treatment for acute ischemic stroke.

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The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke

Frontiers in Neurology ◽

10.3389/fneur.2021.663472 ◽

2021 ◽

Vol 12 ◽

Author(s):

Taylor Haight ◽

Burton Tabaac ◽

Kelly-Ann Patrice ◽

Michael S. Phipps ◽

Jaime Butler ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Emergency Medical ◽

Suspected Stroke

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

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Mortality Risk in Acute Ischemic Stroke Patients With Large Vessel Occlusion Treated With Mechanical Thrombectomy

Journal of the American Heart Association ◽

10.1161/jaha.119.014425 ◽

2019 ◽

Vol 8 (21) ◽

Cited By ~ 7

Author(s):

Aristeidis H. Katsanos ◽

Konark Malhotra ◽

Nitin Goyal ◽

Lina Palaiodimou ◽

Peter D. Schellinger ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mortality Risk ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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E-098 Mechanical thrombectomy in the extended 24 hour time window for acute ischemic stroke patients with large vessel occlusion

10.1136/neurintsurg-2020-snis.131 ◽

2020 ◽

Author(s):

S Salam ◽

C Powers ◽

S Nimjee ◽

P Youssef ◽

S Heaton ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Time Window ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

International Journal of Stroke ◽

10.1177/1747493019873510 ◽

2019 ◽

Vol 15 (3) ◽

pp. 324-331 ◽

Cited By ~ 6

Author(s):

Dylan N Wolman ◽

David G Marcellus ◽

Maarten G Lansberg ◽

Gregory Albers ◽

Adrien Guenego ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Medical Management ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Symptomatic Intracranial Hemorrhage

Background Acute ischemic stroke patients with a large-vessel occlusion but mild symptoms (NIHSS ≤ 6) pose a treatment dilemma between medical management and endovascular thrombectomy. Aims To evaluate the differences in clinical outcomes of endovascular thrombectomy-eligible patients with target-mismatch perfusion profiles who undergo either medical management or endovascular thrombectomy. Methods Forty-seven patients with acute ischemic stroke due to large-vessel occlusion, NIHSS ≤ 6, and a target-mismatch perfusion imaging profile were included. Patients underwent medical management or endovascular thrombectomy following treating neurointerventionalist and neurologist consensus. The primary outcome measure was NIHSS shift. Secondary outcome measures were symptomatic intracranial hemorrhage, in-hospital mortality, and 90-day mRS scores. The primary intention-to-treat and as-treated analyses were compared to determine the impact of crossover patient allocation on study outcome measures. Results Forty-seven patients were included. Thirty underwent medical management (64%) and 17 underwent endovascular thrombectomy (36%). Three medical management patients underwent endovascular thrombectomy due to early clinical deterioration. Presentation NIHSS ( P = 0.82), NIHSS shift ( P = 0.62), and 90-day functional independence (mRS 0–2; P = 0.25) were similar between groups. Endovascular thrombectomy patients demonstrated an increased overall rate of intracranial hemorrhage (35.3% vs. 10.0%; P = 0.04), but symptomatic intracranial hemorrhage was similar between groups ( P = 0.25). In-hospital mortality was similar between groups ( P = 0.46), though all two deaths in the medical management group occurred among crossover patients. Endovascular thrombectomy patients demonstrated a longer length of stay (7.6 ± 7.2 vs. 4.3 ± 3.9 days; P = 0.04) and a higher frequency of unfavorable discharge to a skilled-nursing facility ( P = 0.03) rather than home ( P = 0.05). Conclusions Endovascular thrombectomy may pose an unfavorable risk-benefit profile over medical management for endovascular thrombectomy-eligible acute ischemic stroke patients with mild symptoms, which warrants a randomized trial in this subpopulation.

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