scholarly journals Prehospital triage of patients with suspected stroke symptoms (PRESTO): protocol of a prospective observational study

BMJ Open ◽  
2019 ◽  
Vol 9 (7) ◽  
pp. e028810 ◽  
Author(s):  
Esmee Venema ◽  
Martijne H C Duvekot ◽  
Hester F Lingsma ◽  
Anouk D Rozeman ◽  
Walid Moudrous ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Human Subjects ◽  
Real Life ◽  
Clinical Equipoise ◽  
Hospital Data ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Prehospital Triage ◽  
Suspected Stroke

IntroductionThe efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting.Methods and analysisPrehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve.Ethics and disseminationThe Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients.Trial registration numberNTR7595.

scholarly journals Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

2017 ◽  
Vol 7 (2) ◽  
pp. 95-102 ◽  
Author(s):  
Chee-Keong Wee ◽  
William McAuliffe ◽  
Constantine C. Phatouros ◽  
Timothy J. Phillips ◽  
David Blacker ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Functional Outcome ◽  
Acute Ischaemic Stroke ◽  
Controlled Trial ◽  
Group Versus ◽  
Large Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Neurological Improvement

Background and Purpose: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. Methods: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0–1, or a decrease from baseline of ≤8, at 24 h after stroke onset. Results: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. Conclusion: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.

Abstract WMP21: The Delayed Vessel Sign in Multiphase CT Angiography: Facilitating the Rapid On-table Confirmation of Acute Ischaemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Danielle Byrne ◽  
Gavin Sugrue ◽  
Emma Stanley ◽  
Sean Murphy ◽  
Eoin Kavanagh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Single Phase ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Small Vessels ◽  
Suspected Stroke ◽  
Multiphase Ct ◽  
Contrast Ct ◽  
Confidence Scale

Objective: The “delayed vessel sign” refers to the presence of relative unilateral delayed enhancement of a vessel or vessels in the anterior circulation on delayed phases of a multiphase CTA (MPCTA) distal to the point of vessel occlusion. We aimed to determine if educating radiologists on the “delayed vessel sign” would improve sensitivity, confidence and speed in the detection of distal anterior circulation vessel occlusions in the suspected stroke patient. Methods: Non-contrast CT (NCCT) and MPCTA studies of 53 individual patients, who presented with signs/symptoms of acute anterior circulation stroke, were retrospectively selected by an independent radiologist. 15 cases without a vessel occlusion, 15 cases with a M1 occlusion and 23 cases with a distal anterior circulation (A2/M2/M3) occlusion were included. Initially, NCCT and single phase CTA (SPCTA) studies were independently interpreted by four observers (two neuroradiologists, two radiology trainees) and observers’ confidence (scale 1-5), speed and sensitivity of detection were recorded. Observers were then educated on the “delayed vessel sign” and each study was re-examined after an interval of at least 14 days. Results: There was a significant improvement in the sensitivity of detection of distal anterior circulation vessel occlusions on MPCTA compared to SPCTA (p=0.0003) and this was also true for M1 occlusions (p=0.045). Overall confidence was 4.0 for SPCTA and 4.88 with MPCTA (p<0.0001). Average time taken to interpret each case on SPCTA was 85.5s and decreased to 40.1s with MPCTA (p<0.0001). Conclusion: The “delayed vessel sign” is a reliable indicator of ipsilateral vessel occlusion, and is particularly useful in cases involving distal MCA branches where the occlusion is not easily identified on the initial angiographic phase. We have found this sign facilitates the rapid on-table confirmation of acute ischemic stroke, even when small vessels are involved and the clinical diagnosis is uncertain.

Management of a wake-up stroke

2019 ◽  
Vol 19 (4) ◽  
pp. 326-331
Author(s):  
Xuya Huang ◽  
Vafa Alakbarzade ◽  
Nader Khandanpour ◽  
Anthony C Pereira
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Potential Contribution ◽  
National Guidelines ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Ischaemic Brain

Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from large vessel occlusion presenting within 6 hours from onset. However, a substantial group of patients presents with acute ischaemic stroke beyond these time windows or has an unknown time of onset. Recent studies are set to revolutionise treatment for these patients. Using MRI diffusion/FLAIR (fluid-attenuated inversion recovery) mismatch, it is possible to identify patients within 4.5 hours from onset and safely deliver thrombolysis. Using CT perfusion imaging, it is possible to identify subjects with a middle cerebral artery syndrome who have an extensive area of ischaemic brain but as yet have only a small area of infarction who may benefit from urgent thrombectomy in up to 24 hours. Here, we highlight the recent advances in late window stroke treatment and their potential contribution to clinical practice.

Abstract P380: Eloquence Mapping in Acute Ischaemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Waleed Brinjikji ◽  
Alejandro A Rabinstein ◽  
George Harston ◽  
Olivier Joly ◽  
Mehdi Abbasi ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Clinical Imaging ◽  
Motor Tracts ◽  
Selection For ◽  
Contrast Ct ◽  
Time Of Presentation ◽  
The Relationship

Introduction: Patient selection for acute stroke revascularisation therapies is commonly based on clinical-imaging mismatch paradigms. Anatomical scores or total volumes of brain affected are assumed to correlate with clinical deficit without reference to the functional eloquence of the regions involved. In this study we used the relationship between presenting hypoperfusion abnormality and the corresponding NIHSS to generate functionally weighted atlases from patients with acute ischaemic stroke. Methods: Patients with acute large vessel occlusion (LVO) of the anterior circulation and with CTP at the time of presentation were included in this study. CTP was analysed with e-CTP (Brainomix Ltd., Oxford, UK) and hypoperfusion maps defined (Tmax >6s). Voxelwise lesion to symptom mapping was used to generate probability maps associating regions of hypoperfusion with clinical deficit at presentation. Results: 58 patients with itemised NIHSS and CTP were included. Discrete patterns of deficit were associated with each NIHSS domain. Total NIHSS correlated most strongly with left MCA involvement, consistent with the weighting towards language in this clinical scale. Regions associated with upper and lower limb deficits identified the respective motor cortex regions and descending motor tracts. Example mapping is presented in the Figure (A: total NIHSS, B: left arm paresis, C: left leg paresis). Data from a larger cohort will be presented at the meeting. Conclusions: Functional mapping using associations between presenting NIHSS and hypoperfusion lesion can be used to create eloquence-weighted atlases. Such atlases from stroke patients may be helpful to develop tools to predict clinical deficit associated with a presenting ischemic core lesion defined on non-contrast CT or CTP. This approach could refine clinical-imaging mismatch concepts, expanding endovascular treatment to a wider group of patients who would not currently be treated.

scholarly journals Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis

2021 ◽  
pp. 197140092110091
Author(s):  
Hanna Styczen ◽  
Matthias Gawlitza ◽  
Nuran Abdullayev ◽  
Alex Brehm ◽  
Carmen Serna-Candel ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Intracranial Haemorrhage ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion

Background Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience. Methods A retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010–September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded. Results In total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up. Conclusion Mechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.

scholarly journals Cerebral Haemodynamics following Acute Ischaemic Stroke: Effects of Stroke Severity and Stroke Subtype

2018 ◽  
Vol 8 (2) ◽  
pp. 80-89 ◽  
Author(s):  
Osian Llwyd ◽  
Angela S.M. Salinet ◽  
Ronney B. Panerai ◽  
Man Y. Lam ◽  
Nazia P. Saeed ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Cerebral Blood Flow Velocity ◽  
Cerebral Arteries ◽  
Correlation Coefficients ◽  
Stroke Severity ◽  
Stroke Subtype ◽  
Cerebral Haemodynamics ◽  
Anterior Circulation ◽  
Mean Values

Background: Acute ischaemic stroke (AIS) patients often show impaired cerebral autoregulation (CA). We tested the hypothesis that CA impairment and other alterations in cerebral haemodynamics are associated with stroke subtype and severity. Methods: AIS patients (n = 143) were amalgamated from similar studies. Data from baseline (< 48 h stroke onset) physiological recordings (beat-to-beat blood pressure [BP], cerebral blood flow velocity (CBFV) from bilateral insonation of the middle cerebral arteries) were calculated for mean values and autoregulation index (ARI). Differences were assessed between stroke subtype (Oxfordshire Community Stroke Project [OCSP] classification) and severity (National Institutes of Health Stroke Scale [NIHSS] score < 5 and 5–25). Correlation coefficients assessed associations between NIHSS and physiological measurements. Results: Thirty-two percent of AIS patients had impaired CA (ARI < 4) in affected hemisphere (AH) that was similar between stroke subtypes and severity. CBFV in AH was comparable between stroke subtype and severity. In unaffected hemisphere (UH), differences existed in mean CBFV between lacunar and total anterior circulation OCSP subtypes (42 vs. 56 cm•s–1, p < 0.01), and mild and moderate-to-severe stroke severity (45 vs. 51 cm•s–1, p = 0.04). NIHSS was associated with peripheral (diastolic and mean arterial BP) and cerebral haemodynamic parameters (CBFV and ARI) in the UH. Conclusions: AIS patients with different OCSP subtypes and severity have homogeneity in CA capability. Cerebral haemodynamic measurements in the UH were distinguishable between stroke subtype and severity, including the association between deteriorating ARI in UH with stroke severity. More studies are needed to determine their clinical significance and to understand the determinants of CA impairment in AIS patients.

A quantitative analysis of CT angiography, large vessel occlusion, and thrombectomy rates in acute ischaemic stroke

2019 ◽  
Vol 74 (9) ◽  
pp. 731.e21-731.e25 ◽  
Author(s):  
E. Griffin ◽  
D. Herlihy ◽  
R. Hayden ◽  
M. Murphy ◽  
J. Walsh ◽  
...  
Keyword(s):  
Quantitative Analysis ◽  
Ischaemic Stroke ◽  
Ct Angiography ◽  
Acute Ischaemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

scholarly journals Sedation versus general anaesthesia in endovascular therapy for anterior circulation acute ischaemic stroke: the multicentre randomised controlled AMETIS trial study protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (9) ◽  
pp. e027561 ◽  
Author(s):  
Russell Chabanne ◽  
Charlotte Fernandez-Canal ◽  
Vincent Degos ◽  
Anne-Claire Lukaszewicz ◽  
Lionel Velly ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Functional Outcome ◽  
General Anaesthesia ◽  
Endovascular Therapy ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Acute Pulmonary Oedema ◽  
Anterior Circulation ◽  
Randomised Controlled

IntroductionEndovascular thrombectomy is the standard of care for anterior circulation acute ischaemic stroke (AIS) secondary to emergent large vessel occlusion in patients who qualify. General anaesthesia (GA) or conscious sedation (CS) is usually required to ensure patient comfort and avoid agitation and movement during thrombectomy. However, the question of whether the use of GA or CS might influence functional outcome remains debated. Indeed, conflicting results exist between observational studies with better outcomes associated with CS and small monocentric randomised controlled trials favouring GA. Therefore, we aim to evaluate the effect of CS versus GA on functional outcome and periprocedural complications in endovascular mechanical thrombectomy for anterior circulation AIS.Methods and analysisAnesthesia Management in Endovascular Therapy for Ischemic Stroke (AMETIS) trial is an investigator initiated, multicentre, prospective, randomised controlled, two-arm trial. AMETIS trial will randomise 270 patients with anterior circulation AIS in a 1:1 ratio, stratified by centre, National Institutes of Health Stroke Scale (≤15 or >15) and association of intravenous thrombolysis or not to receive either CS or GA. The primary outcome is a composite of functional independence at 3 months and absence of perioperative complication occurring by day 7 after endovascular therapy for anterior circulation AIS. Functional independence is defined as a modified Rankin Scale score of 0–2 by day 90. Perioperative complications are defined as intervention-associated arterial perforation or dissection, pneumonia or myocardial infarction or cardiogenic acute pulmonary oedema or malignant stroke evolution occurring by day 7.Ethics and disseminationThe AMETIS trial was approved by an independent ethics committee. Study began in august 2017. Results will be published in an international peer-reviewed medical journal.Trial registration numberNCT03229148.

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