Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

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Real-World Experience with Artificial Intelligence-Based Triage in Transferred Large Vessel Occlusion Stroke Patients

Cerebrovascular Diseases ◽

10.1159/000515320 ◽

2021 ◽

pp. 1-6

Author(s):

Jacob R. Morey ◽

Xiangnan Zhang ◽

Kurt A. Yaeger ◽

Emily Fiano ◽

Naoum Fares Marayati ◽

...

Keyword(s):

Artificial Intelligence ◽

Clinical Outcomes ◽

Warning System ◽

Large Vessel ◽

Time Interval ◽

Large Vessel Occlusion ◽

Time Intervals ◽

Vessel Occlusion ◽

Left Behind ◽

Stroke Center

Background and Purpose: Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) in clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A computer-aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, a communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment, leading to improved clinical outcomes. Methods: A retrospective analysis of a prospectively maintained database was assessed for patients who presented to a stroke center currently utilizing Viz LVO and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. Time intervals and clinical outcomes were compared for 55 patients divided into pre- and post-Viz cohorts. Results: The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 min [IQR = 12.0] vs. 40.0 min [IQR = 61.0]; p = 0.01) with less variation (p < 0.05) following Viz LVO implementation. The median initial door-to-skin puncture time interval was 25 min shorter in the post-Viz cohort, although this was not statistically significant (p = 0.15). Conclusions: Preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times. This application can serve as an early warning system and a failsafe to ensure that no LVO is left behind.

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Abstract P129: Initial Real-World Experience With Viz LVO in Transferred Large Vessel Occlusion Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p129 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jacob Morey ◽

Xiangnan Zhang ◽

Kurt Yaeger ◽

Emily Fiano ◽

Naoum Fares Marayati ◽

...

Keyword(s):

New York ◽

Warning System ◽

Large Vessel ◽

Time Interval ◽

Large Vessel Occlusion ◽

Time Intervals ◽

Vessel Occlusion ◽

Left Behind ◽

Time Period ◽

Stroke Center

Background and Purpose: Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) on clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A novel computer aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment. Methods: A prospective database was assessed for patients who presented to a stroke center utilizing Viz LVO in the Mount Sinai Health System in New York and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. This time period was chosen due to the COVID-19 pandemic affecting stroke workflow after March 2020. Time intervals were compared for 55 patients divided into Pre- and Post-Viz cohorts. Results: The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 minutes [IQR=12.0] vs 40.0 minutes [IQR=61.0]; p=0.01) with significantly less variation (p<0.05). The median initial door-to-skin puncture time interval was 25 minutes shorter in the Post-Viz cohort, although not statistically significant (p=0.15). Post Viz LVO implementation, the Viz notification was the first NT notification 38% (10/26) of the time. Conclusions: Our preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times and potentially treatment times. This platform presents a novel application of AI that can serve as an early warning system and a failsafe to ensure that no LVO is left behind. Further studies are warranted.

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Abstract WP142: Intravenous Tissue Plasminogen Activator for Patients with Mild and Rapidly Improving Ischemic Strokes and Large Vessel Occlusions: Examining In-hospital Outcomes

Stroke ◽

10.1161/str.48.suppl_1.wp142 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey Wagner ◽

Constance McGraw ◽

Kathryn McCarthy ◽

Judd Jensen ◽

Alessandro Orlando ◽

...

Keyword(s):

Hospital Mortality ◽

Heart Association ◽

Patient Characteristics ◽

Large Vessel ◽

Stroke Severity ◽

Vessel Occlusion ◽

Intravenous Tissue Plasminogen Activator ◽

Increased Risk ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Upon hospital arrival, patients with mild or rapidly improving acute ischemic strokes (AIS) are frequently not treated with IV-tPA. Recent guidelines from the American Heart Association report that diagnosis on imaging of large vessel occlusion (LVO) despite mild stroke severity leads to increased risk of poorer outcomes. The objective of our study was to examine outcomes following tPA in this AIS population. Methods: The study included all AIS patients with an admission NIHSS ≤7 and diagnosis of a LVO on imaging from a single comprehensive stroke center between 2010-2016. Patients were excluded due to missing contraindications to tPA or with a symptom to arrival time of >4.5 hours (n=234). We compared patients who received tPA to those who received no treatment because of mild or rapidly improving symptoms. Outcomes were sICH, improvement in NIHSS score, discharge mRS ≤2, and in-hospital mortality. Patient characteristics were compared univariately, and step-wise logistic regression was used to adjust for confounding variables. Entry criterion was P=0.2 and exit criterion was P=0.07. Results: There were 76 patients with an AIS diagnosis of LVO. Of these patients, 39 (51%) were treated with tPA and 37 (49%) were not treated. Overall, the median (IQR) age was 72 (61-82.5). Patients treated with tPA had a median admission NIHSS of 5 (3-6), and a larger proportion were male (77%) and smokers (4%). Patients without tPA treatment had a median NIHSS of 2 (1-3), and a larger proportion had hypertension (49%). All outcomes were not significantly different between groups after adjustment (Table 1). There were no patients with sICH. Conclusions: Our study suggests that tPA in mild LVO patients does not introduce additional risk in terms of sICH, in-hospital mortality, change in NIHSS, or discharge mRS. Further justification for withholding tPA in this group should be based on 90-day mRS scores, in order to better understand long-term functional outcomes.

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Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

Acta Radiologica ◽

10.1177/02841851211006897 ◽

2021 ◽

pp. 028418512110068

Author(s):

Yu Hang ◽

Zhen Yu Jia ◽

Lin Bo Zhao ◽

Yue Zhou Cao ◽

Huang Huang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Secondary Endpoints ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

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Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2

Cerebrovascular Diseases ◽

10.1159/000514369 ◽

2021 ◽

Vol 50 (4) ◽

pp. 397-404

Author(s):

Kotaro Tatebayashi ◽

Kazutaka Uchida ◽

Hiroto Kageyama ◽

Hirotoshi Imamura ◽

Nobuyuki Ohara ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Characteristics ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Tandem Occlusion ◽

The Mean ◽

Patient Prognosis

Introduction: The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. Results: Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1–5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30–0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42). Discussion/Conclusion: The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

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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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Abstract TP237: Can We Improve Clinical Detection of Right Hemisphere Large Vessel Occlusion?

Stroke ◽

10.1161/str.51.suppl_1.tp237 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sana Somani ◽

Melissa Gazi ◽

Michael Minor ◽

Joe Acker ◽

Abimbola Fadairo ◽

...

Keyword(s):

Left Hemisphere ◽

Right Hemisphere ◽

Trauma System ◽

Area Under The Curve ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Emergency Medical ◽

The Right

Introduction: The Emergency Medical Stroke Assessment (EMSA) is a six point stroke severity scale with one point each for gaze preference, facial droop, arm drift, leg drift, abnormal naming, and abnormal repetition that was developed to help emergency medical services (EMS) providers identify acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We hypothesized that the EMSA would detect left hemisphere LVO with a higher sensitivity than right hemisphere LVO. Methods: We trained 24 trauma system-based emergency communication center (ECC) paramedics in the EMSA. ECC-guided EMS in performance of the EMSA on patients with suspected stroke. We compared the sensitivity, specificity, area under the curve (AUC), and 95% confidence interval (CI) of ECC-guided prehospital EMSA for right versus left hemisphere ICA or M1 occlusion. Results: We enrolled 569 patients from September 2016 through February 2018, out of which 236 had a discharge diagnosis of stroke and 173 had a diagnosis of AIS. We excluded patients with bilateral (n=21) and brainstem (n=21) AIS. There were 64 patients with left hemisphere AIS including 19 with LVO. There were 67 patients with right hemisphere AIS including 22 with LVO. A score of ≥ 4 points yielded a sensitivity of 84.2 (95% CI = 60.4-96.6) and specificity of 66.7 (51.1-80.0) for left hemisphere LVO compared to a sensitivity of 68.2 (45.1-86.1) and specificity of 73.9 (58.9-85.7) for right hemisphere LVO. For predicting a left hemisphere LVO, the AUC was 0.77 (0.65-0.90) compared to 0.66 (0.50-0.82) for right-sided LVO. Assigning 2 points for abnormal gaze yielded an AUC of 0.78 (0.66-0.91) versus 0.67 (0.52-0.83) for left and right hemisphere LVO, respectively. Conclusions: The EMSA, like the National Institutes of Health Stroke Scale (NIHSS) upon which it is based, is more sensitive to left compared to right hemisphere LVO. More heavily weighting abnormal gaze did not improve the sensitivity of the EMSA for right hemisphere LVO. There is no comparable data on the right versus left hemisphere performance of other prehospital scales. There is a need to develop sensitive tests of right hemisphere dysfunction that are suitable for use in the field.

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Abstract 3183: Prognosis of Mild Ischemic Stroke with Large Vessel Occlusion

Stroke ◽

10.1161/str.43.suppl_1.a3183 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Esteban Cheng-Ching ◽

Russell Cerejo ◽

Ken Uchino ◽

Muhammad S Hussain ◽

Gabor Toth

Keyword(s):

Ischemic Stroke ◽

Endovascular Therapy ◽

Time Window ◽

Optimal Treatment ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Mild Stroke

Background and purpose Large vessel occlusion (LVO) in acute ischemic stroke has been reported to be an independent predictor of unfavorable clinical outcome. However, the prognosis and optimal treatment of patients with only mild neurologic deficits due to LVO are not known. Methods We performed a retrospective chart review from a database of stroke patients admitted to our large academic medical center between July 1, 2010 and June 30 , 2011. Inclusion criteria were acute stroke or TIA, presentation within 9 hours from symptom onset, large vessel occlusion as a culprit of ischemic symptoms, and mild stroke severity with initial NIH Stroke Scale (NIHSS) score <8. Results We identified 59 patients with mild ischemic stroke or TIA, who were evaluated within 9 hours from onset. Of these, 13 (22%) had culprit large vessel occlusions. Five were female, 1 had diabetes, 12 had hypertension, 7 had hyperlipidemia, 2 had atrial fibrillation and 7 were smokers. The median NIHSS score was 5. The location of arterial occlusions were 5 in M1 segment of the middle cerebral artery (MCA), 6 in M2 segment of MCA, 1 each in posterior cerebral and vertebral arteries. Two patients received acute therapy, 1 with intravenous thrombolysis and 1 with endovascular therapy. Reasons for withholding thrombolytic therapy were time window in 8, mild stroke severity in 2, and atypical presentations in 2. Reasons for withholding acute endovascular therapy were mild stroke severity in 7, imaging finding in 2, technical considerations in 2, and lack of consent in 1. From hospital admission to discharge, 10 (77%) patients had symptom improvement, 2 had worsening, and one was unchanged. At 30 days, 5 (38%) had good outcome with a modified Rankin Scale (mRS) of 0-1. Three (23%) had mRS of 2, one (8%) patient had mRS of 3. Outcomes for 4 patients were unknown. Conclusions A significant proportion of patients presenting with mild ischemic symptoms has large vessel occlusion. Acute treatment in this population is frequently withheld due to mild severity or thrombolytic time window. Despite mild symptoms at presentation, some patients are left with moderate disability. Optimal treatment options for this population should be further evaluated in a larger group of patients.

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Abstract WP290: Endovascular Treatment Of In-hospital Strokes: An Open Book

Stroke ◽

10.1161/str.44.suppl_1.awp290 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Dolora Wisco ◽

KEN UCHINO ◽

ESTEBAN CHENG CHING ◽

Shazia Alam ◽

SHUMEI MAN ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Patient Characteristics ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Valve Repair ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ct Brain ◽

Contrast Ct ◽

Iv Tpa

INTRODUCTION: In-hospital stroke (IHS) presents a different treatment challenge than out of hospital stroke. IHS often has contraindication to IV tPA, such as such as recent surgery, MI, and use of anticoagulation. Intra-arterial therapy (IAT) with tPA and/or mechanical thrombectomy is an option for large vessel acute IHS with contraindications to or fail to recanalize with IV tPA, to restore cerebral perfusion. Objective: To assess the characteristics and outcomes of patients with in-hospital strokes large vessel occlusion who receive IAT. Methods: From our database of patients from 1/1/2008 to 12/31/2011 who had IAT for an acute stroke due to large vessel occlusion, in hospital strokes and out of hospital strokes were identified. Patient characteristics, imaging, and outcomes were retrospectively collected. Statistical analysis was performed on JMP 9.0. Result: 151 patients were included, 23 (15%) were in-hospital strokes (IHS) and 128 (85%) were out of hospital strokes (OHS). Initial median NIHSS of 17 and 16 respectively (p=0.3). IHS were frequently in the cardiology/CTS service (14, 60%) for CHF and cardiac valve repair (12, 52%). Other comorbidities present were atrial fibrillation (68%), hypertension (68%), and hyperlipidemia (56%). Seven (30%) were on warfarin prior to admission, but all had subtherapeutic INR. Three (13%) IHS received IV tPA. The time from last known well (LKW) to non-contrast CT brain was 80 min, and to CTA was 113 min in IHS, and 147 min and 229 min respectively in OHS (p = 0.0003). 20 (87%) had lesion in the anterior circulation. LKW to IAT recanalization was 248 min in IHS, compared to 375 min in OHS. Recanalization rate was 68% for IHS and 81% for OHS (p=0.2). Nine (39%) IHS had favorable mRS of 1 to 3 at 90 days, compared to 44 (34%) OHS, (p = 0.6). Despite faster recanalization time, there was no difference in the 90 day mortality of IHS v OHS (48% vs 30%, p = 0.1), and IHS had greater 1 year mortality (65% vs 30%, p = 0.005). Discussion: In-hospital strokes have higher mortality than out of hospital strokes. There is a role for IAT In carefully selected IHS with large vessel occlusion. A multicenter study is needed to reveal the characteristics of IHS patients who may benefit from IAT.

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