Abstract 50: RNA Expression for Diagnosis of Stroke Etiology Differentiating Large Artery and Cardioembolic Stroke: Analytical Validation of Testing From the BASE Clinical Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Edward C Jauch ◽  
Keyword(s):  
Acute Stroke ◽  
Symptom Onset ◽  
Training Data ◽  
Cardioembolic Stroke ◽  
Blood Collection ◽  
Rna Expression ◽  
Large Artery ◽  
Hospital Data ◽  
Stroke Patients ◽  
Stroke Etiology

Background: An accurate test to differentiate large artery stroke (LAS) patients from those with cardioembolic stroke (CES) would be of significant clinical utility. Using the Biomarkers of Acute Stroke Etiology (BASE) trial (NCT02014896) dataset, our purpose was to utilize blood gene expression signatures for accurately differentiating LAS from CES acute stroke etiologies. Methods: The BASE trial enrolled suspected stroke patients presenting to 20 hospitals within 24 hrs of symptom onset. Final gold standard diagnosis and stroke etiology were determined by an adjudication committee using all hospital data but blinded to RNA test results. Whole blood, obtained in PAX tubes, was frozen at -20C within 72 hrs and analyzed at a core lab (Ischemia Care, Dayton, OH) using Affymetrix HTA microarrays. Genes on the HTA microarray were filtered to eliminate genes with low expression or high CV (> 10%) when run on replicate samples leaving 9,513 potential signature genes. A two-way random forest classifier was built through cross validation of the training data resulting in a 45 gene diagnostic signature. Results: This is a planned interim cohort study of the 1700 patients enrolled in the BASE trial that does not include lacunar strokes, TIA, or stroke mimics. Overall, 222 patients were enrolled with NIHSS>5, 70 (32%) with LAS and 152 (68%) with CES; 59% were male, and median (IQR) age was 70.7 yrs (62.0, 80.2). Median (IQR) time from symptom onset to blood collection was 1200 (448, 1568) minutes. Coexistent pathology at presentation included atrial fibrillation 90 (48%), hypertension 153 (82%), hyperlipidemia 87 (47%), diabetes 60 (32%), and coronary artery disease 70 (37%). Patients were randomly divided into training (148), early symptom onset (<18hrs) validation (39) and a late symptom onset (>18 hrs) validation (35). The diagnostic gene signature results in the early validation cohort distinguished LAS from CES; C-statistic 0.78 (0.50-1.0, 95% CI), sensitivity 0.90 (0.55-1.0, 95% CI) and specificity of 0.70 (0.43-1.0, 95% CI). Conclusion: Early RNA expression differentiates large artery stroke patients from those with cardioembolic stroke, and may have therapeutic and secondary prevention implications.

Abstract WMP61: RNA Expression Signature to Diagnosis Stroke Etiology by Atrial Fibrillation versus Large Artery Atherosclerosis Cause: A BASE Clinical Trial Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Glen Jickling ◽  
Frank Sharp ◽  
Edward Jauch ◽  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Symptom Onset ◽  
Training Data ◽  
Rna Expression ◽  
Large Artery ◽  
Sample Collection ◽  
Hospital Data ◽  
Stroke Patients ◽  
Stroke Etiology

Background: Identifying atrial fibrillation in embolic stroke of ischemic stroke populations would be of significant clinical utility. Using the Biomarkers of Acute Stroke Etiology (BASE) trial (NCT02014896) dataset, our goal was to determine if blood gene expression signatures accurately differentiated patients with atrial fibrillation from large artery stroke patients. Methods: The BASE trial enrolled suspected stroke patients presenting to 20 hospitals within 24 hrs of symptom onset. Final gold standard diagnosis and stroke etiology were determined by an adjudication committee using all hospital data but blinded to RNA test results. Whole blood, obtained in PAXgene tubes, was frozen at -20C within 72 hrs and analyzed at a core lab (Ischemia Care, LLC, Dayton, OH) using Affymetrix HTA micro arrays. Approximately 38,000 genes on the HTA microarray were filtered to eliminate genes with low expression or high CV (> 10%) when run on replicate samples leaving 9,513 potential signature genes. A two-way random forest classifier was built through cross validation of the training data resulting in a 23 gene diagnostic signature. Results: There were 58 patients enrolled between 18 and 24 hours of symptom onset, with NIHSS>5, 27 (47%) with atrial fibrillation cause of stroke and 31 (53%) with large artery stroke; 64% were male, and median (IQR) age was 69.7 (62.8, 81.0). Median (IQR) time from symptoms to sample collection was 1323.5 (1208.8, 1381.3) minutes. Coexistent pathology at presentation was high blood pressure 49 (84%), hyperlipidemia 28 (48%), diabetes 9 (16%), and coronary artery disease 15 (26%). The panel was able to distinguish atrial fibrillation from large vessel stroke with a C-statistic 0.92 (0.55-1.0, 95% CI), sensitivity 0.90 (0.51-1.0, 95% CI) and specificity of 0.85. Conclusion: RNA expression differentiates strokes due to atrial fibrillation from large artery stroke and may have therapeutic and outcome implications in ischemic stroke populations.

Abstract TMP100: Biology of Stroke: Role of ELL2, GLIPR1, MAPKAPK3 Genes in Identifying Atrial Fibrillation Cause of Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Glen Jickling ◽  
Frank Sharp ◽  
Edward Jauch ◽  
Keyword(s):  
Atrial Fibrillation ◽  
Training Data ◽  
Blood Collection ◽  
Large Artery ◽  
Hospital Data ◽  
Stroke Patients ◽  
Stroke Etiology ◽  
Signature Genes ◽  
Diagnostic Signature ◽  
Artery Disease

Background: An accurate test to identify atrial fibrillation in ischemic stroke populations would be of significant clinical utility. Using the Biomarkers of Acute Stroke Etiology (BASE) trial (NCT02014896) dataset, our goal was to utilize a database of genes appearing in literature determine if gene expression accurately differentiate patients with atrial fibrillation from those with large artery stroke. Methods: BASE enrolled suspected stroke patients presenting to 20 hospitals within 24 hrs of symptom onset. Final gold standard diagnosis and stroke etiology were determined by an adjudication committee using all hospital data but blinded to RNA test results. Whole blood, obtained in PAXgene tubes, was frozen at -20C within 72 hrs and analyzed at a core lab (Ischemia Care, LLC, Dayton, OH) using Affymetrix HTA micro arrays. Genes were filtered to those appearing in stroke literature resulting in 543 potential signature genes. A two-way random forest classifier was built through cross validation of the training data resulting in a 3 gene diagnostic signature with robust performance conserved across literature consisting of ELL2, GLIPR1, MAPKAPK3 genes. Results: Overall, 99 patients were enrolled with NIHSS>5, 68 (69%) with atrial fibrillation cause of stroke and 31 (31%) with large artery stroke; (48%) were male, and median (IQR) age was 74.4 (66.1,81.7). Median (IQR) time from symptoms to blood collection was 420 (322, 472) minutes. Coexistent pathology at presentation included high blood pressure 84 (85%), hyperlipidemia 45 (45%), diabetes 31 (31%), and coronary artery disease 38 (38%). Three genes were able to differentiate atrial fibrillation from large vessel stroke; C-statistic 0.86 (0.52-1.0, 95% CI), sensitivity 0.93 (0.56-1.0, 95% CI) and specificity of 0.58 (0.35-0.81, 95% CI ). Conclusion: RNA expression of ELL2, GLIPR1, MAPKAPK3 genes differentiates atrial fibrillation stroke patients from those with large artery stroke, and may have therapeutic and outcome implications.

Abstract 180: The Growth Rate of Early DWI Lesions is Highly Variable and Associated with Penumbral Salvage and Clinical Outcomes Following Endovascular Reperfusion

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Hayley M Wheeler ◽  
Michael Mlynash ◽  
Manabu Inoue ◽  
Aaryani Tipirneni ◽  
John Liggins ◽  
...  
Keyword(s):  
Growth Rate ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Endovascular Therapy ◽  
Symptom Onset ◽  
Growth Rates ◽  
Initial Growth ◽  
Stroke Patients ◽  
Final Volume ◽  
Favorable Clinical Response

Background: The degree of variability in the rate of early DWI expansion has not been well characterized. We hypothesized that Target Mismatch patients with slowly expanding DWI lesions have more penumbral salvage and better clinical outcomes following endovascular reperfusion than Target Mismatch patients with rapidly expanding DWI lesions. Methods: This substudy of DEFUSE 2 included all patients with a clearly established time of symptom onset. The initial DWI growth rate was determined from the baseline scan by assuming a volume 0 ml just prior to symptom onset. Target Mismatch patients who achieved reperfusion (>50% reduction in PWI after endovascular therapy), were categorized into tertiles according to their initial DWI growth rates. For each tertile, penumbral salvage (comparison of final volume to the volume of PWI (Tmax > 6 sec)/ DWI mismatch prior to endovascular therapy), favorable clinical response, and good functional outcome (see figure for definitions) were calculated. We also compared the growth rate in patients with the Target mismatch vs. Malignant Profile. Results: 64 patients were eligible for this study. Target mismatch patients (n=44) had initial growth rates (range 0 to 43 ml/hr, median of 3 ml/hr) that were significantly less than the growth rates in Malignant profile (n=7) patients (12 to 92 ml/hr, median 39 ml/hr; p < 0.001). In Target mismatch patients who achieved reperfusion (n=30), slower early DWI growth rates were associated with better clinical outcomes (p<0.05) and a trend toward more penumbral salvage (n=27, p=0.137). Conclusions: The growth rate of early DWI lesions in acute stroke patients is highly variable; Malignant profile patients have higher growth rates than other MRI profiles. Among Target Mismatch patients, a slower rate of DWI growth is associated with a greater degree of penumbral salvage and improved clinical outcomes following endovascular reperfusion.

Abstract WP178: Acute Stroke Ischemic Symptom Onset-to-Arrival Time in Michigan Hospitals

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Muhammad U Farooq ◽  
Kathie Thomas
Keyword(s):  
African American ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Outcomes ◽  
Symptom Onset ◽  
Arrival Time ◽  
Heart Association ◽  
The United States ◽  
Stroke Patients ◽  
White Patients

Objectives: Stroke is the fifth-leading cause of death and the leading cause of disability in the United States. One of the primary goals of the American Heart Association/American Stroke Association is to increase the number of acute stroke patients arriving at emergency departments (EDs) within 1-hour of symptom onset. Earlier treatment with thrombolysis in patients with acute ischemic stroke translates into improved patient outcomes. The objective of this abstract is to examine the association between the use of emergency medical services (EMS) and symptom onset-to-arrival time in patients with ischemic stroke. Methods: A retrospective review of ischemic stroke patients (n = 8873) from 25 Michigan hospitals from January 2012-December 2014 using Get With the Guidelines databases was conducted. Symptom onset-to-ED arrival time and arrival mode were examined. Results: It was found that 17.4% of ischemic stroke patients arrived at the hospitals within 1-hour of symptom onset. EMS transported 69.1% of patients who arrived within 1-hour of symptom onset. During this 1-hour period African American patients (22%) were less likely to use EMS transportation as compared to White patients (72%). The majority of patients, 41.8%, arrived after 6-hours of symptom onset. EMS transported only 40% of patients who arrived after 6-hours of symptom onset. As before, during this 6-hour period African American patients (20%) were also less likely to use EMS transportation as compared to White patients (75%). Symptom onset-to-ED arrival time was shorter for those patients who used EMS. The median pre-hospital delay time was 2.6 hours for those who used EMS versus 6.2 hours for those who did not use EMS. Conclusions: The use of EMS is associated with a decreased pre-hospital delay, early treatment with thrombolysis and improved patient outcomes in ischemic stroke patients. Community interventions should focus on creating awareness especially in minority populations about stroke as a neurological emergency and encourage EMS use amongst stroke patients.

Abstract W MP60: Atrial Fibrillation is Associated with Worse Collaterals in Acute Stroke: Angiography in the ENDOSTROKE Registry

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Christian H Nolte ◽  
Georg Bohner ◽  
Tobias Neumann-Haefelin ◽  
Erich Hofmann ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Acute Stroke ◽  
Endovascular Therapy ◽  
Cardioembolic Stroke ◽  
Baseline Risk ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Stroke Etiology ◽  
The Impact

Background: Risk factors for stroke may alter hemodynamics or invoke ischemic preconditioning, yet the impact of such factors on response to acute stroke treatment and the potential relationship with collateral circulation remains unknown. Methods: Consecutive cases enrolled in the International Multicenter Registry for Mechanical Recanalization Procedures in Acute Stroke (ENDOSTROKE) were analyzed with respect to collateral status on baseline angiography before endovascular therapy. ASITN/SIR collateral grade (0-1/2/3-4) was scored by the core lab, blind to all other data. Collateral grade was analyzed with respect to numerous baseline risk factors, demographics and outcomes after endovascular intervention. Results: 109 patients (median age 69 years (25 th , 75 th percentiles: 56, 77); 51% women; median baseline NIHSS 15 (13, 18)) with complete (TICI 0) anterior circulation occlusions (M1, n=71; ICA, n=28; M2, n=10) at baseline were evaluated based on collateral grade (0-1, n=12; 2, n=41; 3-4, n=56). Worse collaterals were noted in patients with atrial fibrillation (ASITN grades 0-1/2/3-4: 21%/30%/49%) as compared to patients without atrial fibrillation (5%/42%/53%, p=0.024), yet cardioembolic stroke etiology was unrelated. Other baseline features such as age, gender, time to presentation, other co-morbidities and labs were unrelated to collateral grade. Post-procedure reperfusion (TICI 2b-3) was significantly associated with better collaterals (OR 2.58 (1.343-4.957, p=0.004). Similarly, final infarct size was significantly smaller in those with better collaterals. Good clinical outcomes (mRS 0-2 at day 90) were less frequent in those with poorer collaterals (OR 0.403 (0.199-0.813, p=0.011). Conclusions: Atrial fibrillation, but not cardioembolic stroke etiology, is associated with worse collaterals. Hemodynamic implications, such as diminished cardiac output due to atrial fibrillation, may result in less favorable outcomes after endovascular therapy for acute stroke.

Abstract 166: Spleen Contraction in Patients With Ischemic Stroke and Brain Hemorrhage: Validating Animal Studies

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Farhaan S Vahidy ◽  
Mohammad H Rahbar ◽  
MinJae Lee ◽  
Kaushik N Parsha ◽  
Preeti Sahota ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Symptom Onset ◽  
Animal Studies ◽  
Brain Hemorrhage ◽  
Stroke Patients ◽  
Consecutive Period ◽  
Spleen Contraction ◽  
History Of ◽  
And Gender ◽  
Stroke Center

Objectives: Animal models have shown that the spleen contracts and contributes to post-ischemic inflammation that may exacerbate brain injury and impair recovery. Translation of these findings in patients is challenging because of a lack of normative spleen volume (SV) data. We created normograms of SV for an adult at-risk population, quantified splenic contraction (SC) in stroke patients, and characterized patients with SC. Methods: We enrolled 158 healthy volunteers (HV) with matching age and gender distribution with that of our stroke center registry. Spleen ultrasounds were performed on 5 consecutive days. We used quantile regression models to identify predictors of SV for HV. Gender and body surface area (BSA) were used to construct percentile based normograms of SV, and the expected pre-stroke SV were calculated, from which SC was quantified. We also enrolled a cohort of 170 patients with acute stroke and intracerebral hemorrhage within 24 hours of symptom onset and performed serial spleen ultrasound measurements during hospitalization. Logistic regression was used to determine factors associated with SC. Results: Normograms for SV in healthy males and females based on BSA were created (Figure 1). Over a 5-day consecutive period of daily spleen measurements, the maximum day to day variation was 10.6 cm3. Based on these findings, stroke patients with a normalized SV below 20 cm3 of their expected SV, were classified as having SC. Excluding stroke mimics, 158 patients were included in the analyses, of which 64 (40.5%) had SC detected within 24 hrs of symptom onset. African-American race, older age, and history of previous stroke were significantly associated with SC (Table 1). Conclusion: The spleen does appear to reduce in size after stroke in some specific subgroups of patients with acute stroke and brain hemorrhage. The biological relevance of SC to the inflammatory response and functional outcomes of stroke patients are currently being studied in our study cohorts.

Does stroke etiology play a role in predicting outcome of acute stroke patients who underwent endovascular treatment with stent retrievers?

2017 ◽  
Vol 372 ◽  
pp. 104-109 ◽  
Author(s):  
Semih Giray ◽  
Ozcan Ozdemir ◽  
Demet F. Baş ◽  
Yusuf İnanç ◽  
Zulfikar Arlıer ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Stroke Patients ◽  
Stroke Etiology ◽  
Stent Retrievers ◽  
Predicting Outcome

scholarly journals No Association Between Thrombus Perviousness and Cardioembolic Stroke Etiology in Basilar Artery Occlusion Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Anna Kufner ◽  
Matthias Endres ◽  
Michael Scheel ◽  
Christoph Leithner ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Binary Logistic Regression ◽  
Artery Occlusion ◽  
Cardioembolic Stroke ◽  
Basilar Artery Occlusion ◽  
Large Artery ◽  
Anterior Circulation ◽  
Stroke Etiology ◽  
Proximal Middle Cerebral Artery

Background: Thrombus perviousness (TP) quantified by thrombus attenuation increase (TAI) assessed on acute non-contrast computed tomography (NCCT) and CT angiography (CTA) may be associated with stroke etiology in anterior circulation ischemic stroke. We investigated whether TP is associated with stroke etiology and recanalization after mechanical thrombectomy in patients with acute basilar artery occlusion (BAO).Methods: Eighty patients with complete BAO and in-house acute imaging from a prospectively maintained database were included. Two raters independently segmented the complete thrombus on co-registered NCCT and CTA to determine TAI in Hounsfield units (HUCTA–HUNCCT); averaged values of the raters were used for analysis. Recanalization to modified treatment in cerebral ischemia (mTICI) score 2b/3 was considered successful, and 90-day modified Rankin Scale score 0–2 was considered favorable.Results: TAI did not differ between patients with different stroke etiologies; median TAI in patients with cardioembolic stroke (n = 36) was −0.47 (interquartile range −4.08 to 7.72), 1.94 (−8.14 to 10.75) in patients with large artery atherosclerosis (LAA; n = 25), and −0.99 (−6.49 to 5.40) in patients with stroke of undetermined origin (n = 17; p = 0.955). Binary logistic regression analyses did not identify TAI as an independent indicator of cardioembolic stroke (adjusted odds ratio [OR] vs. LAA stroke: 1.0 [95% CI: 0.95–1.0], p = 0.751). There was no association with successful recanalization (adjusted OR 1.4 [0.70–2.7], p = 0.345) or favorable outcome (adjusted OR 1.1 [95% CI: 0.94–1.2], p = 0.304).Conclusion: In contrast to proximal middle cerebral artery occlusions, TP in BAO patients is not associated with cardioembolic stroke etiology. Larger confirmatory studies to establish the potential role of TP for clinical applications should focus on patients with anterior circulation stroke.

Abstract WP97: The Aptamer BT200 Blocks Von Willebrand Factor and Platelet Function in Blood of Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Katarina Kovacevic ◽  
Stefan Greisenegger ◽  
Nina Buchtele ◽  
Georg Gelbenegger ◽  
Agnes Langer ◽  
...  
Keyword(s):  
Shear Stress ◽  
Acute Stroke ◽  
Platelet Function ◽  
Stroke Prevention ◽  
Large Artery ◽  
Secondary Stroke Prevention ◽  
High Shear ◽  
High Shear Stress ◽  
Stroke Patients ◽  
Blood Samples

Background: The effect of conventional anti-platelet agents is limited in secondary stroke prevention, and their effects are further blunted under conditions of high shear stress in the presence of increased levels of circulating VWF. VWF mediates platelet adhesion to collagen under high shear stress and is thereby critically involved in thrombus formation at sites of stenotic extracranial intracranial arteries (reviewed by Buchtele et al. 2018). We have created a novel anti-VWF aptamer (BT200) which could be useful for secondary stroke prevention, because the anti-VWF aptamer ARC1779 effectively reduced cerebral embolization after carotid endarterectomy (Markus et al. 2011). Aims: To characterize the effects of BT200 in blood of patients with large artery atherosclerosis stroke. Methods: Blood samples were obtained from 30 patients with acute stroke Inhibition of VWF activity by BT200 was quantified by REAADS ELISA and VWF ristocetin cofactor activity (VWF:RCo), platelet function under high shear rates with the PFA-100, and ristocetin-induced platelet aggregation in whole blood. Results: The majority of stroke patients had elevated VWF:RCo levels (mean: 198%; range 55-330%). Of 15 patients receiving clopidogrel with or without aspirin, only two had a prolonged collagen adenosine diphosphate closure time (CADP-CT) >123s, and only one patient had a ristocetin induced aggregation of <20U. BT200 concentration dependently inhibited VWF activity to <3% and VWF dependent platelet function (p<0.001): BT200 invariably prolonged CADP-CT to target levels of >300s, and decreased aggregation to <20U in blood samples from all patients. Conclusions: BT200 effectively inhibits VWF activity and VWF-dependent platelet function in blood from patients with acute stroke. Results from this study proved useful for planning of the ongoing phase I and planned phase II trial.

Abstract 26: RACE to Treat Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Andrea M Korsnack ◽  
Andrea Adams
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Arterial Occlusion ◽  
First Responders ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Artery ◽  
Stroke Patients ◽  
Conversion Disorders

Background: Endovascular treatment was shown to drastically improve stroke patient outcomes but earlier identification of eligible patients is crucial. First responders are instrumental to the rapid identification and transportation of stroke patients to the nearest appropriate facility for acute stroke care especially when endovascular intervention is an option. Purpose: To develop and evaluate the effectiveness of an algorithm for first responders to use to differentiate which stroke patients should be transported to the closest Interventional Stroke Center for treatment. Method: We revised the County-Level Emergency Medical Services (EMS) protocol and algorithm to include the Rapid Arterial oCclusion Evaluation (RACE) scale in addition to the Cincinnati Prehospital Stroke Scale (CPPS). Together these simple in-the-field scales assess stroke severity and identify patients with acute stroke and large artery occlusion in a prehospital setting. Lucas County EMS staff received a four hour block of continuing education with credit on acute stroke, the updated protocol and algorithm, and use of the new RACE scale in addition to the CPPS. Effectiveness of the training and use of the RACE alert was measured by the percent of patients accurately identified with and without large artery occlusion. Results: Training was provided to 450 EMS staff in several in-person sessions in June 2015. The RACE protocol went citywide on July first. Of the 18 patients brought in to our hospital by EMS in July using the RACE protocol, 72% were identified correctly using the tool. Of these, 6 were identified correctly as having large vessel occlusions and 7 were correctly identified as not having large vessel occlusions. The remaining 5 patients transported by EMS were identified as large vessel occlusions, but were not found to have strokes (seizures, intoxication, and conversion disorders). Conclusion: Our data suggests that first responders can accurately differentiate between which stroke patients could benefit from endovascular treatment using a simple algorithm. Future evaluation could measure the relationship between accurate pre-hospital identification and treatment rates.

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