Visualization of large vessel occlusion, clot extent, and collateral supply using volume perfusion flat detector computed tomography in acute stroke patients

Introduction25%-30% of patients admitted with acute stroke are stroke mimics. Clinical assessment plays a major role in diagnosis in the hyperacute clinical setting. Identifying physical signs that correctly identify stroke is therefore important. A retrospective study1 suggested that the presence of sensory inattention (or neglect) was seen exclusively in stroke patients, suggesting that inattention might be a reliable discriminator between stroke and mimics. This study aimed to test that hypothesis.MethodsProspective assessment of suspected stroke patients for the presence of neglect (NIHSS definition). Neglect could be visual and/or somatosensory. The presence of neglect was then correlated with eventual diagnosis at 48 hours. Sensitivity, specificity and predictive values were calculated. A post-hoc analysis evaluated the correlation of neglect with large vessel occlusion in patients who underwent angiography.Results115 patients were recruited, 70 ultimately with stroke and 45 with other diagnoses. Neglect was present in 27 patients (of whom 23 had stroke) and absent in 88. This yielded: sensitivity 32.9%, specificity 91.1%, positive predictive value 85.2%, and negative predictive value 41.9%. Two patients with neglect had a diagnosis of functional illness, one a seizure, and one a brain tumour. Neglect was present in 7 out of 8 patients with large vessel occlusion (sensitivity 87.5%) and was absent in all patients who did not have large vessel occlusion on angiogram.ConclusionWhen present, neglect is a strong predictor of organic pathology and large vessel occlusion. However, it is not 100% specific and can be seen in functional presentations.ReferenceGargalas S, Weeks R, Khan-Bourne N, Shotbolt P, Simblett S, Ashraf L, Doyle C, Bancroft V, David AS: Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry 2017, 88:2–6.

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Good recanalization is associated with long term favorable outcomes in acute stroke patients with large vessel occlusion treated with endovascular therapy

Journal of the Neurological Sciences ◽

10.1016/j.jns.2020.117009 ◽

2020 ◽

Vol 416 ◽

pp. 117009

Author(s):

Masafumi Arakawa ◽

Kentaro Suzuki ◽

Akihito Kutsuna ◽

Takehiro Katano ◽

Takuya Kanamaru ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Mathematical Modeling for Decision-Making in the Field for Acute Stroke Patients With Suspected Large Vessel Occlusion

Stroke ◽

10.1161/strokeaha.118.021381 ◽

2019 ◽

Vol 50 (1) ◽

pp. 212-217 ◽

Cited By ~ 3

Author(s):

Jessalyn K. Holodinsky ◽

Mohammed A. Almekhlafi ◽

Mayank Goyal ◽

Noreen Kamal

Keyword(s):

Mathematical Modeling ◽

Decision Making ◽

Acute Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Transfer to the Local Stroke Center versus Direct Transfer to Endovascular Center of Acute Stroke Patients with Suspected Large Vessel Occlusion in the Catalan Territory (RACECAT): Study protocol of a cluster randomized within a cohort trial

International Journal of Stroke ◽

10.1177/1747493019852176 ◽

2019 ◽

Vol 14 (7) ◽

pp. 734-744 ◽

Cited By ~ 10

Author(s):

Sònia Abilleira ◽

Natalia Pérez de la Ossa ◽

Xavier Jiménez ◽

Pere Cardona ◽

Dolores Cocho ◽

...

Keyword(s):

Endovascular Treatment ◽

Acute Stroke ◽

Arterial Occlusion ◽

Large Vessel ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Stroke Center ◽

Cluster Randomized

Rationale Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion have not been assessed in randomized trials. Aim To establish whether stroke subjects with rapid arterial occlusion evaluation scale based suspicion of large vessel occlusion evaluated by emergency medical services in the field have higher rates of favorable outcome when transferred directly to an endovascular center (endovascular treatment stroke center), as compared to the standard transfer to the closest local stroke center (local-SC). Design Multicenter, superiority, cluster randomized within a cohort trial with blinded endpoint assessment. Procedure Eligible patients must be 18 or older, have acute stroke symptoms and not have an immediate life threatening condition requiring emergent medical intervention. They must be suspected to have intracranial large vessel occlusion based on a pre-hospital rapid arterial occlusion evaluation scale of ≥5, be located in geographical areas where the default health authority assigned referral stroke center is a non-thrombectomy capable hospital, and estimated arrival at a thrombectomy capable stroke hospital in less than 7 h from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with three strata: day/night, distance to the endovascular treatment stroke center, and week/week-end day. Study outcome The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is mortality at 90 days. Analysis The primary endpoint based on the modified intention-to-treat population is the distribution of modified Rankin Scale scores at 90 days analyzed under a sequential triangular design. The maximum sample size is 1754 patients, with two planned interim analyses when 701 (40%) and 1227 patients have completed follow-up. Hypothesized common odds ratio is 1.35.

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Comparison of Quantitative and Qualitative Oxygen Extraction Fraction (OEF) in Acute Stroke Patients with Large Vessel Occlusion

Advances in Experimental Medicine and Biology - Oxygen Transport to Tissue XL ◽

10.1007/978-3-319-91287-5_8 ◽

2018 ◽

pp. 45-51

Author(s):

Edwin Nemoto ◽

Ridwan Lin ◽

Ken Uchino ◽

Julia Billigen ◽

Nicholas Bircher ◽

...

Keyword(s):

Acute Stroke ◽

Large Vessel ◽

Oxygen Extraction Fraction ◽

Oxygen Extraction ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Extraction Fraction

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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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