Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review

Abstract Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

Download Full-text

Validated pre-hospital stroke scales to predict large vessel occlusion: a systematic review

Australasian Journal of Paramedicine ◽

10.33151/ajp.16.705 ◽

2019 ◽

Vol 16 ◽

Cited By ~ 1

Author(s):

Wayne Loudon ◽

Andrew Wong ◽

Mark Disney ◽

Vivienne Tippett

Keyword(s):

Systematic Review ◽

Clinical Assessment ◽

Intravenous Thrombolysis ◽

Assessment Tools ◽

Large Vessel ◽

Hospital Environment ◽

Large Vessel Occlusion ◽

Medical Systems ◽

Vessel Occlusion ◽

Sensitivity Specificity

Background Occlusions of large cerebral vessels, including the internal carotid artery and middle cerebral artery, result in significant burden of morbidity. Treatment was previously limited to intravenous thrombolysis, however multiple studies have shown significant improvements when patients undergo endovascular clot retrieval. Early identification and triage to centres capable of delivering this is likely to contribute to improved outcomes. This systematic review aims to compare clinical assessment tools and their performance ‘in-field’ to identify usability and reliability to assist pre-hospital providers with identification of this sub-group of stroke patients. MethodsSeveral databases were reviewed to identify studies that have validated large vessel occlusion clinical assessment tools within the pre-hospital environment. Sensitivity, specificity and predictive value were compared along with any biases. Six studies met the study criteria and were included. A total of 1384 patients were involved in the studies with sensitivities ranging from 51.9% to 100% and specificities ranging from 68% to 90%.ConclusionThere is significant variation among studies and the emergency medical systems they have been performed within. It is likely that no single tool will suit every system and further research is required to determine the best tool for the Australian pre-hospital environment.

Download Full-text

Diagnostic accuracy of clinical tools for assessment of acute stroke: a systematic review

10.21203/rs.2.11249/v2 ◽

2019 ◽

Author(s):

Daria Antipova ◽

Leila Eadie ◽

Ashish Macaden ◽

Philip Wilson

Keyword(s):

Diagnostic Accuracy ◽

Acute Stroke ◽

Clinical Assessment ◽

Diagnostic Performance ◽

Assessment Tools ◽

Cochrane Library ◽

Index Test ◽

Stroke Mimics ◽

Wide Range ◽

Clinical Tools

Abstract Introduction: Recanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities. Methods: Diagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015-2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected. Results: Twenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23% to 99% whereas specificity was 24% to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44% to 91%, and specificity of 27% to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies. Conclusions: A wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.

Download Full-text

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Neurosurgical FOCUS ◽

10.3171/2021.4.focus21139 ◽

2021 ◽

Vol 51 (1) ◽

pp. E5

Author(s):

Muhammad Waqas ◽

Cathleen C. Kuo ◽

Rimal H. Dossani ◽

Andre Monteiro ◽

Ammad A. Baig ◽

...

Keyword(s):

Systematic Review ◽

Cerebral Artery ◽

Medical Management ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Cochrane Library ◽

Large Vessel Occlusion ◽

Vessel Occlusion

OBJECTIVE While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs. METHODS PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3–4, and posterior cerebral artery P2–4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment. RESULTS Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23–5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75–8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66–4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone. CONCLUSIONS The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

Download Full-text

Diagnostic accuracy of clinical tools for assessment of acute stroke: a systematic review

10.21203/rs.2.11249/v1 ◽

2019 ◽

Author(s):

Daria Antipova ◽

Leila Eadie ◽

Ashish Macaden ◽

Philip Wilson

Keyword(s):

Diagnostic Accuracy ◽

Acute Stroke ◽

Clinical Assessment ◽

Diagnostic Performance ◽

Assessment Tools ◽

Cochrane Library ◽

Index Test ◽

Stroke Mimics ◽

Wide Range ◽

Clinical Tools

Abstract Introduction Recanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities. Methods Diagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015-2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected. Results Twenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23% to 99% whereas specificity was 24% to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44% to 91%, and specificity of 27% to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies. Conclusions A wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.

Download Full-text

EXPRESS: Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion, a systematic review and meta-analysis

International Journal of Stroke ◽

10.1177/17474930211012545 ◽

2021 ◽

pp. 174749302110125

Author(s):

Mingming Zha ◽

Qingwen Yang ◽

Shuo Liu ◽

Min Wu ◽

Kangmo Huang ◽

...

Keyword(s):

Endovascular Treatment ◽

Clinical Outcomes ◽

Meta Analysis ◽

Working Hours ◽

Good Prognosis ◽

Large Vessel ◽

Cochrane Library ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Significant Difference

Background There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). Aims This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. Summary of review Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through February 23rd, 2021. The primary outcomes were onset to door, door to imaging, door to puncture, puncture to recanalization, procedural time, successful recanalization, symptomatic intracerebral hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale [mRS] score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture, onset to puncture, onset to recanalization, door to recanalization time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer onset to door (WMD [95%CI], 12.83 [1.84-23.82] min), door to puncture (WMD [95%CI], 11.45 [5.93-16.97] min), imaging to puncture (WMD [95%CI], 10.39 [4.61-16.17] min), onset to puncture (WMD [95%CI], 25.30 [13.11-37.50] min), onset to recanalization (WMD [95%CI], 25.16 [10.28-40.04] min), and door to recanalization (WMD [95%CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95%CI], 0.85 [0.76-0.95]; P=0.004; I2=0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend towards lower OR of good prognosis was witnessed in the off-hour group (OR [95%CI], 0.92 [0.84-1.01]; P=0.084; I2=0%). Conclusions Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend towards worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.

Download Full-text

Abstract 1122‐000223: Direct to Angiography Suite versus Conventional Imaging in Suspected Large Vessel Occlusion Strokes: A Meta‐Analysis

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000223 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Mahmoud H Mohammaden ◽

Mohamed Elfil ◽

Mohamed Fahmy Doheim ◽

Agostinho Camara Pinheiro ◽

Alhamza R Al‐Bayati ◽

...

Keyword(s):

Randomized Clinical Trials ◽

Meta Analysis ◽

Functional Independence ◽

Large Vessel ◽

Cochrane Library ◽

Conventional Imaging ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Angiography Suite ◽

Significant Difference

Introduction : Direct transfer to angiography suite (DTAS) for patients with suspected large vessel occlusion strokes potentially requiring mechanical thrombectomy has been shown to shorten treatment times and improve outcomes compared to conventional imaging (CI) selection. This meta‐analysis compares both approaches to build more concrete evidence. Methods : The potentially relevant studies that were published in four electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) till August 2021 were reviewed. Eligible studies were included if they enrolled >10 patients in both groups, were published in English and reported baseline and procedural characteristics and 90‐day outcomes. Relevant data were then extracted and analyzed. Results : Among 4514 searched studies, six qualified for the analysis. Time from door to puncture (MD = ‐26.76minutes, 95 % CI [‐39.48, ‐14.03], P< 0.0001) as well as door to reperfusion (MD = ‐27.21 minutes,95% CI [‐47.42, ‐7.01], P = 0.008) were significantly shorter and the rates of functional independence(mRS0‐2: RR = 1.28, 95% CI [1.03, 1.60], P = 0.03) at 90‐days were significantly higher in the DTAS versus the CI approach. There was no statistically significant difference between DTAS and CI groups in terms of successful reperfusion (modified Thrombolysis In Cerebral Infraction [mTICI] score2B‐3: RR = 0.99, 95% CI [0.93, 1.06], P = 0.86), near complete/ full reperfusion (mTICI 2C‐3: RR = 0.84,95% CI [0.68, 1.04], P = 0.11), or fair outcomes at 90‐days (mRS 0–3: RR = 1.05, 95% CI [0.67, 1.64],P = 0.84). Moreover, there was no difference between groups regarding symptomatic intracranial hemorrhage (RR = 0.81, 95% CI [0.55, 1.17], P = 0.26) or 90 day‐mortality (RR = 0.85, 95% CI [0.59, 1.24],P = 0.41). Conclusions : Our meta‐analysis showed that DTAS significantly improves time metrics and functional outcome with comparable safety to the CI approach. Multicenter randomized clinical trials are ongoing to confirm these results.

Download Full-text

Artificial Intelligence for Large Vessel Occlusion Stroke: A Systematic Review

World Neurosurgery ◽

10.1016/j.wneu.2021.12.004 ◽

2021 ◽

Author(s):

Nathan A. Shlobin ◽

Ammad A. Baig ◽

Muhammad Waqas ◽

Tatsat R. Patel ◽

Rimal H. Dossani ◽

...

Keyword(s):

Artificial Intelligence ◽

Systematic Review ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Download Full-text

A Systematic Review of the Current State and Validity of Digital Assessment Tools for Psychiatry (Preprint)

10.2196/preprints.32824 ◽

2021 ◽

Author(s):

Nayra Anna Martin-Key ◽

Benedetta Spadaro ◽

Erin Funnell ◽

Eleanor Jane Barker ◽

Thea Sofie Schei ◽

...

Keyword(s):

Mental Health ◽

Systematic Review ◽

Depressive Disorder ◽

Diagnostic Accuracy ◽

Mental Healthcare ◽

Risk Of Bias ◽

Assessment Tools ◽

Cochrane Library ◽

Digital Assessment ◽

Current State

BACKGROUND Given the role digital technologies are likely to play in the future of mental healthcare, there is a need for a comprehensive appraisal of the current state and validity (i.e., screening/diagnostic accuracy) of digital mental health assessments. OBJECTIVE To explore the current state and validity of question-and-answer-based digital tools for diagnosing and screening psychiatric conditions in adults. METHODS This systematic review was based on the Population, Intervention, Comparison, and Outcome (PICO) framework and was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Embase, Cochrane Library, ASSIA, Web of Science Core Collection, CINAHL, and PsycINFO were systematically searched for articles published between 2005 and 2020. A descriptive evaluation of the study characteristics and digital solutions and a quantitative appraisal of the screening/diagnostic accuracy of the included tools was conducted. Risk of bias and applicability were assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) guidelines. RESULTS A total of 25 studies met the inclusion criteria, with the most frequently evaluated conditions encompassing generalized anxiety disorder (GAD), major depressive disorder (MDD), and any depressive disorder. The majority of the studies employed digitized versions of existing pen-and-paper questionnaires, with findings revealing poor to excellent screening/diagnostic accuracy (sensitivity = 0.36-1.00, specificity = 0.37-1.00, AUC = 0.57-0.98) and a high risk of bias for most of the included studies. CONCLUSIONS The current state of the field of digital mental health tools is in its early stages and high-quality evidence is lacking. INTERNATIONAL REGISTERED REPORT RR2-10.2196/25382

Download Full-text

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.

Download Full-text

Abstract 1122‐000022: Delays in Care for Patients with Acute Stroke During Hospitalization for Other Reasons

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000022 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Nicholas Vigilante ◽

Parth Patel ◽

Prasanth Romiyo ◽

Lauren Thau ◽

Mark Heslin ◽

...

Keyword(s):

Acute Stroke ◽

Acute Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Single Center ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Symptom Recognition ◽

Risk Patients ◽

Recognition Imaging

Introduction : In‐hospital stroke (IHS) is defined as stroke that occurs during hospitalization for non‐stroke conditions. We aimed to understand the timing of symptom recognition for patients who experienced IHS and its impact on the care they receive. Methods : A prospective, single center registry of adult patients (9/20/19‐2/28/21) was queried for acute anterior circulation IHS. Indications for hospitalization, delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored. Results : Of 928 consecutively evaluated adults with acute stroke, 85 (9%) developed an anterior circulation IHS, 39 (46%) of whom were female, with a median age of 67 years (IQR 60–76) and median NIHSS of 15 (IQR 4–22). Sixty‐eight (80%) had a >1 hour delay from last known well to symptom recognition. Two patients (2%) received IV thrombolysis, although another 38 (45%) would have been eligible if not for a delay in symptom recognition. An ICA, M1, or M2 occlusion was observed in 18 patients (21%), 7 of whom were treated at a median of 174 minutes after LKW (IQR 65–219). Compared to the 11 patients who did not undergo thrombectomy with large vessel occlusion, those who underwent thrombectomy had non‐significantly shorter delays from LKW until neuroimaging (median 85 [IQR 65‐162] vs. 216 [IQR 133‐507], p = 0.12). Conclusions : While uncommon, patients with IHS experience delays in symptom recognition and treatment, which lead to exclusion from acute care treatment such as thrombolysis and thrombectomy. Earlier detection with more frequent nursing assessments or advanced neuromonitoring devices in at‐risk patients may reduce delays in care.

Download Full-text