Efficacy and safety of intra-arterial tirofiban in acute ischemic stroke without large-vessel occlusion.

Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO. Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented. Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.

Purpose This article studies the safety profile and role of intra-arterial (IA) tirofiban as a rescue therapy in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy. Methods This is a retrospective observational study conducted among AIS patients with large vessel occlusion (LVO) eligible for endovascular revascularization and in whom IA tirofiban is given as rescue therapy. If the target vessel shows reocclusion following initial recanalization, flow limiting or significant residual stenosis after thrombectomy, or requires balloon angioplasty or stenting, IA tirofiban at a dose of 0.4 μg/kg/min was administered through the microcatheter in the target vessel followed by intravenous infusion of 0.1 μg/kg/min. The primary safety measure of the study was the incidence of symptomatic hemorrhage. Results The total number of patients in the study group was 82, 36 were in the tirofiban group and 46 were in the non-tirofiban group. Immediate successful reperfusion was achieved in 31 patients (86.1%) and 41 patients (89%) in the tirofiban and non-tirofiban groups, respectively. Note that 19.4 and 25% of patients in the tirofiban group required adjunct techniques of angioplasty and stenting, respectively. Also, 2.7% patient in the tirofiban group had a symptomatic hemorrhage, while 8.7% in the non-tirofiban group had symptomatic intracranial hemorrhage. On multinomial logistic regression, history of transient ischemic attack, truncal occlusion and watershed infarct pattern predicted the usage of IA tirofiban during mechanical thrombectomy. Conclusion Usage of IA tirofiban with or without adjunct techniques as a rescue therapy during mechanical thrombectomy in LVO improved recanalization rates without increasing the risk of symptomatic hemorrhage.

Introduction: CTP is used to distinguish core infarct from penumbral tissue in the 6-24 hour time window from last known well time (LKW). In addition, routine use of CTP inside of 6 hours may increase the sensitivity of detecting medium vessel occlusion (MeVO) as compared with CTA alone. Therefore, some centers apply a strategy of using CTP/CTA routinely in the first 6 hours from LKW while others reserve CTP for the 6-24 hour delayed time window. We hypothesized that use of CTP/CTA inside of 6 hours from LKW is associated with increased EVT especially for MeVO. Methods: This is a retrospective analysis of acute ischemic stroke (AIS) patients from a multi-state stroke registry between Jan 2018 and Mar 2024 who presented within 6 hours of LKW. The incidence of EVT by triage imaging modality (CTA or CTA/CTP) was analyzed overall and also by occlusion location (Large vessel occlusion (LVO), MeVO) through linear mixed models (LMM). Multivariable models were used to adjust for confounding factors. A two-tailed p value of <0.05 was considered statistically significant. Statistical analyses were performed using the statistical software R (version 4.2.3). Results: Of the 13,778 AIS patients analyzed, 43% were triaged with CTP/CTA and CTA alone was used for 57%. The unadjusted EVT treatment rate was 9.8% in patients triaged with CTA alone and 22% for patients triaged with CTP/CTA. LMMs adjusted for age at diagnosis, sex, race and ethnicity, NIHSS at admit and comorbidities show a higher statistically significant likelihood of receiving EVT in the CTA/CTP triaged patients (OR 1.6, 95%CI 1.3 to 1.8, p <0.001). For LVO, there was no difference in the likelihood of receiving EVT in the CTA/CTP triaged patients (OR 1.3, 95%CI 0.7 to 2.3, p = .4). However, for MeVO there was a higher likelihood of receiving EVT in the CTA/CTP triaged patients (OR 3.2, 95%CI 2.0 to 5.0, p <0.001) ( Fig 1 ) Conclusions: The results here show that in a large system of stroke hospitals that AIS patients presenting within 6 hours of LKWT who received CTP/CTA were more likely to undergo EVT than those who received CTA alone. This increased utilization of EVT was accounted for by increased EVT for MEVO but not for LVO. The increased utilization of EVT in MEVO may reflect increased sensitivity of detecting MeVO with the addition of CTP. If MEVO EVT treatment proves effective in ongoing randomized clinical trials, our data argue for more routine use of CTP as a “MEVO detector” in the early time window.

The rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated the hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium vessel occlusion (MeVO) compared to large vessel occlusion (LVO) stroke and within a larger time frame since stroke onset. Core progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core time criteria, fast progressors had core >70 mL within 6 hours of stroke onset and slow progressors had core ≤70 mL, mismatch ≥15 mL, and mismatch to core ratio ≥1.8 within 6 to 24 hours. The relationship between HI and infarct core progression (core/time) was examined using receiver operating characteristics to determine optimal HI cutoff. The HI cutoff was then tested in the overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24 hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 patients with acute ischemic stroke. In 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core time criteria. HI >0.5 was associated with fast progression and able to distinguish fast from slow progressors (area under the curve [AUC] 0.94; 95% confidence interval [CI] 0.80-0.99). In MeVO (n = 26) HI >0.5 had a core progression of 0.30 mL/min compared to 0.03 mL/min for HI ≤0.5 (p < 0.001). In LVO (n = 80), HI >0.5 had a core progression of 0.26 mL/min compared to 0.02 mL/min for HI ≤0.5 (p < 0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI >0.5 had progression rate of 0.21 mL/min compared to 0.03 mL/min for those with HI ≤0.5 (p < 0.001). Validation in a second cohort of patients with acute ischemic stroke (n = 110; MeVO = 42, LVO = 68) yielded similar results for HI >0.5 to distinguish fast and slow core progression with an AUC of 0.84 (95% CI 0.72-0.97). HI can differentiate fast from slow core progression in MeVO and LVO within the first 24 hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of patients with MeVO and LVO stroke for reperfusion therapy that warrant further study.

Background/Objectives: We report on the association of clinical, demographic, and peri- and intraoperative factors with patient outcomes in large- and, separately, medium-vessel acute ischemic stroke (AIS) occlusions treated with mechanical thrombectomy or medical thrombolysis. Increasingly, neuroimaging, particularly novel markers of collateral status, has become useful in predicting response to endovascular treatment (EVT) among AIS patients. However, the relationship between these neuroimaging markers, documented predictors of stroke outcomes, and post-EVT functional status in anterior circulation large-vessel occlusions (LVOs) as compared to medium-vessel occlusions (MeVOs) remains unclear. We evaluated whether shared predictors of 90-day post-EVT functional outcomes in LVO compared to MeVO AIS patients within our institution exist. Methods: We retrospectively evaluated AIS patients treated at our institution between 9 January 2017 and 10 January 2023. The following were the inclusion criteria were applied: (i) CTA confirmed anterior circulation large or medium vessel occlusion; (ii) diagnostic CT perfusion was performed; (iii) mechanical thrombectomy was performed. A low modified Rankin score (mRS) indicating good functional outcomes (i.e., functional independence) was defined as less than or equal to 2, in accordance with prior studies. Univariate and multivariate logistic regression analyses were conducted to determine associations between demographic, clinical, and radiologic factors and mRS ≤ 2. Results: A total of 249 LVO (mean age 65.3 ± 16.2, 53.8% female) and 91 MeVO (mean age 68.9 ± 13.3, 46.2% female) patients met the inclusion criteria. Upon multivariate regression adjusted for race, age, hypertension, diabetes mellitus, radiologic features, IV alteplase, admission NIHSS, and reperfusion status, young age (p = 0.004), low admission NIHSS (p = 0.0001), and good reperfusion status (p = 0.007) were associated with good functional outcomes in LVO stroke. By contrast, no factors were significantly associated with good functional outcomes in MeVO stroke. Conclusions: Known factors, including young age, low admission stroke severity, and successful reperfusion predict EVT outcomes in LVO stroke but not necessarily in MeVO stroke. Further studies regarding predictors of MeVO outcomes in nonsurgical cases, including collateral status, may guide optimal medical management for this population.

Endovascular thrombectomy for acute ischemic stroke due to medium or distal vessel occlusion: A systematic review and meta-analysis.

Background: Medium vessel occlusions (MeVOs) are an increasingly recognized but heterogeneous target for endovascular therapy (EVT). This study aims to compare primary MeVO, rescue MeVO, and large vessel occlusion (LVO) thrombectomy cases to identify which MeVO subtypes derive a meaningful benefit from EVT under appropriate safety conditions. Methods: We retrospectively analyzed a multicenter registry of patients undergoing EVT for acute ischemic stroke. MeVO was defined as the occlusion of the A1-A3, M2-M3, P1-P3, fetal PCA, or PICA segments and classified as primary or rescue. Clinical outcomes were assessed by NIHSS score at baseline, discharge, and 90 days; functional outcome by the modified Rankin scale (mRS); and reperfusion by modified thrombolysis in cerebral infarction (mTICI). Safety endpoints included intracranial hemorrhage and mortality. Results: Among 603 EVT patients, 202 (33.5%) had MeVO. Compared to LVO, MeVO patients were older and had more prior strokes but achieved similar reperfusion and safety outcomes. At 90 days, mRS distribution differed, with MeVO showing more mRS 2 and LVO more mRS 1, while higher-disability strata were comparable. Within MeVO, 119 (58.9%) were primary and 83 (41.1%) rescue occlusions. Rescue MeVO patients presented with higher baseline severity (NIHSS score of 19 vs. 18) and, despite similar reperfusion, experienced worse 90-day outcomes and higher mortality (21.7% vs. 0.8%). Conclusions: EVT for primary MeVO is feasible, effective, and safe, whereas rescue MeVO is associated with poor functional outcomes and markedly higher mortality. These findings highlight rescue MeVO as a distinct phenotype and support a selective approach prioritizing disabling syndromes, proximal/dominant branch occlusions, and IVT non-response.

Background: Acute ischemic stroke triggers complex cellular cascades and increases the production of oxidative stress. Nrf2 (nuclear erythroid-related factor 2) is a transcription factor that regulates a series of neuroprotective antioxidant genes that can improve the clinical outcome of stroke. Glutathione is an antioxidant that can protect cells against oxidative stress and can increase Nrf2 levels. This study aimed to determine the effect of glutathione supplementation on Nrf2 levels and its impact on clinical stroke outcomes. Methods: The research design was a randomized controlled trial, single-blind, and pre-posttest group. About 41 acute ischemic stroke subjects who met the inclusion and exclusion criteria were divided into 2 groups, namely the treatment and control groups. Serum Nrf2 levels were examined using the ELISA method from venous blood and clinical outcomes were assessed using the NIHSS score between days 1 and 14. The treatment group received 500 mg capsule glutathione supplements per 12 hours orally for 14 days. Analysis was carried out using Statistical Product and Service Solutions (SPSS) edition 29. Results: There was a significant difference in the increase in serum Nrf2 levels between the treatment and control groups (p = 0.005). There was an increase in serum Nrf2 levels in the treatment group compared to the control group. There was no significant correlation between increasing Nrf2 levels and improving NIHSS scores (p = 0.331). Conclusion: There was no correlation between increasing Nrf2 levels and improving NIHSS scores in acute ischemic stroke patients who received glutathione antioxidant supplements.

Introduction: Neuroimaging is increasingly useful in predicting response to endovascular treatment (EVT) among acute ischemic stroke (AIS) patients. While radiologic collateral status is a known correlate of reperfusion and mortality in AIS patients with large vessel occlusions (LVOs) of the anterior circulation, whether this imaging marker is associated with patient functional status following EVT is unclear. Furthermore, the utility of collateral status in predicting outcomes of medium vessel occlusions (MeVOs), which account for 25-40% of AIS and are promising candidates for EVT, remains unknown. We evaluated the adjusted association of collateral status parameters with 90-day post-EVT functional outcomes in AIS patients with LVOs and MeVOs. Methods: We retrospectively evaluated AIS patients treated at our institution between January 9, 2017, and January 10, 2023. The following inclusion criteria were applied: (i) CTA-confirmed anterior circulation large or medium vessel occlusion; (ii) diagnostic CT perfusion was performed; (iii) mechanical thrombectomy was performed. A low modified Rankin score (mRS) indicating good functional outcomes (i.e., functional independence) was defined as less than or equal to 2, in accordance with prior studies. Univariate and multivariate logistic regression analyses were conducted to determine associations between demographic, clinical, and radiologic factors and mRS ≤ 2. Results: A total of 277 LVO (mean age 66.3 ± 16.6, 57.0% female) and 106 MeVO (mean age 70.3 ± 13.9, 57.5% female) patients met inclusion criteria. On multivariate regression adjusted for race, age, sex, hypertension, diabetes mellitus, atrial fibrillation, radiologic features, IV alteplase administration, and admission NIHSS, young age (p = 0.0003) and low admission NIHSS (p = 0.006) were associated with good functional outcomes in LVO stroke (Table 1). Similarly, low admission NIHSS (p = 0.02) was associated with good functional outcomes in MeVO stroke (Table 2). Conclusion: No significant association was detected between collateral status parameters — including single-phase CTA, multiphase CTA, and CT perfusion measures — and AIS functional outcomes following EVT in either LVO or MeVO strokes. Thus, although prior research suggests that good collateral status can predict successful reperfusion, collateral status parameters may be suboptimal for determining management of AIS in patients undergoing EVT where functional outcome is prioritized.

Introduction: Recent trials of endovascular therapy (EVT) for medium vessel occlusion (MeVO) failed to show benefit of EVT. Interestingly, MeVO EVT may be disadvantaged compared to Large Vessel Occlusion (LVO) EVT because of longer time to achieve reperfusion as was observed in recent MeVO trials (Goyal et al NEJM 2025, Psychogios et al NEJM 2025). However, the relative contribution of decision time and procedure time has not been systematically evaluated. Here we we examined a real world sample to determine if MeVO EVT takes longer to achieve than LVO EVT. If so, is this related to longer decision-making or longer procedural time? Methods: We performed a retrospective analysis of patients with acute ischemic stroke from a multi-state registry. Patients discharged between January 2018 and May 2025, age ≥18, with large vessel occlusion (LVO) or middle vessel occlusion (MEVO) were included. To assess differences in DTD times for MEVO vs. LVO patients, a mixed effects linear regression model was used, adjusting for age, sex, race, medical history, patient mode of arrival, administration of IV thrombolytic, and last known well to arrival in minutes. To investigate whether any difference in DTD time was related to longer procedure or decision-making times respectively, we also compared median differences in door to groin (DTG) and groin to device (GTD) times in minutes using Wilcoxon rank sum tests. P-values were considered significant at p = .05 Results: The study population included 3,050 patients; 1,066 (35%) were MEVO and 1,984 (65%) were LVO. DTD times were 9.0 minutes longer (95% CI = 5.9, 12.0, p &lt; .001) for patients with MEVO compared to those with LVO. While median DTG times were also significantly longer for MEVO at 88.0 [67.0, 110.0] minutes vs. 80.0 [63.0, 102.0] minutes for LVO ( p &lt;.001), there was no difference in median GTD times between the two groups (18.0 [11.0, 28.0] minutes for MEVO vs. 17.0 [11.0, 26.0] minutes for LVO; p = .06). Conclusions: Door to device times were longer for MeVO EVT compared to LVO EVT. This delay persisted in the model which corrected for potential confounders (Figure 2). Furthermore, this delay is entirely accounted for by longer decision workflow as measured by DTG. Procedure times on the other hand were the same from MeVO EVT and LVO EVT. Future attempts to maximize benefit of MeVO EVT may be best focused on improving time-to-treatment decisions.

This study aimed to evaluate the treatment effect of intraarterial versus intravenous tirofiban during endovascular thrombectomy in acute ischemic stroke. This study retrospectively examined 503 patients with acute ischemic stroke with large vessel occlusion who received endovascular thrombectomy within 24 hours of stroke onset. Patients were divided into 3 groups: no tirofiban (n=354), intraarterial tirofiban (n=79), and intravenous tirofiban (n=70). The 3 groups were compared in terms of recanalization rate, symptomatic intracerebral hemorrhage, in-hospital death rate, 3-month death, and 3-month outcomes measured by modified Rankin Scale score (good clinical outcome of 0-2, poor outcome of 5-6). The comparison was statistically assessed by propensity score matching, followed by Freidman rank-sum test and pairwise Wilcoxon signed-rank test with Bonferroni correction. The propensity score matching resulted in 92 matched triplets. Compared with the no-tirofiban group, the intravenous tirofiban group showed significantly increased recanalization (96.7% versus 64.1%, P<0.001), an increased rate of 3-month good outcome (69.5% versus 51.2%, P=0.034), and a lower rate of 3-month poor outcome (12.2% versus 41.4%, P<0.001). There was no significant difference between the tirofiban intravenous and no-tirofiban groups in terms of symptomatic intracerebral hemorrhage (2.2% versus 0%, P=1.000). However, symptomatic intracerebral hemorrhage was significantly increased in the intraarterial-tirofiban group compared with the no-tirofiban group (19.1% versus 0%, P<0.001), with an increased rate of in-hospital death (23.6% versus 0% P<0.001), and increased rate of 3-month death (26.8% versus 11.1%, P=0.021). The intraarterial-tirofiban and no-tirofiban group showed no significant difference in recanalization rate (66.3% versus 64.1%, P=1.000). As an adjunct to endovascular thrombectomy, intravenous tirofiban is associated with high recanalization rate and good outcome, whereas intraarterial tirofiban is associated with high hemorrhagic rate and death rate.

Introduction: Intravenous thrombolysis (IVT) is recommended for acute ischemic stroke (AIS) patients presenting within 4.5 hours of symptom onset. Since 2015, mechanical thrombectomy (MT) has been the standard of care for large vessel occlusions (LVO). While both treatments are often used in eligible patients, the added benefit of IVT prior to MT remains uncertain. It is hypothesized that IVT before MT may enhance reperfusion and improve functional outcomes, though this effect may vary based on vessel size, occlusion location, and timing of intervention. Methods: We conducted a single-center retrospective cohort study of 2,259 AIS patients who underwent MT between 2014 and 2025. Demographic, clinical, and procedural data were extracted from medical records. The primary outcome was 90-day functional status, assessed using modified Rankin Scale (mRS). Secondary outcomes included recanalization rates and symptomatic intracranial hemorrhage (sICH) rates. Continuous variables were reported as means (SD) and categorical variables as proportions. Continuous variables were compared using t tests and categorical variables via chi square. Logistic regression was used to evaluate associations between treatment strategy (IVT+MT vs. MT alone) and outcomes, with unadjusted and adjusted odds ratios calculated (adjusting for age, sex, hypertension, and diabetes). Results: Of 2259 patients who underwent MT (mean age 79.1, 50.7% female), 848 (37.5%) received IVT. The IVT group had higher odds of achieving good functional outcome defined as 90-day mRS of 0-2 (OR 1.18, 95% CI 0.99-1.41, p=0.066). After adjusting for confounders, this finding became statistically significant (aOR 1.36, 95% CI 1.19-1.68, p=0.005). Secondary outcomes include similar recanalization rates (aOR 0.87, 95% CI 0.73-1.04, p=0.127) and marginally lower odds of sICH in the IVT group (aOR 0.69, 95% CI 0.48-1.00, p=0.051). Subgroup analysis revealed that IVT was not associated with favorable functional outcome among medium vessel occlusion (MeVO) patients (OR 0.82, 95% CI 0.52–1.29), whereas in LVO patients IVT nearly doubled the odds of good outcome (OR 1.91, 95% CI 1.14–3.19, p=0.014). There was no significant differential interaction between IVT and the specific vessel occluded. Conclusions: In AIS, the combination of IVT and MT raises the odds of favorable functional outcomes compared to MT alone, especially in patients with LVO compared to MeVO regardless of specific vessel location without increasing sICH risk.

### Nitrites in Acute Myocardial Infarction Nishat Siddiqi1, Margaret Bruce1, Christopher J. Neil1, Graeme MacLennan2, Seonaidh Cotton2, Sofia A. Papadopoulou3, Baljit Jagpal1, Sue Brown3, Fatima Perez Gonzalez3, Satnam Singh1, Konstantin Schwarz1, Martin Feelisch4, Nicholas Bunce5, Pitt O Lim5, David Hildick-Smith6, John Horowitz7, Melanie Madhani8, Nicholas Boon9, Dana Dawson10, Juan-Carlos Kaski3, Michael P Frenneaux10. 1Dept of Cardiovascular Rsch, Univ of Aberdeen, Aberdeen, United Kingdom, 2Health Sciences Building (third floor), Centre for Healthcare Randomised Trials (CHaRT), Aberdeen, United Kingdom, 3Cardiovascular Sciences Rsch Centre, St George’s Univ of London, London, United Kingdom, 4Faculty of Medicine, Univ of Southampton, Southampton, 5Cardiology Dept, St George’s Healthcare NHS Trust, 6Cardiology Research Unit, Brighton and Sussex Univ Hospitals, Brighton, United Kingdom, 7Basil Hetzel Unit for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, 8Centre for Cardiovascular Sciences, Univ of Birmingham, Birmingham, United Kingdom, 9Centre for Cardiovascular Sciences, Univ of Edinburgh, Edinburgh, United Kingdom, 10School of Medicine and Dentistry, Univ of Aberdeen, Aberdeen Introduction :Despite reperfusion therapy for acute myocardial infarction (AMI), heart failure remains a major sequel. Reperfusion leads to further damage, described as ischemia-reperfusion-injury (IRI). This contributes up to 50% of the final infarct size. In pre-clinical models nitrite potently protects against IRI in the heart and other organs. Hypothesis :Intravenous (iv) sodium nitrite, administered immediately before opening of the infarct-related artery, results in significant reduction of IRI in patients with acute ST elevation MI (STEMI). Methods :In this phase II, randomised, placebo-controlled, double-blind, multicentre trial, 220 patients with first acute STEMI and TIMI 0 or 1 flow were randomised …

Introduction: Stroke symptom assessment tools are used in various settings, including telestroke triage, to identify patients who may be candidates for endovascular therapy (EVT). EVT is now being offered to more patients including those with medium vessel occlusions (MeVOs). We hypothesize that triage screening tools have differing rates of detection for large vessel occlusions (LVOs) versus medium vessel occlusions (MeVOs). Methods: Using our 2021 stroke registry, we created a retrospective cohort of ischemic stroke patients with LVO, MeVO or no occlusion. Patients were treated with the standard of care (e.g., thrombolytics, EVT). Clinical and radiographic data were abstracted for each case. Patients were evaluated for hemiparesis (HP) and vision, aphasia, or neglect (VAN) using the documented presenting exam. ROC analysis was conducted to evaluate the ability of the HP + VAN screening tool to detect LVOs and MeVOs. Results: The cohort consisted of 299 patients (median age 66 years, 48% female, 36% Black, median NIHSS score 9). Among the 175 patients with recorded HP + one of the VAN signs, 81% (n=141) had an occlusion (LVO or MeVO). HP+VAN criteria was not met by 11% of LVOs and 33% of MeVOs. HP + VAN tool performed best for the combined endpoint of LVO or MeVO (sensitivity 0.83, specificity 0.74, AUC 0.786, Figure). Variations of this tool did not significantly improve performance (additional models with AUCs will be presented) with the exception of changing the score to from HP+VAN to “HP or VAN” (sensitivity 1.00, specificity 0.25). Conclusions: In our sample from a tertiary care center, HP+VAN is a reasonable tool for the detection of LVOs or MeVOs. The only variation that improved sensitivity was screening for hemiparesis or VAN. While this prevented us from missing any LVOs or MeVOs, this approach comes at a heavy cost of reduced specificity.

IntroductionA significant proportion of acute ischemic stroke (AIS) patients do suffer from a medium vessel occlusion (MeVO). Despite the lack of clearly established safety and efficacy through randomized trials, an...