Emergent Large Vessel Occlusion Research Articles

Monocyte to high-density lipoprotein ratio as an independent predictor of intracranial atherosclerotic stenosis-related emergency large vessel occlusion

ObjectiveTo evaluate the correlation between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and intracranial atherosclerotic stenosis-related emergent large vessel occlusion (ICAS-ELVO) in acute ischemic stroke patients with endovascular thrombectomy. MethodsIncluded in this study were 215 patients who underwent endovascular thrombectomy. They were randomly assigned to training and testing datasets. The patients in training dataset (n=128) were divided into ICAS group (n=65) and embolism group (n=63). MHR was compared between the two groups. According to the cut-off value, patients in testing dataset (n=87) were divided into low-MHR group (n=54) and high-MHR group (n=33). MHR was compared between the two groups. ResultsIn training dataset, the proportion of male patients, diabetic patients and smokers in ICAS group was significantly higher than that in embolism group [(50 (76.9%) vs. 30 (47.6%), P=0.001; 29 (44.6%) vs. 14(22.2%), P=0.007; 37(56.9%) vs. 14 (22.2%), P=0.001; 37 (56.9%) vs. 14 (22.2%), P=0.001], while the mean age and the proportion of patients with coronary heart disease (CHD), stroke and atrial fibrillation were significantly lower [(64.74±9.13 vs. 71.38±13.34, P=0.001; 6 (9.2%) vs. 14 (22.2%), P=0.043; 12 (18.5%) vs. 22 (34.9%), P=0.035; 5 (7.7%)vs. 56 (88.9%), P<0.001)]. The laboratory test results showed that monocyte count was significantly higher and high-density lipoprotein level was significantly lower in ICAS group than those in embolism group (0.61±0.26 vs. 0.45±0.13, P=0.001; 1.17±0.28 vs. 1.37±0.27, P=0.001). MHR in ICAS group was significantly higher than that in embolism group (0.55±0.26 vs. 0.34±0.11, P=0.001). In training set, MHR was found to be an independent predictor for the occurrence of ICAS-ELVO with an adjusted OR of 2.39 (95%CI 1.29–4.48, P=0.006). ROC curve analysis showed that the area under the curve (AUC) of MHR was 0.8 (95% CI, 0.72–0.87, p < 0.001), with a sensitivity of 0.60 and a specificity of 0.873. The optimal cut-off value of the MHR level was 0.46. In testing dataset, the rate of ICAS-ELVO in higher quartile was significantly higher than that in the lower quartile (81.8% vs. 33.3%, P<0.001). Patients with a low MHR had a higher rate of cerebral hemorrhagic than those with a high MHR. ConclusionMHR was associated with ICAS-ELVO in acute ischemic stroke patients with endovascular thrombectomy, and the higher level of MHR does benefit to differentiate ICAS from intracranial embolism, suggesting that MHR may prove to be an independent predictor for ICAS-ELVO.

[Safety and efficacy of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis].

Objective: To investigate the efficacy and safety of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis. Methods: A retrospective analysis was carried out on 46 patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis who received endovascular treatment at the Strategic Support Force Medical Center from January 2015 to August 2022. Twenty-seven patients underwent balloon angioplasty alone and 19 patients underwent acute stent implantation. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of the responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality of the two groups were evaluated. Results: The proportion of effective recanalization of the offending vessels (mTICI≥2b) in the acute stenting group was slightly higher than that in the balloon angioplasty group (16/19 vs. 81.5%), but the difference was not statistically significant (P>0.05). Besides, there was no significant difference in the median of mRS between the acute stenting group [3.0(0, 4.0)] and the balloon angioplasty group [4.0(1.0, 5.0)] 90 days after operation (P>0.05). In terms of safety, the incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups (P>0.05). Conclusions: The effect of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis is not inferior to that of balloon angioplasty, and it does not increase the risk of intracranial bleeding complications.

Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions.

This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.

Effect of Intravenous Thrombolysis Prior to Mechanical Thrombectomy According to the Location of M1 Occlusion.

The additive effects of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remain unclear. We aimed to investigate the efficacy and safety of IVT prior to MT depending on the location of M1 occlusion. We reviewed the cases of patients who underwent MT for emergent large-vessel occlusion of the M1 segment. Baseline characteristics as well as clinical and periprocedural variables were compared according to the location of M1 occlusion (i.e., proximal and distal M1 occlusion). The main outcome was the achievement of functional independence (modified Rankin Scale score, 0-2) at 3 months after stroke. The main outcomes were compared between the proximal and distal groups based on the use of IVT before MT. Among 271 patients (proximal occlusion, 44.6%; distal occlusion, 55.4%), 33.9% (41/121) with proximal occlusion and 24.7% (37/150) with distal occlusion underwent IVT prior to MT. Largeartery atherosclerosis was more common in patients with proximal M1 occlusion; cardioembolism was more common in those with distal M1 occlusion. In patients with proximal M1 occlusion, there was no association between IVT before MT and functional independence. In contrast, there was a significant association between the use of IVT prior to MT (odds ratio=5.30, 95% confidence interval=1.56-18.05, P=0.007) and functional independence in patients with distal M1 occlusion. IVT before MT was associated with improved functional outcomes in patients with M1 occlusion, especially in those with distal M1 occlusion but not in those with proximal M1 occlusion.

Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden.

The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden. Consecutive ICAS-ELVO patients presenting with microcatheter "first-pass effect" during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared. Seventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5min vs. 89.0min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" (adjusted odds ratio = 6.01, 95% confidence interval: 1.15-31.51, p = .034). Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.

Clinical Impact of a Local Triage System Using the Emergent Large Vessel Occlusion Screen with a Rotation System of Thrombectomy-Capable Hospitals.

Early intervention with mechanical thrombectomy (MT) is expected to improve the functional outcome in patients with large vessel occlusion (LVO); however, a method for the effective detection of these patients in a prehospital setting and early transport to MT-capable hospitals has not been established. This study aimed to analyze the clinical impact and diagnostic performance of the emergent large vessel occlusion (ELVO) screen and its influence on the transportation time. The emergency medical services (EMS) in one of the secondary medical areas in Akita, Japan, introduced a prehospital triage system employing an ELVO screen and a rotation system of three MT-capable hospitals on December 1, 2021. Patients who were transferred to each of the three hospitals involved in the rotation system according to a predefined priority list from December 2021 to November 2022 were included in the triage group. Patients who underwent MT in the three hospitals before the introduction of the triage system were assigned to the pre-triage group. We compared the transportation time parameters between the two groups and analyzed the performance of the ELVO screen for the diagnosis of LVOs. This study was approved by the institutional review boards of all three hospitals. Time parameters were compared between the 37 and 42 patients who underwent MT and had detailed data in the triage (n = 351) and pre-triage (n = 43) groups, respectively. The time from door to puncture tended to decrease in the triage group in all hospitals, with one hospital showing a statistically significant shortening of 14 min (p = 0.018). In the triage group, 209 ELVO screen-positive patients were present, with 60 (28.7%) of these having LVO. The sensitivity, specificity, positive and negative predictive values, and area under the curve of the ELVO screen to detect LVO under the present triage system were 87.0%, 47.2%, 28.7%, 93.7%, and 0.671, respectively. The present study demonstrated that the introduction of a triage system may have shortened the time required for MT. ELVO screen may be considered a useful marker for screening LVO in prehospital settings in terms of the sensitivity and negative predictive value; however, further improvement may be necessary to reduce the rate of false positive results.

Abstract 061: Identification of Proteins Predictive of Post‐Thrombectomy Outcome Based on an Appalachian vs. Non‐Appalachian Cohort

Introduction The Appalachia region of North America is known to have significant health disparities, specifically, worse risk factors and outcomes for stroke. Appalachians are more likely to have comorbidities related to stroke, such as diabetes, obesity, and tobacco use, and are often less likely to have stroke interventions such as mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO). As our Comprehensive Stroke Center directly serves stroke subjects from both Appalachian and non‐Appalachian areas, we set out to identify proteomic biomarkers predictive of stroke outcomes specific to subjects residing in Appalachia. Methods Eighty‐one subjects met inclusion criteria for this study. These subjects underwent MT for ELVO, and during the procedure, carotid arterial blood samples were acquired and subsequently sent for proteomic analysis. Samples were processed in accordance with the Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC; clinicaltrials.gov; NCT 03153683). Statistical analyses were utilized to examine whether relationships between protein expression and outcomes differed by Appalachian status for functional outcomes (NIH Stroke Scale; NIHSS and Modified Rankin Score; mRS), cognitive outcomes (Montreal Cognitive Assessment; MoCA), and mortality. Results No significant differences were found in demographic data nor co‐morbidities when comparing Appalachia to non‐Appalachia subjects. However, time from stroke onset to treatment (last known normal) was significantly longer in patients from Appalachia, so this datapoint was entered as a co‐variate in all predictive models. A comprehensive analysis of 184 cardiometabolic and inflammatory proteins revealed seven Appalachia‐specific proteins predictive of NIHSS, fourteen predictive of MoCA, six predictive of mRS, and seven proteins related to mortality. Specifically, within the Appalachian group, the protein multiple epidermal growth factor‐like domains protein 9 (MEGF9) was positively correlated to discharge NIHSS, elevated levels of the proteins coagulation factor XI (F11) and mannose binding protein (MBL2) were found to have an increased likelihood of worse mRS, but there were no proteins identified from the Appalachian cohort that were predictive of worse MoCA score, nor worse mortality. Conclusion Appalachia is an underserved population with significantly worse health disparities, specifically related to ischemic stroke. Our study found that patients who presented from Appalachian regions have a different proteomic response at time of MT when compared to otherwise similar subjects presenting from non‐Appalachian communities. These differentially expressed proteins could be used as prognostic biomarkers as well as novel therapies targeted at an underserved population. Lastly, expression differences may be in part related to environmental exposures, such as coal pollution, which will require additional studies moving forward.

Abstract 011: Endovascular therapy for acute ischemic stroke utilizing SOFia Aspiration System as first line Technique (SOFAST)

Introduction Mechanical thrombectomy using stent retrievers and aspiration techniques has emerged as the standard of care for patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (LVO). This study intended to collect real‐world clinical evidence on the safety and effectiveness of endovascular treatment of AIS using the SOFIA Flow Plus 6F aspiration catheter. The primary endpoint was the proportion of subjects achieving mTICI ≥2b. Secondary endpoints included good functional outcomes (mRS 0‐2) at Day 90, revascularization time, first line and first pass mTICI ≥2b, occurrence of procedure‐related SAEs, vasospasm involving the accessed vascular tree, embolization to new territories (ENTs), symptomatic intracerebral hemorrhage (sICH) within 24 hours and mortality at Day 90. Methods SOFAST was a prospective, multicenter, single‐arm, observational post‐market study. The enrolled subjects were ≥21 and ≤85 years with large vessel (ICA or MCA) proximal occlusion, pre‐morbid mRS ≤1, baseline NIHSS ≥5, and for whom groin puncture was within 8 hours of symptom onset. A total of 108 patients were enrolled and treated using aspiration thrombectomy with SOFIA 6F as the first line treatment device. Patients were followed at 24 hours, 7 days/discharge, and 90 days post‐procedure. Cerebral angiography was performed pre‐ and post‐procedure. Clinical assessments included the NIHSS and mRS scales. All neurological, device‐related, and procedure‐related AEs and deaths were adjudicated by independent medical reviewers. Angiographic and other imaging data was adjudicated by an independent core laboratory. Results A total of 108 subjects were enrolled (mean age 62.7 years, 50% men) with a median NIHSS of 15.5. Of 108 subjects, 97.2% (105/108), 85.2% (92/108) and 55.6% (60/108) achieved mTICI ≥2b, ≥2c and =3 revascularization, respectively. With first line aspiration using SOFIA 6F, 87.0%, 79.6% and 52.8% achieved mTICI ≥2b, ≥2c and =3 revascularization, respectively. Median number of passes was one (range 1‐3). First pass rate of mTICI 2c or 3 using SOFIA 6F was 70.4%, of which 50.9% patients achieved mTICI score of 3. Mean duration from groin puncture to initial clot contact was 13.0 min and to successful revascularization was 17.9 min. Good functional outcome was achieved in 66.7% (72/108) of subjects at Day 90 (mRS 0‐2), procedure‐related SAEs occurred in 2.8% (3/108) of subjects and sICH in 0.9% (1/108) of subjects within 24 hours. Procedural vasospasm was recorded in in 9.3% (10/108) of subjects, and mortality in 7.4% (8/108) subjects at Day 90 (none related to the study device). No ENTs occurred. Conclusion In SOFAST study, mTICI ≥2b revascularization was achieved in the majority of patients at the end of all procedures (97.2%) and with first line treatment (87.0%) with a large fraction of these subjects achieving mTICI ≥2c following the first SOFIA 6F pass (70.4%). Durations from groin puncture to clot contact and successful revascularization were relatively short. The study presented high rates of good functional outcome at Day 90 and low rates of safety events. In summary, the study provides encouraging evidence of the safety and effectiveness of the SOFIA 6F device for aspiration thrombectomy in acute ischemic stroke subjects.

Safety and functional outcomes of early antiplatelet therapy within 24 hours following mechanical thrombectomy for secondary prevention in emergent large-vessel occlusion strokes: a registry study.

The aim of this study was to demonstrate the safety and functional outcomes of antiplatelet use within 24 hours following mechanical thrombectomy (MT). A retrospective review of prospectively collected data for consecutive patients who underwent MT for acute ischemic stroke (AIS) between 2016 and 2020 was performed. Patient demographics, comorbidities, Alberta Stroke Program Early CT Score (ASPECTS), antiplatelet use, neurological status, and tissue plasminogen activator use were collected. Patients were stratified into two groups, early (< 24 hours) or late (> 24 hours), based on when antiplatelet therapy was initiated post-MT. The primary outcome was safety, determined based on the rate of symptomatic intracranial hemorrhage (sICH) and inpatient mortality. The secondary outcome was functional independence (defined as modified Rankin Scale [mRS] score ≤ 2) at discharge and 30 days and 90 days postoperatively. The two cohorts were compared using univariate analysis. Multiple imputations were used to create complete data sets for missing data. Multivariable analysis was used to identify predictors for sICH and functional outcomes. A total of 190 patients met inclusion criteria (95 per group). Significant differences between the early and late groups included sex, preoperative intravenous thrombolysis, angioplasty, stent placement, and thrombectomy site. ICH (symptomatic and asymptomatic) and inpatient mortality were not significantly different between the groups. The mRS score was significantly lower at discharge (p < 0.001), 30 days (p = 0.011), and 90 days (p = 0.024) following MT in the early group. Functional independence was significantly higher in the early antiplatelet group at discharge (p = 0.015) and at 30 days (p = 0.006). Early antiplatelet use was independently associated with significantly increased odds of achieving functional independence at discharge (OR 3.07, p = 0.007) and 30 days (OR 5.78, p = 0.004). Early antiplatelet therapy was not independently associated with increased odds of sICH. Early antiplatelet initiation after MT in patients with AIS was independently associated with significantly increased odds of improved postoperative functional outcomes without increased odds of developing sICH.

A systemized strategy to reduce door‐to‐puncture time using the ELVO screen: “Code AIS”

AbstractBackgroundA shorter onset‐to recanalization (O2R) time in mechanical thrombectomy for acute ischemic stroke (AIS) results in better outcomes. Thus, we should reduce the door‐to‐puncture (D2P) time.AimTo evaluate the effectiveness of a triage system named “Code AIS.” We adopted the emergency large vessel occlusion (ELVO) screen as a screening test.MethodsUsing the ELVO screening test, Code AIS was invoked when ≥1 positive results were obtained without witnessed seizures. The Code AIS system requires the assembly of neurologists, neurosurgeons, and an endovascular team in the emergency department before a patient arrives at the hospital. In total, 104 consecutive patients who underwent thrombectomy after emergency transport from January 2015 to December 2022 were included. The Code AIS system was initiated on February 17, 2022, and patients were divided into the pre‐Code AIS and Code AIS era groups. D2P time, outcome, and other parameters were compared between the groups.ResultsEighty‐eight and 16 cases were in the pre‐Code AIS and Code AIS era groups, respectively. Background factors, including age, sex, and etiology, did not differ between the groups. The median (interquartile range) time of D2P in the Code AIS era was 60 (41–102) min and significantly shortened compared to 135 (109–161) min in the pre‐Code AIS era (p &lt; 0.001). The proportion of patients with favorable outcomes (modified Rankin Scale score, 0–2) improved significantly from 33% (pre‐Code AIS era) to 63% (Code AIS era) (p = 0.047).ConclusionUsing Code AIS, we succeeded in shortening D2P time and improving patient outcomes.

Management of intracranial arterial stenosis during mechanical thrombectomy: Survey of neuro-interventionalists.

The optimal management of emergent large vessel occlusion due to underlying intracranial stenosis (intracranial stenosis related large vessel occlusion) remains unknown. The primary aim of this survey analysis was to measure variation in the clinical management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. A survey was designed using a web-based survey-building platform and distributed via the Society of NeuroInterventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN) websites for a response. Predictors of respondents' level of comfortability stenting were estimated using a binomial logistic regression model. We received 105 responses to the survey. Most respondents (54.3%) practiced at an academic Stroke Center. Nearly half of the respondents (49%) had been practicing for 5 or more years independently after fellowship. An average of 54 mechanical thrombectomies were performed by each respondent annually. There was variation in the definition of intracranial stenosis related large vessel occlusion, number of passes performed before pursuing rescue stenting, as well as intra and post-procedural antiplatelet management. Of respondents, 58% felt rescue stenting was very risky, and 55.7% agreed that there was equipoise regarding emergent angioplasty and/or stenting versus medical therapy for intracranial stenosis related large vessel occlusion. Respondents who encountered intracranial stenosis related large vessel occlusion more frequently thought that rescue stenting was less risky. There is notable variability in the diagnosis and management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. While most respondents felt rescue stenting was risky, the majority believed the benefit could outweigh the risk. The majority of respondents agreed that equipoise exists regarding the management of intracranial stenosis related large vessel occlusion, highlighting the need for clinical trials in this rare patient population.

Predictive Factors of First-Pass Effect in Patients Who Underwent Successful Endovascular Thrombectomy for Emergent Large Vessel Occlusion.

The primary treatment goal of current endovascular thrombectomy (EVT) for emergent large-vessel occlusion (ELVO) is complete recanalization after a single maneuver, referred to as the 'first-pass effect' (FPE). Hence, we aimed to identify the predictive factors of FPE and assess its effect on clinical outcomes in patients with ELVO of the anterior circulation. Among the 129 patients who participated, 110 eligible patients with proximal ELVO (intracranial internal carotid artery and proximal middle cerebral artery) who achieved successful recanalization after EVT were retrospectively reviewed. A comparative analysis between patients who achieved FPE and all others (defined as a non-FPE group) was performed regarding baseline characteristics, clinical variables, and clinical outcomes. Multivariate logistic regression analyses were subsequently conducted for potential predictive factors with p<0.10 in the univariate analysis to determine the independent predictive factors of FPE. FPE was achieved in 31 of the 110 patients (28.2%). The FPE group had a significantly higher level of functional independence at 90 days than did the non-FPE group (80.6% vs. 50.6%, p=0.002). Pretreatment intravenous thrombolysis (IVT) (odds ratio [OR], 3.179; 95% confidence interval [CI], 1.025-9.861; p=0.045), door-to-puncture (DTP) interval (OR, 0.959; 95% CI, 0.932-0.987; p=0.004), and the use of balloon guiding catheter (BGC) (OR, 3.591; 95% CI, 1.231-10.469; p=0.019) were independent predictive factors of FPE. In conclusion, pretreatment IVT, use of BGC, and a shorter DTP interval were positively associated with FPE, increasing the chance of acquiring better clinical outcomes.

The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department.

Early identification of patients with an emergent large vessel occlusion (ELVO) ischemic stroke is crucial in the Emergency Department (ED), as they are the ideal candidates for endovascular therapy.With this study, we have attempted to use Vision, Aphasia, Neglect (VAN) screening tool in the ED for rapid identification of ELVO ischemic stroke and compared its performance with the National Institute of Health Stroke Severity (NIHSS) scale. A prospective observational study was conducted in the ED of a tertiary care hospital over 18 months among all suspected stroke patients. Vision, aphasia, neglect and NIHSS scores were calculated on arrival. Magnetic resonance imaging + magnetic resonance angiography (MRI + MRA) were taken as gold standard. This study found that VAN identified ELVO with 85.19% sensitivity (p-value < 0.0001), 88.64% specificity (p-value < 0.0001), and 87% diagnostic accuracy, with respect to the gold standard test. Vision, aphasia, neglect had a positive predictive value (PPV) and negative predictive value (NPV) of 82.14% and 90.7%, respectively. Time taken to perform VAN score in the ED was on average 2 minutes. National Institute of Health Stroke Severity detected ELVO with a sensitivity of 88%, specificity of 51.11%, a PPV of 53.33%, and a NPV of 88.4%. Diagnostic accuracy was 66%, and it took approximately 5 minutes to perform. When both scores were applied together for ELVO detection, NPV was 100%. Vision, Aphasia, Neglect score as well as NIHSS scale are both tools for clinical prediction of ELVO with VAN having a better diagnostic accuracy and utility as a screening tool in the ED. Krishnan A, Srinivasarangan M, Jagadish S, Bheemanna AS, Sivasankar A. The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department. Indian J Crit Care Med 2023;27(7):475-481.

External Validation of Atherosclerotic Neuroimaging Biomarkers in Emergent Large‐Vessel Occlusion

Background Intracranial atherosclerosis related large vessel occlusion (ICAS‐LVO) is the major cause of failed mechanical thrombectomy. ICAS‐LVO causes reocclusion or a fixed focal stenosis, leading to suboptimal revascularization and poor functional outcomes. We aimed to externally validate 4 preidentified imaging biomarkers of ICAS‐LVO: absent hyperdense sign, Hounsfield units (Hu ratio ≤1.1 and Delta Hu &lt;6) and truncal‐type occlusion, observed on admission noncontrast computed tomography and computed tomography angiography in patients presenting with emergent large‐vessel occlusion (ELVO). Methods We conducted a retrospective cohort observational study of consecutive patients presenting with acute M1/terminal internal carotid artery occlusions undergoing mechanical thrombectomy. Inability to locate a hyperdense vessel on noncontrast computed tomography at the corresponding ELVO on computed tomography angiography was labeled absent hyperdense sign. Delta Hu and Hu ratio were defined as the difference and ratio of the Hu of the ELVO on noncontrast computed tomography and its mirror contralateral patent vessel, respectively. ELVO was classified as truncal‐type occlusion if the bifurcation distal to the occlusion was spared on computed tomography angiography. ICAS‐LVO was defined as the presence of fixed focal stenosis or reocclusion after mechanical thrombectomy. Statistical analysis was performed using C statistics, receiver operating characteristic curve analysis, and multivariate logistic regression. Results Of 161 patients, 30 (18.6%) had suspected ICAS‐LVO. Absent hyperdense sign had a sensitivity of 90% and specificity of 87% (area under the curve [AUC], 0.88), in predicting ICAS‐LVO. Hu ratio ≤1.1 (AUC, 0.89) and Delta Hu &lt;6 (AUC, 0.96) had sensitivity of 100% and 97% and specificity of 79% and 95%, respectively. Truncal‐type occlusion showed a sensitivity of 75% and specificity of 98% (AUC, 0.87). When comparing receiver operating characteristic AUC, Delta Hu &lt;6 was significantly better than absent hyperdense sign ( P =0.006); Hu ratio ≤1.1 ( P =0.006); and truncal‐type occlusion ( P =0.02). Conclusion Combination of neuroimaging biomarkers using noncontrast computed tomography and computed tomography angiography in ELVO identify ICAS‐LVO with high predictive power. Larger, prospective, multicenter studies are warranted to further evaluate their effectiveness in diagnosing ICAS‐LVO.

Parenchymal Blood Volume Changes Immediately After Endovascular Thrombectomy Predict Futile Recanalization in Patients with Emergent Large Vessel Occlusion

More than one third of acute ischemic stroke (AIS) patients do not recover to functional independence even if endovascular thrombectomy (EVT) is performed rapidly and successfully. This suggests that angiographic recanalization does not necessarily lead to tissue reperfusion. Although recognition of reperfusion status after EVT is pivotal for optimal postoperative management, reperfusion imaging assessment immediately after recanalization has not been fully investigated. The present study aimed to evaluate whether reperfusion status based on parenchymal blood volume (PBV) assessment after angiographic recanalization influences infarct growth and functional outcome in patients who have undergone EVT following AIS. Seventy-nine patients who underwent successful EVT for AIS were retrospectively analyzed. PBV maps were acquired from flat-panel detector computed tomography (CT) perfusion images before and after angiographic recanalization. Reperfusion status was assessed from PBV values and their changes in regions of interest and collateral score. Post-EVT PBV ratio and ΔPBV ratio, as PBV parameters indicating the degree of reperfusion, were significantly lower in the unfavorable prognosis group (P < 0.01 each). Poor reperfusion on PBV mapping was associated with significantly longer puncture-to-recanalization time, lower collateral score, and higher frequency of infarct growth. Logistic regression analysis identified low collateral score and low ΔPBV ratio as associated with poor prognosis after EVT (odds ratios, 2.48, 3.72; 95% confidence intervals, 1.06-5.81, 1.20-11.53; P=0.04, 0.02, respectively). Poor reperfusion in severely hypoperfused territories on PBV mapping immediately after recanalization may predict infarct growth and unfavorable prognosis in patients who undergo EVT following AIS.

Prediction of large vessel occlusion for ischaemic stroke by the Van scale

ABSTRACT Background: Rapid and accurate detection of stroke by paramedics or emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage Identification of emergent large vessel occlusion (ELVO) stroke has become increasingly important with the recent publications of favorable acute stroke thrombectomy trials. Multiple screening tools exist but the length of the examination and the false positive rate range from good to adequate. A screening tool was designed and tested in the emergency department using nurse responders without a scoring system. Methods: Suspected stroke patients admitted by ambulance paramedics directly to an acute stroke unit through a rapid ambulance protocol were examined by a neurologist or admitting stroke physician. The vision, aphasia, and neglect (VAN) screening tool was designed to quickly assess functional neurovascular anatomy, which was used as an LVO screen for all stroke patients. Results: There were 162 consecutive code stroke activations during the pilot study. 60 (37%) of the patients were VAN positive and 128 (79%) had a National Institutes of Health Stroke Scale (NIHSS) score of ≥ 6. NIHSS &gt; 6 was more sensitive (100% vs 93% for VAN) but VAN was more specific (90% vs 74% for NIHSS ≥ 6). Similarly, VAN had 83% positive predictive value while NIHSS ≥ 6 had only a 42% positive predictive value. No patient that was NIHSS &lt; 6 had an LVO (100% negative predictive value), there were 4 patients with VAN negative who had LVO (97% negative predictive value). However, VAN had 91% specificity versus 32% for NIHSS. Conclusions: VAN assessment performed well in identifying patients with LVO. Keywords: Stroke, VAN, NIHSS, Large vessel occlusion.

Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience

A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community. Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time. We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p<0.001) and IVT (15.34% vs. 21.58%, p=0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23min, p<0.001), longer door-to-CT time (median 10 vs 11min, p<0.001), longer DTN time (median 53 vs 54.5min, p<0.001) but shorter DTP time (median 141 vs 139.5min, p<0.001). The prehospital bypass strategy with G-FAST showed benefits for stroke patients.

Comparing a novel Catfish flow restoration device and the Solitaire stent retriever for thrombectomy revascularisation in emergent largevessel occlusion stroke: a prospective randomised controlled study

BackgroundThe Catfish stent retriever is a newly developed mechanical thrombectomy device for rapid recanalisation in emergent large vessel occlusion (ELVO) stroke. The current trial aimed to assess whether the Catfish...

Contraintuitive fallacy in a big-risk-no-gain stroke scenario? Please verify!

What the hell is a mild stroke, in my opinion there is no such thing like a mild stroke. Werner Hacke during rounds in Heidelberg 1997 In the personal opinion of this comment's author, we have a serious problem and lack of data if we withhold intravenous thrombolysis (IVT) and/or endovascular therapy (EVT) from any patient that fulfills the criteria for these treatments based on all the randomized trials that finally led to US Federal Drug Administration and European Medicines Agency (FDA/EMA) labelling and guideline recommendation of these therapies. The gain we experienced is the broad application of IVT to all acute stroke patients aged 16 years or older within 4.5 h based on a non-contrast computed tomography (CT) regardless of age, National Institutes of Health Stroke Scale (NIHSS) score, and with only few strict contraindications. The same holds true for such patients up to 6 h with a proximal vessel occlusion shown on computed tomography angiography (CTA) for EVT and most recently for basilar artery occlusion. A metanalysis of IVT trials did not show any significant difference in the proportional effect of IVT on outcomes stratified by NIHSS severity, by point estimates the “milder” and the more severe patients fared better [1]. Not dwelling on settings with heroically long time windows and selection criteria with advanced imaging and not-so-advanced artificial intelligence applications, and with respect to the article by Schwarz and colleagues in this issue of EJoN [2], I refer here to the standard 4.5–6 h known time window patient with a clinically “mild stroke”. Present guidelines are mostly inconclusive or inconsistent also when compared to each other. The European Stroke Organisation (ESO) guideline, for instance, differentiates the indication for IVT based on the prematurely stopped small PRISMS trial [3] definition of non-disabling and disabling minor stroke criteria (semantically nonsense) and does not recommend treatment in patients with symptoms such as isolated mild aphasia, mild cortical hand, hemimotor loss, or ataxia [4]. All the latter are in many a patient's and stroke physician's view disabling symptoms that one would rather see ameliorated by a given treatment, with twice as high odds for recovery suggested by some authors [5]. On top of this, just imagine that this “mild” stroke is caused by a proximal vessel occlusion in the ICA/MCA-M1 territory, a situation where we have now overwhelming data in general in favor of combined IVT/EVT whenever possible. For the specific “mild stroke” population discussed here there are far fewer data from small observational trials. To my clinical mind, this warrants the standard approach until proven otherwise as is also expert consensus in the current ESO guideline [6]. Regarding EVT or IVT/EVT in “mild” strokes, the expert consensus in the 2019 ESO guideline recommends recruitment into trials or otherwise treatment. Even for so-called non-disabling minor stroke (whatever that may be), the vote was 5 of 11 experts in favor of IVT/EVT [6]. Ghil Schwarz and colleagues present a Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR)-derived, propensity score-matched analysis of patients with a “mild stroke” (i.e., patients with NIHSS scores ≤5 points treated with IVT/EVT vs IVT alone) [2]. Out of more than 1000 patients, 312 patients were matched per group. The result in brief was a twice higher rate of poor outcomes, numerically more symptomatic intracranial hemorrhages (sICH), and significantly more of any types of ICH and subarachnoid hemorrhage (SAH) with IVT/EVT compared to IVT alone. This is a somewhat counterintuitive but also disconcerting result and, strikingly, the lack of effect is not exclusively explained by ICH but also by a higher rate of (unexplained) early neurological deterioration. This article is important to the critical reader as it sheds further doubt on how to best proceed with this group of patients, does so on a high-quality albeit registry-style dataset, besides the distinct discussion of all limitations and caveats by the authors themselves. Part of the inconsistency may be explained by intergroup differences despite propensity score matching that cannot be corrected for because they have not been assessed or are nonexistent such as a significant number of missing modified Rankin Scale (mRS) outcome scores. Another recent analysis showed a 11% absolute difference for functional independence in favor of IVT/EVT in patiens with “mild” stroke and emergent large vessel occlusion (ELVO) [7]. In fact, the inconsistent results from varying but sparse analyses should oblige us to recruit into adequately sized trials for this question such as MOSTE (NCT03796468) and ENDOLOW (NCT04167527). Unless these and other trials show a clear issue with additional damage and/or lack of effect from bridging therapy in stroke patients with proximal occlusions and NIHSS scores ≤5, we should treat our stroke patients with the generally proven treatments that we currently to have something AT hand. Open Access funding enabled and organized by Projekt DEAL. PDS received honoraria, travel grants, and/or consulting fees from Boehringer Ingelheim, BMS-Pfizer, Daichi, Biogen, and Astra Zeneca. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

RESCUE‐ICAS: Rationale and Study Design

Background Mechanical thrombectomy (MT) failure occurs in ≈10% to 20% of MTs. Among the common causes of failed MT is residual underlying intracranial stenosis (ICAS), typically attributable to atherosclerotic disease. ICAS large‐vessel occlusion (ICAS‐LVO) remains poorly understood, and management of ICAS‐LVO is unclear. The RESCUE‐ICAS (Registry of Emergent Large Vessel Occlusion Due to Intracranial Stenosis) aims at providing better understanding of the prevalence of ICAS‐LVO, and the overall safety and efficacy of various rescue therapies. Methods RESCUE‐ICAS is a multicenter, international, prospective registry that is currently enrolling patients with ICAS‐LVO who underwent MT. All sites are required to report monthly MT cases that meet inclusion criteria. The decision of whether to use rescue therapy is up to the interventionist. Results We will collect patients’ demographic, clinical, and radiographic data at baseline. Also, we will capture variables related to the MT procedure and rescue therapy (if performed), and postprocedural clinical and imaging variables. Outcomes include the rate of successful recanalization, defined by modified Thrombolysis in Cerebral Infarction score of ≥2b, the rate of symptomatic intracranial hemorrhage, the 90‐day modified Rankin scale score, and mortality. Conclusions No strong evidence is currently available to support an optimal treatment strategy for patients with ICAS‐LVO undergoing MT. RESCUE‐ICAS is a prospective cohort study that will provide important data to help design randomized controlled trials.