ASPECTS-Region-Dependent Functional Outcomes after Endovascular Therapy in Patients with Cardioembolic Stroke.

OBJECTIVES: Cardioembolic stroke has a poor prognosis. We evaluated the region-dependent efficacy of endovascular therapy (EVT) based on diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS). METHODS: This post-hoc analysis of the RELAXED study, which investigated the optimal timing of rivaroxaban to prevent nonvalvular atrial fibrillation (NVAF) recurrence in patients with acute ischemic stroke (AIS), included NVAF patients admitted with AIS or transient ischemic attack in the middle cerebral artery (MCA), with internal carotid artery (ICA), M1, or M2-MCA occlusion. Relationships between DWI-ASPECTS region and functional outcome (modified Rankin Scale [mRS]), mortality, recurrence, and hemorrhagic stroke were compared between patients with and without EVT, and adjusted odds ratios for age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS), ICA occlusion, infarct size, recombinant tissue plasminogen activator (rt-PA) use, and onset-to-hospitalization time were estimated. RESULTS: EVT patients had significantly lower hemoglobin levels, higher median NIHSS scores, more lentiform nucleus infarcts, ICA or M1-MCA occlusions, treatment with rt-PA, and fewer M3, M5, or M6 infarcts and M2-MCA occlusions than no-EVT patients. EVT patients had shorter onset-to-hospitalization times and more frequent favorable functional outcomes (p=0.007). Mortality, recurrent ischemic stroke, and hemorrhagic infarction were similar in both groups. EVT was associated with significantly better functional outcomes among patients with insular ribbon (p=0.043) and M3 (p=0.0008) infarcts. M3 patients had significantly fewer rt-PA and EVT, and longer onset-to-hospitalization times. CONCLUSIONS: An occlusion in the insular ribbon or M3 region was associated with favorable functional outcomes in patients treated with EVT after cardioembolic stroke.

Clinical Prediction Rules to Classify Types of Stroke at Prehospital Stage.

Background and Purpose- Endovascular therapy is effective against acute cerebral large vessel occlusion (LVO). However, many patients do not receive such interventions because of the lack of timely identification of the type of stroke. If the types of stroke (any stroke, LVO, intracranial hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) were to be predicted at the prehospital stage, better access to appropriate interventions would be possible. Japan Urgent Stroke Triage (JUST) score was clinical prediction rule to classify suspected patients of acute stroke into different types at the prehospital stage. Methods- We obtained information for signs and symptoms and medical history of consecutive suspected patients of acute stroke at prehospital stage from paramedics and final diagnosis from the receiving hospital. We constructed derivation cohort in the historical multicenter cohort study from June 2015 to March 2016 and validation cohort in the prospective multicenter cohort study from August 2016 to July 2017. The derivation and the validation cohorts included 1229 and 1007 patients, respectively. We constructed multivariate logistic regression models with 21 variables to develop clinical prediction rules, which distinguish between different types of stroke: any stroke, LVO, ICH, and SAH. Results- Among the 1229 patients (median age, 72 years; 55% men) in the derivation cohort, 533 stroke, 104 LVO, 169 ICH, and 57 SAH cases were observed. The developed rules showed that the areas under the receiver operating curves were 0.88 for any stroke, 0.92 for LVO, 0.84 for ICH, and 0.89 for SAH. The validation cohort of 1007 patients (median age, 75 years; 56% men) showed that the areas under the curves of any stroke, LVO, ICH, and SAH were 0.80, 0.85, 0.77, and 0.94, respectively. Conclusions- These clinical prediction rules can help paramedics classify the suspected patients of stroke into any stroke, LVO, ICH, and SAH groups with excellent accuracy.

Safety and Effectiveness of Drip, Ship, and Retrieve Paradigm for Acute Ischemic Stroke: a Single Center Experience.

This study analyzed the efficacy and safety of the "drip, ship, and retrieve (DSR)" approach used to improve patient access to thrombectomy for acute stroke. METHODS: The study participants were 45 patients who underwent thrombectomy following intravenous tissue plasminogen activator between September 2013 and August 2015. Patients were divided into two groups according to whether they were transferred from another hospital (DSR group; n = 33) or were brought in directly (Direct group; n = 12). The two groups were compared based on their baseline characteristics, time from stroke onset to reperfusion, outcome, and adverse events. RESULTS: There were no significant differences in baseline characteristics. Time from onset until admission to our facility was significantly shorter in the Direct group (56.9 min) than in the DSR group (163.5 min) (P <0.0001). Conversely, time from arrival at the hospital to arterial puncture was significantly shorter in the DSR group (25.0 min) than in the Direct group (109.5 min) (P <0.0001). Time from onset to reperfusion did not differ significantly between the groups. There was no significant difference in patient outcomes, with a modified Rankin scale score of 0-2 (44.8% in DSR group versus 48.7% in Direct group). Moreover, there was no difference in the incidence of adverse events. DISCUSSION: Despite the time required to transfer patients in the DSR group between hospitals, reducing the time from arrival until commencement of endovascular therapy meant that the time from onset to reperfusion was approximately equivalent to that of the Direct group. CONCLUSION: Time-saving measures need to be taken by both the transferring and receiving hospitals in DSR paradigm.