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

Objective: 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. Methods: 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. Results: 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. Conclusion: 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.

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

OBJECTIVE: To 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. METHODS: Included 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. RESULTS: In 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. CONCLUSION: MHR 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.

Prediction of Intracranial Atherosclerotic Disease-Related Large-Vessel Occlusion Stroke on the Basis of Novel Cerebral Blood Volume Parameters.

BACKGROUND: Mechanical thrombectomy is an effective treatment method for large-vessel occlusion stroke (LVOS); however, it has limited efficacy for intracranial atherosclerotic disease (ICAD)-related LVOS. We investigated the use of cerebral blood volume (CBV) maps for identifying ICAD as the underlying cause of LVOS before the initiation of endovascular treatment (EVT). METHODS AND RESULTS: We reviewed clinical and imaging data from patients who presented with LVOS and underwent endovascular treatment between January 2011 and May 2021. The CBV patterns were analyzed to identify an increase in CBV within the hypoperfused area and estimate infarct patterns within the area of decreased CBV. Comparisons were made between the patients with an increase in CBV and those without, and among the estimated infarct patterns: territorial, cortical wedge, basal ganglia-only, subcortical, and normal CBV. Overall, 243 patients were included. CBV increase in the hypoperfused area was observed in 23.5% of patients. A significantly higher proportion of ICAD was observed in those with increased CBV than in those without (56.4% versus 19.8%; P<0.001). Regarding the estimated infarct patterns on the CBV, ICAD was most frequently observed in the normal CBV group (territorial, 14.9%; cortical wedge, 10.0%; basal ganglia-only, 43.8%; subcortical, 35.7%; normal, 61.7%). CBV parameters, including "an increase in CBV," "normal CBV infarct pattern," and "an increase in CBV or normal CBV infarct pattern composite," were independently associated with ICAD. CONCLUSIONS: An increased CBV or normal CBV pattern may be associated with ICAD LVOS on the pretreatment perfusion imaging.

Author Response.

How to cite this article: Krishnan A. Author Response. Indian J Crit Care Med 2023;27(12):945-946.

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

Background: 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. Materials and methods: 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. Results: 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%. Conclusion: 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. How to cite this article: 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.

Isolation and identification of leukocyte populations in intracranial blood collected during mechanical thrombectomy.

Using standard techniques during mechanical thrombectomy, the Blood and Clot Thrombectomy Registry and Collaboration (BACTRAC) protocol (NCT03153683) isolates intracranial arterial blood distal to the thrombus and proximal systemic blood in the carotid artery. We augmented the current protocol to study leukocyte subpopulations both distal and proximal to the thrombus during human stroke (n = 16 patients), and from patients with cerebrovascular disease (CVD) undergoing angiography for unrelated conditions (e.g. carotid artery stenosis; n = 12 patients). We isolated leukocytes for flow cytometry from small volume (<1 mL) intracranial blood and systemic blood (5-10 mL) to identify adaptive and innate leukocyte populations, in addition to platelets and endothelial cells (ECs). Intracranial blood exhibited significant increases in T cell representation and decreases in myeloid/macrophage representation compared to within-patient carotid artery samples. CD4+ T cells and classical dendritic cells were significantly lower than CVD controls and correlated to within-patient edema volume and last known normal. This novel protocol successfully isolates leukocytes from small volume intracranial blood samples of stroke patients at time of mechanical thrombectomy and can be used to confirm preclinical results, as well as identify novel targets for immunotherapies.

IV tPA given in the golden hour for emergent large vessel occlusion stroke improves recanalization rates and clinical outcomes.

BACKGROUND: Early thrombolysis for acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) is associated with better clinical outcome. This is thought to be due to greater tissue salvage with earlier recanalization. We explored whether ultra-early administration of intravenous tissue plasminogen activator (IV tPA) within 60 min (Golden Hour) of symptom onset for AIS due to ELVO is associated with a higher rate of recanalization. METHODS: We performed a retrospective analysis of recanalization rates and clinical outcomes in patients with AIS due to ELVO treated with IV tPA, comparing patients who received IV tPA within 60 min of stroke symptom onset with those treated beyond 60 min. RESULTS: Between January 2013 and December 2016, 158 patients with AIS due to ELVO were treated with IV tPA. Of these, 25 (15.8%) patients received IV tPA within 60 min of stroke symptom onset, while the remaining 133 (84.2%) patients received IV tPA beyond 60 min. The ultra-early treatment group was found to have a higher rate of complete recanalization (28.0% vs 6.8%, 95% CI 1.78-16.63), better chance of early neurological improvement (76.0% vs 50.4%, 95% CI 1.16-8.65), favorable clinical outcomes (mRS ≤ 2 or return to premorbid mRS) (65.0% vs 36.8%, 95% CI 1.42-9.34), and lower mortality (5% vs 31.1%, 95% CI 0.01-0.74) at 90-day follow-up compared to the later treatment group. CONCLUSION: Our data suggest that ultra-early administration of IV tPA significantly improves recanalization rates and clinical outcomes in patients with AIS due to ELVO.

External validation of prehospital stroke scales for emergent large vessel occlusion.

BACKGROUND: It is suggested that a prehospital scale should be utilized to identify patients with emergent large vessel occlusion (ELVO). We aimed to perform external validation of nine ELVO scales. METHODS: This single center retrospective observational study included patients with ischemic stroke visiting the emergency department (ED) within 6 h of symptom onset. Participants were excluded if individual items of the National Institute of Health Stroke Scale scores were not recorded or they did not receive brain computed tomography angiography or magnetic resonance imaging before intravenous thrombolysis or endovascular thrombectomy, and within 24 h of ED admission. The first definition of ELVO was emergent occlusion of the internal carotid artery (ICA) and middle cerebral artery segment 1 (M1). The second definition was emergent occlusion of ICA, M1, basilar artery, middle cerebral artery segment 2, anterior cerebral artery segment 1, and posterior cerebral artery segment 1. Area under the receiver operating characteristic curve (AUROC) was constructed to examine discrimination. The sensitivity, specificity, positive predictive value, and negative predictive value of the nine scales under the two ELVO definitions were calculated. RESULTS: A total of 1231 patients were included in the study. No significant differences were observed in the AUROC under the two ELVO definitions. However, sensitivity values of these scales were largely different, ranging from 44.56% to 93.68% under the first ELVO definition. The sensitivity values among scales were also different under the second ELVO definition. CONCLUSION: Stakeholders in the community should choose suitable scales according to their own system conditions.

The Therapeutic Effects of Endovascular Therapy with mTICI2b and 3 Recanalization for Acute Anterior Circulation Stroke Patients.

BACKGROUND AND PURPOSE: Modified Thrombolysis in Cerebral Infarction (mTICI)2b/3 has been considered the criterion for successful reperfusion in endovascular treatment. This study aimed to compare the therapeutic safety and efficacy of mTICI2b and mTICI3 recanalization, and to analyze the factors related to outcomes in everyday clinical practice. MATERIALS AND METHODS: This is a single-center retrospective analysis of 224 patients who underwent successful thrombectomy (achieving a mTICI score ≥2b). The primary outcomes included a modified Rankin score (mRS) of 0-2 at 90-day, mortality, and symptomatic intracranial hemorrhage. RESULTS: A total of 111 patients achieved mTICI2b status (49.6%), and 113 achieved mTICI3 status (50.4%). The comparison between mTICI2b and 3 reperfusions showed no differences in short-term outcomes, 90-day mRS, complications, and mortality. There was a trend toward more passes in mTICI2b patients, although the difference was not significant. The univariate analysis showed that poor outcomes after endovascular treatment were associated with older age, previous history of coronary heart disease, atrial fibrillation, diabetes, tandem occlusions, high National Institutes of Health Stroke Scale (NIHSS) score on admission, and general anesthesia. A previous history of coronary heart disease, a high NIHSS score on admission, and the use of general anesthesia were independent factors that affected the therapeutic effects. CONCLUSION: The superiority (efficacy and safety) of mTICI3 reperfusion was not significant compared with that of mTICI2b reperfusion. Prolonged efforts to achieve mTICI3 after achieving mTICI2b should be considered prudently for those with difficulty achieving 100% reperfusion.

Etiologic Subtypes of Ischemic Stroke in SARS-CoV-2 Patients in a Cohort of New York City Hospitals.

Objective: To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis. Background: Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Methods: Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected. Results: The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59-82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis. Conclusion: COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.

Predictors of mortality for patients with COVID-19 and large vessel occlusion.

BACKGROUND: This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. METHODS: We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. RESULTS: Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. CONCLUSION: Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

Mandatory Neuroendovascular Evolution: Meeting the New Demands.

BACKGROUND: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. SUMMARY: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. KEY MESSAGES: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

Initial experience with React 68 aspiration catheter.

INTRODUCTION: We describe our initial experience with the React 68 catheter (Medtronic, Dublin, Ireland), an FDA-approved catheter designed for aspiration in cases of emergent large vessel occlusion, as compared with the ACE 68 catheter (Penumbra, Alameda, CA). METHODS: This observational study followed consecutive patients treated with the React catheter over a seven-month period at a comprehensive stroke center. Use of the device was per discretion of the operator. Patient demographics, thrombectomy technique, reperfusion scoring, and disposition were assessed. Performance was compared with patients treated with the ACE 68 catheter over a comparable period. RESULTS: We treated 47 patients using the React 68 catheter using either aspiration alone or a combination of aspiration and stent retriever technique. The catheter was used in a variety of circumstances including proximal and distal occlusions involving the anterior and posterior circulation. Modified TICI 2b-3 was achieved in 45 of the 47 patients. The React 68 was comparable to the ACE 68 by all performance measures. CONCLUSION: The React 68 catheter is a large-bore reperfusion catheter with trackability suitable for use in direct aspiration for recanalization of emergent large vessel occlusion.

Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy.

INTRODUCTION: The shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs. METHODS: All EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital. RESULTS: In total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals. CONCLUSIONS: A short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.

Major Causes for Not Performing Endovascular Therapy Following Inter-Hospital Transfer in a Complex Urban Setting.

INTRODUCTION: Endovascular therapy (EVT) has emerged as the standard of care for emergent large vessel occlusion (ELVO) acute ischemic stroke. An increasing number of patients with suspected ELVO are being transferred to stroke centers with interventional capacity. Not all such inter-hospital transfers result in EVT. AIM: To identify the major causes for not performing EVT following transfer. METHODS: An analysis of 222 consecutive patients with suspected ELVO transferred for potential EVT between January 2015 and -December 2017 within a New York City health system was performed. About 36% (80/222) were deemed EVT ineligible and compared to an EVT cohort. RESULTS: Major causes for not performing EVT were established infarct (34%), no or recanalized ELVO (31%), and mild or clinically improved symptoms (21%). In the established infarct subgroup, 28% (7/27) arrived at a stroke center with interventional capacity within 5 h of last known well, compared to 61% (83/142) in the EVT cohort (p = 0.003). In the no or recanalized ELVO subgroup, 40% (10/25) received computed tomographic angiography at the primary stroke center (PSC), compared to 73% (104/142) in the EVT cohort (p = 0.001). Among patients treated with intravenous thrombolysis, 6% (6/104) improved from a NIHSS of ≥6 to <6 following transfer. CONCLUSIONS: Established infarct, no or recanalized ELVO, and mild or clinically improved symptoms were the major causes for not performing EVT for patients transferred for ELVO management. These may be addressed by decreasing stroke onset to treatment times and timely ELVO detection at the PSC and/or pre-hospital triage.

Widening Time Disparities between Two Paradigms: Tama-REgistry of Acute Endovascular Thrombectomy.

BACKGROUND: The Tama-REgistry of Acute endovascular Thrombectomy (TREAT) is a multicenter registry of endovascular thrombectomy in the Tama area of Tokyo. The objective of this study was to confirm the real-world status of 2 paradigms of transportation. METHODS: This was a retrospective analysis of data from TREAT. Patients were divided into 2 groups and 2 periods: directly admitted to an endovascular thrombectomy-capable center (ECC; group D)/secondary transfer from a non-ECC (group S), and the first period/the second period. Transfer distance, workflow metrics, and clinical outcomes were analyzed. RESULTS: A total of 326 patients, including 264 in group D and 62 in group S, were analyzed. The median distance from the onset-to-ECC was 3.62km for group D and 7.87km for group S (P < .001). The median onset-to-needle (OTN) time was longer for group S (168 minutes) than group D (138 minutes; P = .006). The median onset-to-reperfusion (OTR) time was significantly shorter for group D (247 minutes) than for group S (304 minutes; P = .029). With respect to the 2 periods, there was no significant difference in onset-to-puncture time between the 2 groups in the first period (207 minutes versus 243.5 minutes, respectively, P = .50), while there was one in the second period (164 minutes versus 246.5 minutes, respectively, P = .02). CONCLUSIONS: This region-wide registry study showed longer OTN and OTR times, with no improvement of the time course over time in patients transported via non-ECCs. These results should be used to create a regional medical policy for the management of acute ischemic stroke.

Design, Application and Infield Validation of a Pre-Hospital Emergent Large Vessel Occlusion Screening Tool: Ventura Emergent Large Vessel Occlusion Score.

BACKGROUND: The outcome of endovascular treatment for emergent large vessel occlusion (ELVO) is dependent on timely recanalization. To identify ELVO in the field, we present a simplified score, which has been applied and validated in the field by emergency medical services (EMS). Methods and Analysis: Ventura ELVO Scale (VES) comprise of 4 components: Eye Deviation, Aphasia, Neglect, and Obtundation with score range 0-4. The score of greater than or equal to 1 will be considered as ELVO positive. A positive VES along with positive Cincinnati scale prompts ELVO activation. EMS then notify to neurointervention protocol at the receiving stroke center. The performance of VES was evaluated retrospectively. For statistical analysis, SAS version 9.4 was used and Fisher's modelling was used for the comparative analysis. RESULTS: Total 184 patients were included in the final analysis, 62 (33.7%) patients were called VES positive from the field. Out of 62, 36 (58%) patients had ELVO. The mean NIHSS on arrival was 16 in VES positive and 5 in VES negative patients. VES was 94.7% sensitive and 82.4% specific while the PPV and NPV of VES were 58.1% and 98.4%, respectively. It showed 84.9% accuracy. CONCLUSIONS: VES is an effective and simplified prehospital screening tool for detection of ELVO in the field. Its implementation can beat the target door to groin time to improve outcomes and in future it can be used for rerouting of ELVO patients to comprehensive stroke center.

Comparative Safety and Efficacy of Modified TICI 2b and TICI 3 Reperfusion in Acute Ischemic Strokes Treated With Mechanical Thrombectomy.

BACKGROUND: Mechanical thrombectomy (MT) is the current standard of care for acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO). Successful reperfusion of ELVO is traditionally defined by modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b or 3. OBJECTIVE: To evaluate the comparative safety and efficacy of mTICI 2b and mTICI 3 reperfusion in AIS patients treated with MT. METHODS: Consecutive ELVO patients who underwent MT at 6 high-volume centers were included in this analysis. Standard safety (3-mo mortality, symptomatic intracranial hemorrhage [sICH]) and efficacy (absolute and relative reduction in NIHSS-scores during hospitalization, functional-improvement [shift analysis in mRS-scores], and functional-independence [mRS-scores of 0-2] at 3-mo) were compared between patients who had mTICI 2b and mTICI 3 reperfusion post MT. RESULTS: A total of 416 ELVO patients achieved successful reperfusion with mTICI 2b (n = 216) and mTICI 3 (n = 200) following MT. The mTICI 3 group had significantly (P < .05) greater absolute (11 vs 9 points) and relative (77% vs 63%) reduction in NIHSS-scores during hospitalization, lower sICH (6% vs 12%), and higher 3-mo functional-independence (55% vs 44%) rates. Successful reperfusion with mTICI 3 was independently (P < .05) associated with greater absolute and relative reduction in NIHSS-scores during hospitalization as well as higher odds of 3-mo functional improvement (common odds ratios: 1.67; 95% confidence interval: 1.10-2.56) and functional independence (odds ratio: 2.08; 95% confidence interval: 1.22-3.53) in multivariable regression models adjusting for confounders. CONCLUSION: Successful reperfusion with mTICI 3 was associated with greater neurological improvement during hospitalization and better 3-mo functional outcomes in comparison to mTICI 2b reperfusion.

Standards of practice in acute ischemic stroke intervention: International recommendations.

This article was first published in JNIS. Cite this article as: Pierot L, Jayaraman MV, Szikora I, et al. Standards of practice in acute ischemic stroke intervention: international recommendations. Journal of NeuroInterventional Surgery. Published Online First: 28 August 2018. doi: 10.1136/neurintsurg-2018-014287.

Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis.

OBJECTIVEThe optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients.METHODSA total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed.RESULTSOverall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0-2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094-0.689, p = 0.007).CONCLUSIONSBoth intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.