Reliability of Field Assessment Stroke Triage for Emergency Destination Scale Use by Paramedics: Mobile Stroke Unit First-Year Experience.

Background and Purpose: Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale is a helpful tool to triage patients with stroke in the field. However, data on its reliability in the prehospital setting are lacking. We aim to test the reliability of FAST-ED scale when used by paramedics in a mobile stroke unit covering a metropolitan area. Methods: As part of standard operating mobile stroke unit procedures, paramedics initially evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic upon patient contact (in-person) and then independently by a vascular neurologist (VN) immediately after paramedic evaluation (remotely/telemedicine). This allowed testing of the interrater agreement of the FAST-ED scoring performance between on-site prehospital providers and remotely located VN. Results: Of a total of 238 patients transported in the first 15 months of the mobile stroke unit's activity, 173 were included in this study. Median age was 63 (interquartile range, 55.5­75) years and 52.6% were females. A final diagnosis of ischemic stroke was made in 71 (41%), transient ischemic attack in 26 (15%), intracranial hemorrhage in 15 (9%), whereas 61 (35%) patients were stroke mimics. The FAST-ED scores matched perfectly among paramedics and VN in 97 (56%) instances, while there was 0 to 1-point difference in 158 (91.3%), 0 to 2-point difference in 171 (98.8%), and 3 or more point difference in 2 (1.1%) patients. The intraclass correlation between VN and paramedic FAST-ED scores showed excellent reliability, intraclass correlation coefficient 0.94 (95% CI, 0.92­0.96; P<0.001). When VN recorded FAST-ED score ≥3, paramedics also scored FAST-ED≥3 in majority of instances (63/71 patients; 87.5%). A large vessel occlusion was identified in 16 (9.2%) patients; 13 occlusions were identified with a FAST-ED≥3 while 3 were missed. All of the latter patients had National Institutes of Health Stroke Scale score ≤5. Conclusions: We demonstrate excellent reliability of FAST-ED scale performed by paramedics when compared with VN, indicating that it can be accurately performed by paramedics in the prehospital setting.

Stroke Thrombolysis in Patients Taking Ticagrelor -Two Successful Cases and a Review of the Literature.

BACKGROUND: Ticagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. METHODS: We identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. RESULTS: Of the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. CONCLUSION: Despite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.

Safety of Ticagrelor in Moderate and Severe Acute Ischemic Stroke: A Single-Center Retrospective Review.

OBJECTIVES: Ticagrelor may be superior to aspirin after minor ischemic stroke or TIA, particularly in patients with symptomatic atherosclerotic disease. However, there may be an increased risk of intracerebral hemorrhage in patients with moderate to severe ischemic stroke, and ticagrelor has not been studied in this patient population. Therefore, we sought to evaluate the safety of ticagrelor after moderate or severe ischemic stroke. MATERIALS AND METHODS: Retrospective chart review of all patients admitted with acute ischemic stroke and NIHSS 6 or greater who were discharged on ticagrelor between January 2016 and December 2019. Patients who underwent angioplasty, stenting or carotid revascularization during the hospitalization were excluded. RESULTS: Of 183 patients discharged on ticagrelor, 61 patients were included. Median age was 61 (IQR 52-68); 33 (54%) patients were men. Median NIHSS was 11 (IQR 8-15). Fourteen (23%) patients received IV alteplase and 35 (57%) patients received mechanical thrombectomy. Stroke mechanism was large artery atherosclerosis in 53 (87%) of patients, of which 40 (71%) were deemed intracranial atherosclerosis. Final infarct volume was greater than 10 mL in 32 (52%) patients. Follow-up information was available for 53 (87%) patients; median length of follow-up was 3 (IQR 2-6) months. Six (10%) patients experienced recurrent ischemic stroke. No patients experienced symptomatic intracerebral hemorrhage after initiation of ticagrelor. One (2%) patient experienced major bleeding. CONCLUSIONS: This study provides preliminary evidence supporting the potential safety of ticagrelor following moderate or severe acute ischemic stroke. These findings support the need for future prospective studies.

Vision, Aphasia, Neglect Assessment for Large Vessel Occlusion Stroke.

BACKGROUND AND PURPOSE: Vision, Aphasia, Neglect (VAN) is a large vessel occlusion (LVO) screening tool that was initially tested in a small study where emergency department (ED) nurses were trained to perform VAN assessment on stroke code patients. We aimed to validate the VAN assessment in a larger inpatient dataset. METHODS: We utilized a large dataset and used National Institute of Health Stroke Scale (NIHSS) performed by physicians to extrapolate VAN. VAN was compared to NIHSS greater than or equal to 6 and established prehospital LVO screening tools including Rapid Arterial Occlusion Evaluation scale (RACE), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and Cincinnati Pre-hospital Stroke Scale (CPSS). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under receiver operating characteristics curve was calculated to estimate the predictive value of LVO. RESULTS: VAN was comparable in sensitivity (79% versus 80%) and NPV (88% versus 87%) to NIHSS greater than or equal to 6. It was superior in specificity (69% versus 57%), PPV (53% versus 46%) and accuracy to NIHSS greater than or equal to 6 (72% versus 64%) with significant receiver operating curve (.74 versus .69, P = .02). VAN also had comparable area under the curve when compared to RACE, FAST-ED, and CPSS however slightly lower accuracy (69%-73%) compared to RACE (76%), FAST-ED (77%), and CPSS (75%). VAN had the highest NPV among all screening assessments (88%). CONCLUSIONS: VAN is a simple screening tool that can identify LVOs with adequate accuracy in hospital setting. Future studies need to be conducted in prehospital setting to validate its utility to detect LVOs in the field.

Vision, Aphasia, Neglect Assessment to Predict Neurosurgical Intervention in Patients with Nontraumatic Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: The Vision, Aphasia, and Neglect (VAN) screening tool is a simple bedside test developed to identify patients with large vessel occlusion stroke. In the setting of intracerebral hemorrhage (ICH), there are very few bedside predictors of need for neurosurgical interventions other than age and Glasgow Coma Scale (GCS). We aimed to assess the utility of the VAN screening tool in predicting the need for neurosurgical intervention in patients with ICH. METHODS: We accessed sensitivity, specificity, positive predictive value, negative predictive value (NPV), and area under receiver operating characteristics curve of VAN for identifying ICH patients who require neurosurgical intervention. RESULTS: Among 228 ICH patients, 176 were VAN positive and 52 were VAN negative. On unadjusted analyses, VAN positive patients had a significantly higher ICH volume, GCS score, and National Institutes of Health Stroke Scale score (P < .001 for all). As compared to VAN negative patients, significantly higher proportion of VAN positive ICH patients (15.4% versus 32.4%) underwent a neurosurgical procedure such as external ventricular drain (EVD) and/or hematoma evacuation with craniotomy or craniectomy. The VAN screening tool had high sensitivity and NPV (100%) in predicting the need for craniectomy or hematoma evacuation, but had lower sensitivity (87.7%) for any neurosurgical procedure, as 15.4% of VAN negative patients received EVD. CONCLUSIONS: Our study suggests that VAN screening tool can identify high-risk ICH patients who are more likely to undergo craniotomy or craniectomy but is less sensitive to rule out need for EVD.

Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population.

BACKGROUND: Earlier tissue plasminogen activator treatment improves ischemic stroke outcome, but aspects of the time-benefit relationship still not well delineated are: (1) the degree of additional benefit accrued with treatment in the first 60 minutes after onset, and (2) the shape of the time-benefit curve through 4.5 hours. METHODS: We analyzed patients who had acute ischemic stroke treated with intravenous tissue plasminogen activator within 4.5 hours of onset from the Get With The Guidelines-Stroke US national program. Onset-to-treatment time was analyzed as a continuous, potentially nonlinear variable and as a categorical variable comparing patients treated within 60 minutes of onset with later epochs. RESULTS: Among 65 384 tissue plasminogen activator-treated patients, the median onset-to-treatment time was 141 minutes (interquartile range, 110-173) and 878 patients (1.3%) were treated within the first 60 minutes. Treatment within 60 minutes, compared with treatment within 61 to 270 minutes, was associated with increased odds of discharge to home (adjusted odds ratio, 1.25; 95% confidence interval, 1.07-1.45), independent ambulation at discharge (adjusted odds ratio, 1.22; 95% confidence interval, 1.03-1.45), and freedom from disability (modified Rankin Scale 0-1) at discharge (adjusted odds ratio, 1.72; 95% confidence interval, 1.21-2.46), without increased hemorrhagic complications or in-hospital mortality. The pace of decline in benefit of tissue plasminogen activator from onset-to-treatment times of 20 through 270 minutes was mildly nonlinear for discharge to home, with more rapid benefit loss in the first 170 minutes than later, and linear for independent ambulation and in-hospital mortality. CONCLUSIONS: Thrombolysis started within the first 60 minutes after onset is associated with best outcomes for patients with acute ischemic stroke, and benefit declined more rapidly early after onset for the ability to be discharged home. These findings support intensive efforts to organize stroke systems of care to improve the timeliness of thrombolytic therapy in acute ischemic stroke.

PR Interval Prolongation and Cryptogenic Stroke: A Multicenter Retrospective Study.

BACKGROUND: Atrial dysfunction or "cardiopathy" has been recently proposed as a mechanism in cryptogenic stroke. A prolonged PR interval may reflect impaired atrial conduction and thus may be a biomarker of atrial cardiopathy. We aim to compare the prevalence of PR interval prolongation in patients with cryptogenic stroke (CS) when compared with known non-cryptogenic non-cardioembolic stroke (NCNCS) subtypes. METHODS: We used prospective ischemic stroke databases of 3 comprehensive stroke centers to identify patients 18 years or older with a discharge diagnosis of ischemic non-cardioembolic stroke between December 1, 2013 and August 31, 2015. The main outcome was ischemic stroke subtype (CS versus NCNCS). We compared PR intervals as a continuous and categorical variable (<200 milliseconds; ≥200 milliseconds) and other clinical and demographic factors between the 2 groups and used multivariate regression analyses to determine the association between PR interval prolongation and CS. RESULTS: We identified 644 patients with ischemic non-cardioembolic stroke (224 CS and 420 NCNCS). Patients with CS were more likely to have a PR of 200 milliseconds or greater when compared with those with NCNCS (23.2% versus 13.8%, P = .009). After adjusting for factors that were significant in univariate analyses, a PR of 200 milliseconds or greater was independently associated with CS (odds ratio [OR] 1.70, 95% CI 1.08-2.70). The association was more pronounced when excluding patients on atrioventricular nodal blocking agents (OR 2.64, 95% CI 1.44-4.83). CONCLUSIONS: A PR of 200 milliseconds or greater is associated with CS and may be a biomarker of atrial cardiopathy in the absence of atrial fibrillation. Prospective studies are needed to confirm this association.

Higher prehospital blood pressure prolongs door to needle thrombolysis times: a target for quality improvement?

BACKGROUND: Per the American Heart Association guidelines, blood pressure (BP) should be less than 185/110 to be eligible for stroke thrombolysis. No studies have focused on prehospital BP and its impact on door to needle (DTN) times. We hypothesized that DTN times would be longer for patients with higher prehospital BP. METHODS: We conducted a retrospective review of acute ischemic stroke patients who presented between January 2010 and December 2010 to our emergency department (ED) through emergency medical services within 3 hours of symptom onset. Patients were categorized into 2 groups: prehospital BP greater than or equal to 185/110 (group 1) and less than 185/110 (group 2). Blood pressure records were abstracted from emergency medical services run sheets. Primary outcome measure was DTN time, and secondary outcome measures were modified Rankin Score at discharge, symptomatic intracranial hemorrhage, length of stay in stroke unit, and discharge disposition. RESULTS: A total of 107 consecutive patients were identified. Of these, 75 patients (70%) were thrombolysed. Mean DTN times were significantly higher in group 1 (adjusted mean [95% confidence interval], 86minutes [76-97] vs 56minutes [45-68]; P<.0001). A greater number of patients required antihypertensive medications before thrombolysis in the ED in group 1 compared to group 2 (54% vs 27%; P=.02). CONCLUSION: Higher prehospital BP is associated with prolonged DTN times and DTN time remains prolonged if prehospital BP greater than or equal to 185/110 is untreated before ED arrival. Prehospital BP control could be a potential area for improvement to reduce DTN times in patients with acute ischemic stroke.

Exploration of screening practices for obstructive sleep apnea in stroke medical community: A pilot study.

BACKGROUND: Frequency of sleep-disordered breathing (SDB) among stroke and transient ischemic attack (TIA) patients ranges from 30-80% and is associated with poor neurological outcomes. Per current stroke prevention guidelines from American Heart Association/American Stroke Association (AHA/ASA), SDB is included in the list of modifiable risk factors for stroke and TIA prevention. Goal of our study is to determine screening practices for SDB in stroke medical community. METHODS: A web-based survey was sent to physicians taking care of stroke patients across North America and Europe. RESULTS: Among 112 total responses, 91 (81%) were stroke physicians, nine (8%) were general neurologists, nine (8%) were from other specialties and three (3%) were sleep medicine physicians. Majority of physicians (72%, n=81) do not use SDB screening questionnaires in their stroke patients. Epworth sleepiness scale is the most used among SDB questionnaires (24%, n=25/105), followed by Berlin sleep questionnaire (10%) and STOP-BANG questionnaire (7%). Only 13% of physicians use screening questionnaires in both in-patients and outpatients, whereas 21% use only in outpatients and 5% use only in acute stroke setting. Only 50% (n=56/111) of physicians would refer their stroke patients to a sleep medicine specialist when patients screen positive for SDB on questionnaires. CONCLUSION: Despite being an independent risk factor for stroke and TIA, majority of physicians in the pilot targeted cohort of medical professionals, who are involved in the management of stroke and TIA, do not screen these patients for SDB. Further work involving systematic, more detailed standardized surveys are needed to be developed to objectively evaluate and improve screening practices for SDB in national and international stroke medical communities.

Clotting factors to treat thrombolysis-related symptomatic intracranial hemorrhage in acute ischemic stroke.

BACKGROUND: Symptomatic intracranial hemorrhage (sICH) occurs uncommonly after ischemic stroke therapy with tissue plasminogen activator (tPA). Clotting factor administration may be a treatment option. OBJECTIVE: To determine if treatment with clotting factors (fresh frozen plasma [FFP] or cryoprecipitate) was associated with improved outcomes in sICH. METHODS: We conducted a retrospective cohort study within University of Texas at Houston Stroke registry involving consecutive patients from February 1, 2007, to June 30, 2011, with tPA-related sICH, including cases with subsequent intra-arterial therapy. Outcomes were Modified Rankin Scale (mRS) score at discharge, death, and hematoma expansion. RESULTS: Of 921 patients treated with tPA, 48 (5.2%) had sICH and 45 met criteria for the study. Nineteen patients received clotting factors (42.2%; 18 received FFP and 7 received cryoprecipitate), whereas 26 (57.8%) patients received conservative management without clotting factors. None of the patients treated with clotting factors and only 2 of those who did not receive clotting factors had a good outcome, mRS score of 2 or less. All the patients treated with clotting factors and most of those not treated were left bedridden or dead (mRS score 4-6), 19 (100%) versus 22 (85%). Mortality was 9 (47.4%) versus 9 (34.6%), respectively. There was no difference in hematoma expansion between the 2 groups. CONCLUSIONS: We found no evidence that treatment for sICH with clotting factors has a favorable effect on clinical or radiological outcomes. However, the sample was small because of the low frequency of sICH. New treatments are urgently needed for this uncommon yet serious condition.

Stent-retriever alone vs. aspiration and stent-retriever combination in large vessel occlusion stroke: A matched analysis.

BACKGROUND: Three randomized clinical trials have reported similar safety and efficacy for contact aspiration and stent-retriever thrombectomy. AIM: We aimed to determine whether the combined technique (stent-retriever + contact aspiration) was superior to stent-retriever alone as first-line thrombectomy strategy in a patient cohort where balloon guide catheter was universally used. METHODS: A prospectively maintained mechanical thrombectomy database from January 2018 to December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent stent-retriever alone thrombectomy or stent-retriever + contact aspiration as first-line therapy. The primary outcome was the first-pass effect (mTICI2c-3). Secondary outcomes included modified first-pass effect (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤ 2). Safety outcomes included rate of parenchymal hematoma type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups. RESULTS: A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16 (11-21)). As compared to first-line stent-retriever alone, first-line stent-retriever + contact aspiration resulted in similar rates of first-pass effect (53% vs. 51%, adjusted odds ratio (aOR) 1.122, 95%CI (0.745-1.691), p = 0.58), modified first-pass effect (63% vs. 60.4%, aOR1.250, 95%CI (0.782-2.00), p = 0.35), final successful reperfusion (97.6% vs. 98%, p = 0.75), and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%, aOR 2.033, 95%CI (1.209-3.419), p = 0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line stent-retriever + contact aspiration treatment (81.8% vs. 73.6%, aOR 1.881, 95%CI (1.039-3.405), p = 0.037). CONCLUSIONS: Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a combined technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, the addition of contact aspiration after initial stent-retriever failure might be beneficial in achieving earlier reperfusion.

Factor VIII in Acute Cerebral Ischemia Pilot Study: Biomarker in Patients With Large Vessel Occlusion?

We conducted a prospective serial laboratory cohort study to assess the correlation of factor VIII (FVIII) levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS). Patients with AIS with anterior circulation LVO were eligible for enrollment if treated within 4.5 hours from last seen normal with intravenous tissue plasminogen activator (tPA). Patients (n = 29) had a mean age of 71 years and median National Institute of Health Stroke Scale of 14. Baseline pre-tPA FVIII was not significantly correlated with clot burden score (-0.147, P = .447) or vessel recanalization (-0.133, P = .499). Median FVIII decreased significantly from baseline to 6 hours post-tPA (282% to 161%, P = .002), but delta in FVIII level did not correlate with vessel recanalization (0.013, P = .948). There was no difference between median FVIII level at baseline and 90 days post-AIS. FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after thrombolysis, or symptomatic hemorrhage.

Blood pressure management in stroke: Five new things.

Hypertension is a major modifiable risk factor for stroke, with an estimated 51% of stroke deaths being attributable to high systolic blood pressure globally.1,2 The management of hypertension in stroke is determined by timing, the type of stroke, use of thrombolysis, concurrent medical conditions, and pharmacologic variables. We highlight the details of elevated blood pressure management in the hyperacute/acute, subacute, and chronic stages of ischemic stroke and intracerebral hemorrhage.

Progressive leg pain and weakness.

A 54-year-old man presented with progressive asymmetric leg pain and weakness. He had a history of invasive squamous cell carcinoma that was fully treated 2 years earlier. His leg symptoms progressed relentlessly during several months. Imaging studies demonstrated enhancement of the cauda equina and leptomeninges of the lower spinal cord. Initial cerebrospinal fluid examination showed an elevated protein concentration and lymphocytic pleocytosis with no malignant cells on cytological analysis. There was short-term improvement in symptoms and cerebrospinal fluid abnormalities with intravenous steroids. Two additional cerebrospinal fluid studies showed normal cytological findings, elevated IgG synthesis, and elevated antibody titers to varicella-zoster virus. Over time, the patient worsened, developed cranial neuropathies, and ultimately died. The pathological diagnosis and the approach to the clinical data are discussed.