National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke

Neuroprotective mechanisms of 3-n-butylphthalide in neurodegenerative diseases

Since 3-n-butylphthalide (NBP) was approved by the China Food and Drug Administration for the treatment of acute ischemia stroke in 2002, a number of studies have investigated NBP worldwide. In recent years, NBP has also demonstrated potential as treatment of several neurodegenerative diseases, which has increased the interest in its mechanisms of protection and action. Clinical studies and studies that used cell or animal models, have directly demonstrated neuroprotective effects of NBP via the following mechanisms: i) Inhibiting the inflammatory reaction; ii) reducing mitochondrial oxidative stress; iii) regulating apoptosis and autophagy; iv) inducing resistance to endoplasmic reticulum stress; and v) decreasing abnormal protein deposition. Therefore, NBP may be a potential drug for neurodegenerative diseases, and it is particularly important to identify the mechanism of NBP as it may assist with the development of new drugs for neurodegeneration. The present review summarizes the neuroprotective mechanisms of NBP and discusses new perspectives and prospects. The aim of the current review is to provide a new summary regarding NBP and its associated mechanisms.

Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke

Background and Purpose- The strong evidence of endovascular therapy in acute ischemic stroke patients with large vessel occlusion (LVO) is revealed. Such patients are required to direct transport to the hospital capable of endovascular therapy. There are several prehospital scales available for paramedics to predict LVO. However, they are time consuming, and several of them include factors caused by other types than LVO. Therefore, we need a fast, simple, and reliable prehospital scale for LVO. Methods- We developed a new prehospital stroke scale, emergent large vessel occlusion (ELVO) screen, for paramedics to predict LVO. The study was prospectively performed by multistroke centers. When paramedics referred to stroke center to accept suspected stroke patients, we obtain the following information over the telephone. ELVO screen was designed focusing on cortical symptoms: 1 observation; presence of eye deviation and 2 questions; paramedics show glasses, what is this? and paramedics show 4 fingers, how many fingers are there? If the presence of eye deviation or ≥1 of the 2 items were incorrect, ELVO screen was identified as positive. We evaluated between results of ELVO screen and presence of LVO on magnetic resonance angiography at hospital arrival. Results- A total of 413 patients (age, 74±13 years; men, 234 [57%]) were enrolled. Diagnosis was ischemic stroke, 271 (66%); brain hemorrhage 73 (18%); subarachnoid hemorrhage, 7 (2%); and not stroke, 62 (15%). One hundred fourteen patients had LVO (internal carotid artery, 33 [29%]; M1, 52 [46%]; M2, 21 [18%]; basilar artery, 5 [4%]; P1, 3 [3%]). Sensitively, specificity, positive predictive value, negative predictive value, and accuracy for ELVO screen to predict LVO were 85%, 72%, 54%, 93% and 76%, respectively. Among 233 patients with negative ELVO screen, only 17 (7%) had LVO, which indicated to be an ideal scale to avoid missing endovascular therapy. Conclusions- The ELVO screen is a simple, fast, and reliable prehospital scale for paramedics to identify stroke patients with LVO for whom endovascular therapy is an effective treatment.

Pre-hospital Assessment of Large Vessel Occlusion Strokes: Implications for Modeling and Planning Stroke Systems of Care

The social and financial burden of stroke is remarkable. Stroke is a leading cause of death and long-term disability worldwide. For several years, intravenous recombinant tissue plasminogen activator (IV rt-PA) remained as the only proven therapy for acute ischemic stroke. However, its benefit is hampered by a narrow therapeutic window and limited efficacy for large vessel occlusion (LVO) strokes. Recent trials of endovascular therapy (EVT) for LVO strokes have demonstrated improved patient outcomes when compared to treatment with medical treatment alone (with or without IV rt-PA). Thus, EVT has become a critical component of stroke care. As in IV rt-PA, time to treatment is a crucial factor with high impact on outcomes. Unlike IV rt-PA, EVT is only available at a limited number of centers. Considering the time sensitive benefit of reperfusion therapies of acute ischemic stroke, costs and logistics associated, it is recommended that regional systems of acute stroke care should be developed. These should include rapid identification of suspected stroke, centers that provide initial emergency care, including administration of IV rt-PA, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate. In the pre-hospital setting, the development of scales easier and quicker to perform than the NIHSS yet with a maintained accuracy for detecting LVO strokes is of paramount importance. Several scales have been developed. On the other hand, the decision whether to transport to a primary stroke center (PSC) or to a comprehensive stroke center (CSC) is complex and far beyond the simple diagnosis of a LVO. Ongoing studies will provide important answers to the best transfer strategy for acute stroke patients. At the same time, the development of new technologies to aid in real time the decision-making process will simplify the logistics of regional systems for acute stroke care and, likely improve patients' outcomes through tailored selection of the most appropriate recanalization strategy and destination center.

Magnitude of Benefit of Combined Endovascular Thrombectomy and Intravenous Fibrinolysis in Large Vessel Occlusion Ischemic Stroke

Background and Purpose—

Quantifying the benefit magnitude of combined endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) versus nonreperfusion care in patients with acute ischemic stroke caused by large vessel occlusion would aid organization of regional stroke care systems.

Methods—

NINDS rt-PA Study (National Institute for Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator) and SWIFT PRIME trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment) patients were matched for prognosis (based on age and National Institutes of Health Stroke Scale) and definite/likely anterior circulation large vessel occlusion (based on National Institutes of Health Stroke Scale total score and item pattern), using optimal inverse variance matching, to determine comparative outcomes with nonreperfusion care alone, IVT alone, and IVT+EVT.

Results—

Matching yielded 240 patients, including 80 each treated with nonreperfusion care, IVT alone, and IVT+EVT, with, respectively, mean age 67.1, 67.1, and 66.9 and presenting deficit severity (National Institutes of Health Stroke Scale) mean 15.8, 15.9, and 15.9. Outcomes at 3 months for IVT+EVT versus nonreperfusion care included freedom from disability (modified Rankin Scale score, 0–1) 48.1% versus 21.3%, P =0.0004; functional independence (modified Rankin Scale score, 0–2) 62.9% versus 32.6, P =0.0001; and reduced disability over all 7 modified Rankin Scale levels, common odds ratio 3.34, P <0.0001. Outcomes for IVT alone versus nonreperfusion care included: freedom from disability 30.0% versus 21.3%, P =0.28 and reduced disability over all 7 modified Rankin Scale levels, common odds ratio 1.14, P =0.65. Compared with nonreperfusion care, the number needed to treat with EVT+IVT for 1 more patient to have reduced disability was 1.8.

Conclusions—

Matched patient analysis across randomized trials provides evidence that the strategy of combined IVT and mechanical thrombectomy is a highly beneficial treatment strategy for acute ischemic stroke caused by large vessel occlusion patients. A reasonable effect magnitude estimate is that, among every 100 patients treated, combined IVT+EVT reperfusion therapy, compared with no reperfusion therapy, reduces long-term disability in 57, including conferring functional independence upon 30.

Effect of definition and methods on estimates of prevalence of large vessel occlusion in acute ischemic stroke: a systematic review and meta-analysis

Introduction

Accurate estimation of the incidence of large vessel occlusion (LVO) is critical for planning stroke systems of care and approximating workforce requirements. This systematic review aimed to estimate the prevalence of LVO among patients with acute ischemic stroke (AIS), with emphasis on definitions and methods used by different studies.

Methods

A systematic literature review was performed to search for articles on the prevalence of LVO and AIS. All articles describing the frequency of LVO frequency among AIS patients were included. Studies without consecutive recruitment or confirmation of LVO with CT angiography or MR angiography were excluded. Heterogeneity of the studies was assessed; meta-regression was performed to estimate the effect of LVO definition and study methods on LVO prevalence.

Results

18 articles met the inclusion criteria: 5 studies presented population based estimates; 13 provided single hospital experiences (5 prospective, 8 retrospective). The AIS denominator (number of all AIS) from which LVO rates were generated was variable. Nine different definitions were used, based on occlusion site. Significant heterogeneity existed among the studies (I2=99%, P<0.001). The prevalence of LVO among patients with suspected AIS ranged from 13% to 52%. Overall prevalence was 30.0% (95% CI 25.0% to 35.0%). Pooled prevalence of LVO among suspected AIS patients was 21% (95% CI 19% to 30%). Based on meta-regression, the method of AIS denominator determination significantly influenced heterogeneity (P=0.018).

Conclusion

The heterogeneity of LVO estimates was remarkably high. The method of AIS denominator determination was the most significant predictor of LVO estimates. Studies with a standardized LVO definition and methods of AIS estimation are necessary to estimate the true prevalence of LVO among patients with AIS.

The role of the Cincinnati Prehospital Stroke Scale in the emergency department: evidence from a systematic review and meta-analysis

INTRODUCTION

Stroke is one of the leading causes of morbidity, disability, and mortality in high-income countries. Early prehospital stroke recognition plays a fundamental role, because most clinical decisions should be made within the first hours after onset of symptoms. The Cincinnati Prehospital Stroke Scale (CPSS) is a validated screening tool whose utilization is suggested during triage. The aim of this study is to review the role of the CPSS by assessing its sensitivity and specificity in prehospital and hospital settings.

METHODS

A systematic review and a meta-analysis of the literature reporting the CPSS sensitivity and specificity among patients suspected of stroke were undertaken. Electronic databases were searched up to December 2018, and the quality assessment was carried out by using the Revised Quality Assessment of Diagnostic Accuracy Studies -2  (QUADAS-2).

RESULTS

Eleven studies were included in the meta-analysis. Results showed an overall sensitivity of 82.46% (95% confidence interval [CI] 74.83-88.09%) and specificity of 56.95% (95% CI 41.78-70.92). No significant differences were found in terms of sensitivity when CPSS was performed by physicians (80.11%, 95% CI 66.14-89.25%) or non-physicians (81.11%, 95% CI 69.78-88.87%). However, administration by physicians resulted in higher specificity (73.57%, 95% CI 65.78-80.12%) when compared to administration by non-physicians (50.07%, 95% CI 31.54-68.58%). Prospective studies showed higher specificity 71.61% (95% CI 61.12-80.18%) and sensitivity 86.82% (95% CI 74.72-93.63) when compared to retrospective studies which showed specificity of 33.37% (95% CI 22.79-45.94%) and sensitivity of 78.52% (95% CI 75.08-81.60).

CONCLUSIONS

The CPSS is a standardized and easy-to-use stroke screening tool whose implementation in emergency systems protocols, along with proper and consistent coordination with local, regional, and state agencies, medical authorities and local experts are suggested.

Efficacy and safety of endovascular thrombectomy in mild ischemic stroke: results from a retrospective study and meta-analysis of previous trials

Background

Mechanical thrombectomy has been proven as a standard care for moderate to severe ischemic stroke with anterior large vessel occlusion (LVO); however, whether it is equally effective in mild ischemic stroke (MIS) is controversial.

Methods

In this retrospective study, a total of 177 Chinese patients presenting with MIS (NIHSS ≤8) and LVO between January 2014 and September 2017 from seven comprehensive stroke centers were identified. Odds of good outcome with endovascular thrombectomy versus medical treatment were obtained by logistic regression analysis and propensity-score matching method, and a meta-analysis pooled results from six studies (n = 733).

Results

Good outcome (mRS: 0–1) was 58.2% (46/79) in the thrombectomy and 46.9% (46/98) in the medical group, which showed no statistical significance before adjustment (P = 0.13; OR = 1.57, 95% CI: 0.86 to 2.86). The adjusted ORs of thrombectomy versus medical group were 3.23 (95% CI, 1.35 to 7.73; P = 0.008) by multivariable logistic analysis, 2.78 (1.12 to 6.89; P = 0.02) by propensity score matching analysis, and 3.20 (1.22 to 8.37; P = 0.01) by propensity score matching analysis with additional adjustments, respectively. Thrombectomy treatment did not result in excessive mortality or symptomatic intracranial hemorrhage after adjustments. The meta-analysis did not confirm the associations between good outcome and endovascular treatment.

Conclusions

The current study indicates that endovascular thrombectomy is associated with good functional outcome in MIS patients with LVO, and without additional risk of symptomatic intracranial hemorrhage and mortality. Although the meta-analysis failed to demonstrate its superiority compared to medical treatment, randomized clinical trials are needed.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1372-9) contains supplementary material, which is available to authorized users.

Clinical prediction of thrombectomy eligibility: A systematic review and 4-item decision tree

BACKGROUND

A clinical large anterior vessel occlusion (LAVO)-prediction scale could reduce treatment delays by allocating intra-arterial thrombectomy (IAT)-eligible patients directly to a comprehensive stroke center.

AIM

To subtract, validate and compare existing LAVO-prediction scales, and develop a straightforward decision support tool to assess IAT-eligibility.

METHODS

We performed a systematic literature search to identify LAVO-prediction scales. Performance was compared in a prospective, multicenter validation cohort of the Dutch acute Stroke study (DUST) by calculating area under the receiver operating curves (AUROC). With group lasso regression analysis, we constructed a prediction model, incorporating patient characteristics next to National Institutes of Health Stroke Scale (NIHSS) items. Finally, we developed a decision tree algorithm based on dichotomized NIHSS items.

RESULTS

We identified seven LAVO-prediction scales. From DUST, 1316 patients (35.8% LAVO-rate) from 14 centers were available for validation. FAST-ED and RACE had the highest AUROC (both >0.81, p < 0.01 for comparison with other scales). Group lasso analysis revealed a LAVO-prediction model containing seven NIHSS items (AUROC 0.84). With the GACE (Gaze, facial Asymmetry, level of Consciousness, Extinction/inattention) decision tree, LAVO is predicted (AUROC 0.76) for 61% of patients with assessment of only two dichotomized NIHSS items, and for all patients with four items.

CONCLUSION

External validation of seven LAVO-prediction scales showed AUROCs between 0.75 and 0.83. Most scales, however, appear too complex for Emergency Medical Services use with prehospital validation generally lacking. GACE is the first LAVO-prediction scale using a simple decision tree as such increasing feasibility, while maintaining high accuracy. Prehospital prospective validation is planned.

Radiological Eye Deviation as a Predictor of Large Vessel Occlusion in Acute Ischaemic Stroke

BACKGROUND

Detection of large vessel occlusion (LVO) is required for endovascular therapy in acute ischemic stroke (AIS) but CT angiography (CTA) is not always performed at primary stroke centers. Eye deviation on CT brain has been associated with improved stroke detection, but comparisons with angiographic status have been limited. This study sought to determine if radiological eye deviation was associated with LVO.

METHODS

All AIS patients given intravenous thrombolysis who had acute CTA performed in 2 stroke units were reviewed over 2013-2015 for the presence of LVO. Eye deviation was determined by 2 clinicians blinded to LVO status. Logistic regression was performed to determine which factors predicated LVO.

RESULTS

Total 195 AIS patients with acute CTA were identified; 124 (64%) had LVO. Median age was 72 (IQR 64-82) years, median National Institutes of Health Stroke Scale (NIHSS) was 12 (IQR 7-14). LVO patients had a higher NIHSS (15 versus 7, p < .01) and were more likely to have eye deviation on CT brain (71% versus 22.5%, p < .01). Logistic regression confirmed NIHSS score and eye deviation were associated with LVO, with odds ratios of 1.15 (per point) and 5.13 respectively. NIHSS less than equal to 11 gave greatest sensitivity (78.5%) and specificity (76.1%) for LVO with a positive predictive value of 84.7%. Eye deviation was similar with sensitivity 71%, specificity 77.5%, and 84.6%.

CONCLUSIONS

Eye deviation on CT brain is strongly associated with LVO. Presence of eye deviation on CT should alert clinicians to probability of LVO and for formal angiographic testing if not already performed.

Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST): A Modified Scale to Detect Large Vessel Occlusion Stroke

Background and Purpose: Patients with large vessel occlusion stroke (LVOS) need to be rapidly identified and transferred to comprehensive stroke centers (CSC). However, previous pre-hospital strategy remains challenging. We aimed to develop a modified scale to better predict LVOS.

Methods: We retrospectively reviewed our prospectively collected database for acute ischemic stroke (AIS) patients who underwent CT angiography (CTA) or time of flight MR angiography (TOF-MRA) and had a detailed National Institutes of Health Stroke Scale (NIHSS) score at admission. Large vessel occlusion (LVO) was defined as the complete occlusion of large vessels, including the intracranial internal carotid artery (ICA), M1, and M2 segments of the middle cerebral artery (MCA), and basilar artery (BA). The Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST) scale consisted of Level of Consciousness (LOC) questions, Gaze deviation, Facial palsy, Arm weakness, and Speech changes. Receiver Operating Characteristic (ROC) analysis was used to obtain the Area Under the Curve (AUC) of CG-FAST and previously established pre-hospital prediction scales.

Results: Finally, 1,355 patients were included in the analysis. LVOS was detected in 664 (49.0%) patients. The sensitivity, specificity, positive predictive value, and negative predictive value of CG-FAST were 0.617, 0.810, 0.785, and 0.692 respectively, at the optimal cutoff (≥4). The AUC, Youden index and accuracy of the CG-FAST scale (0.758, 0.428, and 0.728) were all higher than other pre-hospital prediction scales.

Conclusions: CG-FAST scale could be an effective and simple scale for accurate identification of LVOS among AIS patients.

Clinical effect of successful reperfusion in patients presenting with NIHSS < 8: data from the BEYOND-SWIFT registry

BACKGROUND AND PURPOSE

If patients presenting with large vessel occlusions (LVO) and mild symptoms should be treated with endvoascular treatment (EVT) remains unclear. Aims of this study were (1) assessing the safety and technical efficacy of EVT in patients with NIHSS < 8 as opposed to a comparison group of patients presenting with NIHSS ≥ 8 and (2) evaluation of the clinical effect of reperfusion in patients with NIHSS < 8.

METHODS

Patients included into the retrospective multicenter BEYOND-SWIFT registry (NCT03496064) were analyzed. Clinical effect of achieving successful reperfusion (defined as modified Thrombolysis in Cerebral Infarction grade 2b/3) in patients presenting with NIHSS < 8 (N = 193) was evaluated using multivariable logistic regression analyses (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI). Primary outcome was excellent functional outcome (modified Rankin Scale, mRS 0-1) at day 90. Safety and efficacy of mechanical thrombectomy in patients with NIHSS < 8 was compared to patients presenting with NIHSS ≥ 8 (N = 1423).

RESULTS

Among patients with NIHSS < 8 (N = 193, 77/193, 39.9% receiving pre-interventional IV-tPA), successful reperfusion was significantly related to mRS 0-1 (aOR 3.217, 95%-CI 1.174-8.816) and reduced the chances of non-hemorrhagic neurological worsening (aOR 0.194, 95%-CI 0.050-0.756) after adjusting for prespecified confounders. In interaction analyses, the relative merits of achieving successful reperfusion were mostly comparable between patients presenting with NIHSS < 8 and NIHSS ≥ 8 as evidenced by non-significantly different aOR. Interventional safety and efficacy metrics were similar between patients with NIHSS < 8 and NIHSS ≥ 8.

CONCLUSIONS

Achieving successful reperfusion is beneficial in patients with persisting LVO presenting with NIHSS < 8 and reduces the risk of non-hemorrhagic neurological worsening.

[Reperfusion therapy in patients with minor or mild ischemic stroke]

A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.

The Large ARtery Intracranial Occlusion Stroke Scale: A New Tool With High Accuracy in Predicting Large Vessel Occlusion

Objectives: The combination of systemic thrombolysis and mechanical thrombectomy is indicated in patients with ischemic stroke due to a large vessel occlusion (LVO) and these treatments are time-dependent. Rapid identification of patients with suspected LVO also in a prehospital setting could influence the choice of the destination hospital. Aim of this pilot study was to evaluate the predictive role of a new stroke scale for LVO, comparing it to other scores.

Patients and Methods: All consecutive patients admitted to our comprehensive stroke center with suspected ischemic stroke were studied with a CT angiography and 5 different stroke scales were applied. The Large ARtery Occlusion (LARIO) stroke scale consists of 5 items including the assessment of facial palsy, language alteration, grip and arm weakness, and the presence of neglect. A Receiving Operating Characteristic curve was evaluated for each stroke scale to explore the level of accuracy in LVO prediction.

Results: A total of 145 patients were included in the analysis. LVO was detected in 37.2% of patients. The Area Under Curve of the LARIO score was 0.951 (95%CI: 0.902–0.980), similar to NIHSS and higher than other scales. The cut-off score for best performance of the LARIO stroke scale was higher than 3 (positive predictive value: 77% and negative predictive value: 100%).

Conclusion: The LARIO stroke scale is a simple tool, showing high accuracy in detecting LVO, even if with some limitations due to some false positive cases. Its efficacy has to be confirmed in a pre-hospital setting and other centers.

Are you suffering from a large arterial occlusion? Please raise your arm!

Background and purpose

Triage tools to identify candidates for thrombectomy are of utmost importance in acute stroke. No prognostic tool has yet gained any widespread use. We compared the predictive value of various models based on National Institutes of Health Stroke Scale (NIHSS) subitems, ranging from simple to more complex models, for predicting large artery occlusion (LAO) in anterior circulation stroke.

Methods

Patients registered in the SITS international Stroke Register with available NIHSS and radiological arterial occlusion data were analysed. We compared 2042 patients harbouring an LAO with 2881 patients having no/distal occlusions. Using binary logistic regression, we developed models ranging from simple 1 NIHSS-subitem to full NIHSS-subitems models. Sensitivities and specificities of the models for predicting LAO were examined.

Results

The model with highest predictive value included all NIHSS subitems for predicting LAO (area under the curve (AUC) 0.77), yielding a sensitivity and specificity of 69% and 76%, respectively. The second most predictive model (AUC 0.76) included 4-NIHSS-subitems (level of consciousness commands, gaze, facial and arm motor function) yielding a sensitivity and specificity of 67% and 75%, respectively. The simplest model included only deficits in arm motor-function (AUC 0.72) for predicting LAO, yielding a sensitivity and specificity of 67% and 72%, respectively.

Conclusions

Although increasingly more complex models yield a higher discriminative performance for predicting LAO, differences between models are not large. Assessing grade of arm dysfunction along with an established stroke-diagnosis model may serve as a surrogate measure of arterial occlusion-status, thereby assisting in triage decisions.

Effect of routing paradigm on patient centered outcomes in acute ischemic stroke

Background

To compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.

Methods

We simulated different routing paradigms in a system comprising one primary stroke center (PSC) and one comprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the nearest center paradigm, patients are initially sent to the nearest center, while in CSC first, patients are sent to the CSC. In the Rhode Island and distributive paradigms, patients with a FAST-ED (Facial palsy, Arm weakness, Speech changes, Time, Eye deviation, and Denial/neglect) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome, determined by type and timing of treatment using clinical trial data, and number needed to bypass (NNB).

Results

Good clinical outcome was achieved in 43.76% of patients in nearest center, 44.48% in CSC first, and 44.44% in Rhode Island and distributive in an urban setting; 43.38% in nearest center, 44.19% in CSC first, and 44.17% in Rhode Island in a suburban setting; and 41.10% in nearest center, 43.20% in CSC first, and 42.73% in Rhode Island in a rural setting. In all settings, NNB was generally higher for CSC first compared with Rhode Island or distributive.

Conclusion

Routing paradigms that allow bypass of nearer hospitals for thrombectomy capable centers improve population level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, paradigm choice may be most impactful in rural settings. Selective bypass, as implemented in the Rhode Island and distributive paradigms, improves system efficiency with minimal impact on outcomes.

Large Vessel Occlusion Score: A Screening Tool to Detect Large Vessel Occlusion in the Acute Stroke Setting

BACKGROUND

The results of recent trials of mechanical thrombectomy for acute ischemic stroke have increased the demand for identification of patients with large vessel occlusion (LVO) at the primary stroke center, where a prompt detection may expedite transfer to a comprehensive stroke center for endovascular treatment. However, in developing countries, a noncontrast computed tomography (NCCT) may be the only neuroimaging modality available at the primary stroke center scenario, what calls for a screening strategy accurate enough to avoid unnecessary transfers of noneligible patients for endovascular therapy. Algorithms based on National Institute of Health Stroke Scale (NIHSS) and NCCT findings can be used to screen for LVO in patients with anterior circulation stroke (ACS).

OBJECTIVE

To test the accuracy of a score based on NIHSS and NCCT to detect LVO in patients with ACS.

METHODS

We evaluated 178 patients from a prospective stroke registry of patients admitted to an academic tertiary emergency unit. NIHSS and vessel attenuation values of the middle cerebral artery on NCCT absolute vessel attenuation (VA) were collected by 2 investigators that were blind to CT angiography (CTA) findings. We used receiver operating characteristics curve analysis and C-statistics to predict LVO on CTA.

RESULTS

NIHSS and vessel attenuation were highly associated with LVO with an area under the curve (AUC) of .86 and .77. The LVO score, built by logistic regression coefficients of the NIHSS and VA, showed the highest accuracy for the presence of LVO on CTA (AUC of .91).

CONCLUSION

The LVO score may be a useful screening approach to identify LVO in patients with ACS.

Number of ischemic strokes potentially eligible for revascularization treatments in an Italian Comprehensive Stroke Center: a modeling study

To rationally plan acute services, the proportion of ischemic strokes that may be eligible for revascularization treatments should be estimated. We aimed to estimate the proportion of patients directly admitted to an Italian Comprehensive Stroke Center who may be eligible for intravenous thrombolysis (IVT), combined IVT and endovascular thrombectomy (ET), or direct ET according to the current guidelines. We conducted a retrospective analysis based on data prospectively collected from 876 consecutive adult ischemic stroke patients who were directly admitted to the Stroke Unit of the University Hospital of Verona within 12 h of stroke onset. A theoretical model was created to calculate the proportion of patients potentially eligible for revascularization treatments. In our cohort, 289 (33%) patients would be eligible for IVT alone, 193 (22%) for combined IVT and ET, and 39 (4%) for direct ET with level of evidence IA according to the current guidelines. According to our theoretical model, more than half of the ischemic stroke patients directly admitted to Verona Stroke Unit within 12 h of stroke onset would be eligible for IVT and more than a quarter for ET. Systems of care should promptly organize to offer each patient the best treatment.

Mechanical Thrombectomy by a Direct Aspiration First Pass Technique (ADAPT) in Ischemic Stroke: Results of Monocentric Study Based on Multimodal CT Patient Selection

Introduction

Mechanical thrombectomy with ADAP-technique of ischemic stroke has been reported as fast and effective. Aim of this study is to evaluate imaging criteria as possible predictors of stroke severity, therapeutic success, and outcome.

Materials and Methods

Patients (30) presenting from October 2015 to April 2017 with Emergent Large Vessel Occlusion of the anterior circulation were treated with ADAP-technique. 22 received also IV tPA; 8 underwent endovascular treatment only. Every patient was evaluated with noncontrast CT, multiphase angiography-CT, and perfusion CT. Clinical and radiological characteristics were measured. Good clinical outcome was an improvement of 8 points on NIHSS at discharge or a modified Rankin Scale ≤2 at discharge and at 90 days.

Results

Successful revascularization was obtained in 57% of patients, no procedural complications were witnessed, and only two hemorrhages were reported. Good outcome at discharge was obtained in 11 patients (37%) and predicted by NCCT ASPECT and TICI; outcome at 90 days was predicted by NCCT ASPECT, clot length, and premorbid mRS. Mortality was 23% at discharge and 30% at 90 days.

Conclusion

ADAPT is an effective endovascular method of stroke treatment with fast procedural times. Multimodal CT evaluation is effective in assessing stroke severity, providing important prognostic information, which is able to select patients for the appropriate treatment.

Disability Adjusted Life Years due to Ischaemic Stroke Preventable by Real-Time Stroke Detection-A Cost-Utility Analysis of Hypothetical Stroke Detection Devices

Background: Ischaemic stroke remains a significant contributor to permanent disability world-wide. Therapeutic interventions for acute ischaemic stroke (AIS) are available, but need to be administered early after symptom onset in order to be effective. Currently, one of the main factors responsible for poor clinical outcome is an unnecessary long time between symptom onset and arrival at a hospital (pre-hospital delay). In the future, technological devices with the capability of real-time detection of AIS may become available. The health economic implications of such devices have not been explored. Methods: We developed a novel probabilistic model to estimate the maximally allowable annual costs of different hypothetical real-time AIS detection devices in different populations given currently accepted willingness-to-pay thresholds. Distributions of model parameters were extracted from the literature. Effectiveness of the intervention was quantified as reduction in disability-adjusted life-years associated with faster access to thrombolysis and mechanical thrombectomy. Incremental costs were calculated from a societal perspective including acute treatment costs and long-term costs for nursing care, home help, and loss of production. The impact of individual model parameters was explored in one-way and multi-way sensitivity analyses. Results: The model yields significantly shorter prehospital delays and a higher proportion of acute ischaemic patients that fulfill the time-based eligibility criteria for thrombolysis or mechanical thrombectomy in the scenario with a real-time stroke detection device as compared to the control scenario. Depending on the sociodemographic and geographic characteristics of the study population and operating characteristics of the device, the maximally allowable annual cost for the device to operate in a cost-effective manner assuming a willingness-to-pay threshold of GBP 30.000 ranges from GBP 22.00 to GBP 9,952.00. Considering the results of multiway sensitivity analyses, the upper bound increases to GBP 29,449.10 in the subgroup of young patients with a very high annual risk of ischaemic stroke (50 years/20% annual risk). Conclusion: Data from probabilistic modeling suggest that real-time AIS detection devices can be expected to be cost-effective only for a small group of highly selected individuals.

Patterns of Stroke Transfers and Identification of Predictors for Thrombectomy

BACKGROUND

Interhospital transfers for endovascular thrombectomy (EVT) evaluation have increased since the publication of landmark neuroendovascular stroke trials in 2015. The lack of guidelines to select potential EVT candidates prior to transfer can lead to instances where, despite considerable costs and transport risks, transferred patients do not ultimately undergo EVT. Our aim was to characterize the patterns and identify predictors for EVT on transfer.

METHODS

In this observational cohort study, we retrospectively analyzed patients with acute ischemic stroke (AIS) transferred to our institution for EVT evaluation from January 2015 to March 2016. Clinical and radiographic predictors for EVT on transfer were determined with multivariable logistic regression analysis.

RESULTS

A total of 103 transfer patients with AIS were included in the study, and 52% were women. A higher collateral score (P < 0.01), a higher National Institutes of Health Stroke Scale (NIHSS) score (P < 0.01), computed tomography angiography (CTA) at referring hospital (P < 0.01), and large vessel occlusion on arrival CTA (P < 0.01) were significant in patients who underwent EVT on univariable analysis. More than half (61.1%) of transfers were futile and primarily related to absence of large vessel occlusion on arrival. A higher collateral score (P = 0.02), a higher NIHSS score (P = 0.006), and having undergone a CTA at the referring center (P = 0.002) remained the independent predictors of EVT. The C statistic for the model was 0.94.

CONCLUSIONS

A higher collateral score, the acquisition of CTA imaging at the referring centers, and a higher NIHSS score independently predicted EVT on transfer.

Large Vessel Occlusion in Acute Stroke

Background and Purpose—

To date, no clinical score has become widely accepted as an eligible prehospital marker for large vessel occlusion (LVO) and the need of mechanical thrombectomy (MT) in ischemic stroke. On the basis of pathophysiological considerations, we propose that cortical symptoms such as aphasia and neglect are more sensitive indicators for LVO and MT than motor deficits.

Methods—

We, thus, retrospectively evaluated a consecutive cohort of 543 acute stroke patients including patients with ischemia in the posterior circulation, hemorrhagic stroke, transient ischemic attack, and stroke mimics to best represent the prehospital setting.

Results—

Cortical symptoms alone showed to be a reliable indicator for LVO (sensitivity: 0.91; specificity: 0.70) and MT (sensitivity: 0.90; specificity: 0.60) in acute stroke patients, whereas motor deficits showed a sensitivity of 0.85 for LVO (specificity: 0.53) and 0.87 for MT (specificity: 0.48).

Conclusions—

We propose that in the prehospital setting, the presence of cortical symptoms is a reliable indicator for LVO and its presence justifies transportation to an MT-capable center.

Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time

Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention (NI) team for EVT candidate prior to imaging, NI team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.

Prehospital stroke scales and large vessel occlusion: A systematic review

BACKGROUND AND PURPOSE

Time sensitivity for pharmacological and mechanical arterial recanalization in acute ischemic stroke influences the choice of the reference hospital. The accurate selection and identification of patients with high probability of a large vessel occlusion (LVO) in the prehospital setting improve the rationalization of the transport in the more suitable centers. Aim of this analysis was to determine the diagnostic accuracy of prehospital stroke scales detecting LVO.

MATERIAL AND METHODS

Studies were searched into MEDLINE, EMBASE, and CINHAL databases between January 1990 and September 2017. Principal measurements of the meta-analysis were the overall accuracy level, sensitivity, and specificity of prehospital stroke scales.

RESULTS

Nineteen scoring systems were included in the analysis coming from 13 studies. A total of 9824 patients were considered. Although a higher heterogeneity was observed in the analysis, three scores showed better results in predicting a LVO (the stroke Vision, Aphasia, Neglect assessment, the National Institute of Health Stroke scale and the Los Angeles Motor Scale). We observed significant differences of overall accuracy only for scores including hemineglect as cortical neurological sign (P < .05).

CONCLUSIONS

This meta-analysis suggests that some prehospital scoring systems including cortical signs showed better accuracy to predict stroke due to LVO. However, the assessment of these signs could be difficult to investigate by paramedics and personnel of Emergency Medical Services, and for this reason, further prospective evaluations are needed.

Relation between lipoprotein-associated phospholipase A2 mass and incident ischemic stroke severity

BACKGROUND

Manifestations of ischemic stroke vary widely, and serum biomarkers may be useful for stratification of risk of severe stroke. This study evaluated the association of lipoprotein-associated phospholipase A₂ (Lp-PLA₂) mass and initial severity.

METHODS

We employed a retrospective analysis on our hospital-based registry and recruited 488 first-onset ischemic stroke patients admitted within 24 h after onset and with Lp-PLA₂ mass measured. Stroke severities evaluated by National Institutes of Health Stroke Scale (NIHSS) were compared between Lp-PLA₂ categories dichotomized by median. Multivariate logistic regression was used to detect the independent risk factors of severe stroke (NIHSS ≥ 7) and receiver operator curve (ROC) was constructed to detect the value of addition of Lp-PLA₂ to the model of other risk factors for predicting severe stroke.

RESULTS

Of the overall patients, the median admission NIHSS scores was 3 and 28.1% had severe manifestation. Admission NIHSS scores were different between patients of Lp-PLA₂ above and under the median (median NIHSS 4 vs. 3, P < 0.001). Lp-PLA₂ levels was correlated with admission NIHSS (r = 0.268, P < 0.001). Logistic regression showed Lp-PLA₂ category (OR 2.37, 95%CI 1.44-3.90, P < 0.001) and levels per 100 ng/ml (OR 1.69, 95%CI 1.35-2.11, P < 0.001) were both independently associated with severe stroke. Addition of Lp-PLA₂ category and levels to other independent risk factors both increased the area under curves (from 0.676 to 0.718 with category and 0.734 with levels).

CONCLUSION

Lp-PLA2 was independently related to admission severity in ischemic stroke patients, implying a potential predictive value of Lp-PLA2 for severe stroke in prevention.

Reperfusion Injury after ischemic Stroke Study (RISKS): single-centre (Florence, Italy), prospective observational protocol study

INTRODUCTION

Treatments aiming at reperfusion of the acutely ischaemic brain tissue may result futile or even detrimental because of the so-called reperfusion injury. The processes contributing to reperfusion injury involve a number of factors, ranging from blood-brain barrier (BBB) disruption to circulating biomarkers. Our aim is to evaluate the relative effect of imaging and circulating biomarkers in relation to reperfusion injury.

METHODS AND ANALYSIS

Observational hospital-based study that will include 140 patients who had ischaemic stroke, treated with systemic thrombolysis, endovascular treatment or both. BBB disruption will be assessed with CT perfusion (CTP) before treatment, and levels of a large panel of biomarkers will be measured before intervention and after 24 hours. Relevant outcomes will include: (1) reperfusion injury, defined as radiologically relevant haemorrhagic transformation at 24 hours and (2) clinical status 3 months after the index stroke. We will investigate the separate and combined effect of pretreatment BBB disruption and circulating biomarkers on reperfusion injury and clinical status at 3 months. Study protocol is registered at http://www.clinicaltrials.gov (ClinicalTrials.gov ID: NCT03041753).

ETHICS AND DISSEMINATION

The study protocol has been approved by ethics committee of the Azienda Ospedaliero Universitaria Careggi (Università degli Studi di Firenze). Informed consent is obtained by each patient at time of enrolment or deferred when the participant lacks the capacity to provide consent during the acute phase. Researchers interested in testing hypotheses with the data are encouraged to contact the corresponding author. Results from the study will be disseminated at national and international conferences and in medical thesis.

TRIAL REGISTRATION NUMBER

NCT03041753.

Mechanical Thrombectomy-A Brief Review of a Revolutionary new Treatment for Thromboembolic Stroke

The recent success of endovascular stroke treatment has heralded a new era in the management of acute ischemic stroke (AIS) with significantly improved outcome for patients. A large number of patients may be amenable to this new treatment and as the evidence expands the number of patients eligible for mechanical thrombectomy continues to increase. Recent evidence suggests that the time window for treatment can be extended up to 24 h after symptom onset for patients with anterior circulation strokes; however, many clinicians and medical professionals may not be aware of these recent changes and it is important that they are kept up-to-date with this rapidly evolving treatment. This review provides an overview of the recent successful trials and highlights important steps that should be instituted in order to achieve rapid reperfusion and optimize the outcome for ischemic stroke patients. It also looks at the remaining controversies facing the field of thrombectomy. A short summary of each of these contentious areas is provided and the current state of the art.

Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time

Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention team for EVT candidate prior to imaging, neurointervention team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.

Clinical Outcomes of Endovascular Treatment within 24 Hours in Patients with Mild Ischemic Stroke and Perfusion Imaging Selection

BACKGROUND AND PURPOSE

Endovascular thrombectomy has been accepted as the standard of care for patients with acute ischemic stroke. Our aim was to investigate the clinical outcomes of patients with mild ischemic stroke with acute proximal large-vessel occlusion after endovascular treatment within 24 hours of symptom onset.

MATERIALS AND METHODS

Between January 2014 and August 2017, ninety-three Chinese patients with mild ischemic stroke (NIHSS scores, 0-8) and large-vessel occlusion with endovascular treatment were retrospectively enrolled from 7 comprehensive stroke centers. They were divided into 2 groups: ≤6 hours and 6-24 hours from symptom onset to groin puncture. We analyzed their modified Rankin Scale scores at 90 days, symptomatic intracranial hemorrhage at 48 hours, and mortality during 90 days. Multivariable linear regression analysis was used to identify predictors for NIHSS shift after discharge.

RESULTS

Twenty-nine patients received endovascular treatment within 6-24 hours after symptom onset and had an imaging mismatch based on perfusion CT or diffusion-weighted MR imaging. There were no substantial differences between the 2 groups in 90-day functional independence (P = .54) and the risks of the combination of symptomatic intracranial hemorrhage and death (P = .72). Two significant indicators of NIHSS shift were 48-hour symptomatic intracranial hemorrhage (unstandardized β = 7.28; 95% CI, 3.48-11.1; P < .001) and baseline systolic blood pressure (unstandardized β = 0.08; 95% CI, 0.03-0.14; P = .005).

CONCLUSIONS

Patients with mild ischemic stroke and large-vessel occlusion in the anterior circulation, an imaging mismatch, and endovascular treatment within 6-24 hours of initial symptoms showed no heterogeneity in the efficacy and safety outcome compared with those treated ≤6 hours from symptom onset.

Delays in the Air or Ground Transfer of Patients for Endovascular Thrombectomy

BACKGROUND AND PURPOSE

For suspected large vessel occlusion patients efficient transfer to centers that provide endovascular therapy (ET) is critical to maximizing treatment opportunity. Our objective was to examine associations between transfer time, modes of transfer, ET, and outcomes within a hub-and-spoke telestroke network.

METHODS

Patients with ischemic stroke were included if transferred to a single hub hospital between January 2011 and October 2015 with National Institutes of Health Stroke Scale>6, onset<12 hours from hub arrival with complete clinical, imaging, and transfer data. Transfer time was the interval between initiation of telestroke consult and arrival at the hub. Algorithms were created for ideal transfer times; ideal time was subtracted from actual time to calculate delay. We examined bivariate relationships between transfer time and several clinical outcomes and used multivariable regression modeling to explore possible predictors of delay.

RESULTS

Of 234 patients that met inclusion criteria, 51% were transferred by ambulance and 49% by helicopter; 27% underwent ET (36% achieved modified Rankin Scale score of 0-2 at 90 days). Median actual transfer time was 132 minutes (interquartile range, 103-165), compared with median ideal transfer time at 102 minutes (interquartile range, 96-123). Longer transfer time was associated with decreased likelihood of undergoing ET (odds ratio, 0.990; P=0.003). Nocturnal transfer (18:00 to 06:00 hours) was associated with significantly longer delay (β=20.5; P<0.0005), whereas intravenous tissue-type plasminogen activator (tPA) delivery at spoke hospital was not. The median delay for nocturnal transfer was 31 minutes (interquartile range, 11-51), compared with daytime at 14 minutes (interquartile range, -9 to 36).

CONCLUSIONS

Within a large telestroke network, there was an association between longer transfer time and decreased likelihood of undergoing ET. Nocturnal transfers were associated with a substantial delay relative to daytime transfers. In contrast, delivery of tPA was not associated with delays, underscoring the impact of effective protocols at spoke hospitals. More efficient transfer may enable higher ET treatment rates. Metrics and protocols for transfer, especially at night, may improve transfer times.

Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens

BACKGROUND AND PURPOSE

Prehospital scales have been developed to identify patients with acute cerebral ischemia (ACI) because of large vessel occlusion (LVO) for direct routing to Comprehensive Stroke Centers (CSCs), but few have been validated in the prehospital setting, and their impact on routing of patients with intracranial hemorrhage has not been delineated. The purpose of this study was to validate the Los Angeles Motor Scale (LAMS) for LVO and CSC-appropriate (LVO ACI and intracranial hemorrhage patients) recognition and compare the LAMS to other scales.

METHODS

The performance of the LAMS, administered prehospital by paramedics to consecutive ambulance trial patients, was assessed in identifying (1) LVOs among all patients with ACI and (2) CSC-appropriate patients among all suspected strokes. Additionally, the LAMS administered postarrival was compared concurrently with 6 other scales proposed for paramedic use and the full National Institutes of Health Stroke Scale.

RESULTS

Among 94 patients, age was 70 (±13) and 49% female. Final diagnoses were ACI in 76% (because of LVO in 48% and non-LVO in 28%), intracranial hemorrhage in 19%, and neurovascular mimic in 5%. The LAMS administered by paramedics in the field performed moderately well in identifying LVO among patients with ACI (C statistic, 0.79; accuracy, 0.72) and CSC-appropriate among all suspected stroke transports (C statistic, 0.80; accuracy, 0.72). When concurrently performed in the emergency department postarrival, the LAMS showed comparable or better accuracy versus the 7 comparator scales, for LVO among ACI (accuracies LAMS, 0.70; other scales, 0.62-0.68) and CSC-appropriate (accuracies LAMS, 0.73; other scales, 0.56-0.73).

CONCLUSIONS

The LAMS performed in the field by paramedics identifies LVO and CSC-appropriate patients with good accuracy. The LAMS performs comparably or better than more extended prehospital scales and the full National Institutes of Health Stroke Scale.

Influence of blood glucose level on the prognosis of patients with diabetes mellitus complicated with ischemic stroke

We carried out this meta-analysis for the aim of exploring the influence of diabetes mellitus (DM) on the prognosis of patients with ischemic stroke. Relevant studies were identified using computerized databases supplemented with manual search strategies. The included studies were strictly followed the inclusion and exclusion criteria. Case-control studies which related to the influence of DM on the prognosis of patients with ischemic stroke were selected. Statistical analyses were implemented with the STATA version 12.0 statistical software. Our current meta-analysis initially retrieved 253 studies (227 in Chinese and 26 in English), 13 studies (6 in English and 7 in Chinese) were eventually incorporated in this meta-analysis. These 13 case-control studies included 8463 patients altogether (3249 patients with DM complicated with ischemic stroke and 5214 patients with ischemic stroke). The results of this meta-analysis manifested that there was a significant difference of the blood glucose level at 48 h after stroke between patients with DM complicated with ischemic stroke and patients with ischemic stroke (standard mean difference [SMD] =1.27, 95% confidence interval [CI] =0.02–2.51, P = 0.047); however, the effectiveness, fatality, and the National Institutes of Health Stroke Scale (NIHSS) score in patients with DM complicated with ischemic stroke, and patients with ischemic stroke had no significant difference (effectiveness: risk ratio [RR] = 0.88, 95% CI = 0.75–1.03, P = 0.121; fatality: RR = 1.29, 95% CI = 0.97–1.71, P = 0.081; NIHSS score: SMD = −0.14, 95% CI = −1.56-1.28, P = 0.849). The current evidence suggests that there is statistical difference of the blood glucose level at 48 h after stroke between patients with DM complicated with ischemic stroke and patients with ischemic stroke, but there is no statistical difference of prognostic indicators between patients in two groups. Thus, our study provides certain clinical value.

Dysphagia in patients with isolated pontine infarction

Little is known about dysphagia after pontine infarction. In this study, we evaluated the incidence of dysphagia after isolated pontine infarction and identified the predictive factors for the occurrence of dysphagia. A total of 146 patients were included in this study. All patients underwent clinical testing for dysphagia within 1 day after admission and at the time of discharge. We compared the incidence of dysphagia between patients with unilateral pontine infarction and those with bilateral pontine infarction. To evaluate the functional status of patients, we investigated their initial modified Rankin Scale (mRS) score and initial National Institutes of Health Stroke Scale (NIHSS) score within 1 day of admission. Of 146 patients, 50 (34.2%) had dysphagia initially within 1 day after admission. At the second evaluation at the time of discharge, dysphagia was diagnosed in 24 patients (16.4%). Patients with bilateral pontine infarction were more likely to present with dysphagia. In addition, clinical severity (in terms of mRS and NIHSS scores) was identified as a predictor of dysphagia in patients with cerebral infarction (multiple binary logistic regression analysis, mRS: P = 0.011, NIHSS: P = 0.004). Dysphagia frequently occurs in patients with isolated pontine infarction. Clinicians should pay particular attention to the occurrence of dysphagia, especially in patients with bilateral pontine infarction or high functional disability.

Spatially extended versus frontal cerebral near-infrared spectroscopy during cardiac surgery: a case series identifying potential advantages

Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.

Ischemic Strokes Due to Large-Vessel Occlusions Contribute Disproportionately to Stroke-Related Dependence and Death: A Review

Background

Since large-vessel occlusion (LVO)-related acute ischemic strokes (AIS) are associated with more severe deficits, we hypothesize that the endovascular thrombectomy (ET) may disproportionately benefit stroke-related dependence and death.

Methods

To delineate LVO-AIS impact, systematic search identified studies measuring dependence or death [modified Rankin Scale (mRS) 3–6] or mortality following ischemic stroke among consecutive patients presenting with both LVO and non-LVO events within 24 h of symptom onset.

Results

Among 197 articles reviewed, 2 met inclusion criteria, collectively enrolling 1,467 patients. Rates of dependence or death (mRS 3–6) within 3–6 months were higher after LVO than non-LVO ischemic stroke, 64 vs. 24%, odds ratio (OR) 4.46 (CI: 3.53–5.63, p < 0.0001). Mortality within 3–6 months was higher after LVO than non-LVO ischemic stroke, 26.2 vs. 1.3%, OR 4.09 (CI: 2.5–6.68), p < 0.0001. Consequently, while LVO ischemic events accounted for 38.7% (CI: 21.8–55.7%) of all acutely presenting ischemic strokes, they accounted for 61.6% (CI: 41.8–81.3%) of poststroke dependence or death and 95.6% (CI: 89.0–98.8%) of poststroke mortality. Using literature-based projections of LVO cerebral ischemia patients treatable within 8 h of onset, ET can be used in 21.4% of acutely presenting patients with ischemic stroke, and these events account for 34% of poststroke dependence and death and 52.8% of poststroke mortality.

Conclusion

LVOs cause a little more than one-third of acutely presenting AIS, but are responsible for three-fifths of dependency and more than nine-tenths of mortality after AIS. At the population level, ET has a disproportionate benefit in reducing severe stroke outcomes.

Specific Factors to Predict Large-Vessel Occlusion in Acute Stroke Patients

BACKGROUND

The effectiveness of thrombectomy for acute ischemic stroke has been established, and earlier treatment produces better outcomes. If possible to identify large-vessel occlusion (LVO) at the prehospital phase, eligible patients can be shipped directly to a hospital that can perform thrombectomy. The purpose of this study was to determine factors that are specific to LVO and can be known before hospital arrival.

METHODS

The subjects were stroke patients during the period between July 2014 and June 2016, who had a National Institutes of Health Stroke Scale (NIHSS) score of 8 or higher and came to our hospital within 6 hours of onset. These patients were divided into an LVO group and a non-LVO group, and background factors, mode of onset, individual NIHSS item scores, and blood pressure at the time of the visit were retrospectively investigated. The selected factors were compared with LVO prediction scales reported in the past.

RESULTS

There were 196 stroke patients who had NIHSS scores of 8 or higher and arrived at the hospital within 6 hours. Of these 196 patients, 56 had LVO. This LVO group included a significantly higher number of patients with the 2 items of atrial fibrillation (odds ratio [OR], 11.5: 95% confidence interval [CI], 4.04-32.9; P < .0001) and systolic blood pressure of 170 mm Hg or lower (OR, 2.99: 95% CI, 1.33-6.71, P = .008). These 2 items predicted LVO equally to existing LVO prediction scales.

CONCLUSIONS

The 2 items of atrial fibrillation and systolic blood pressure of 170 mm Hg or lower were significantly correlated with LVO.

Derivation and Validation of the Emergency Medical Stroke Assessment and Comparison of Large Vessel Occlusion Scales

BACKGROUND

This study aims to develop a simple scale to identify patients with prehospital stroke with large vessel occlusion (LVO), without losing sensitivity for other stroke types.

METHODS

The Emergency Medical Stroke Assessment (EMSA) was derived from the National Institutes of Health Stroke Scale (NIHSS) items and validated for prediction of LVO in a separate cohort. We compared the EMSA with the 3-item stroke scale (3I-SS), Cincinnati Prehospital Stroke Severity Scale (C-STAT), Rapid Arterial oCclusion Evaluation (RACE) scale, and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) for prediction of LVO and stroke. We surveyed paramedics to assess ease of use and interpretation of scales.

RESULTS

The combination of gaze preference, facial asymmetry, asymmetrical arm and leg drift, and abnormal speech or language yielded the EMSA. An EMSA less than 3, 75% sensitivity, and 50% specificity significantly reduced the likelihood of LVO (LR- = .489, 95% confidence interval .366-0.637) versus 3I-SS less than 4 (.866, .798-0.926). A normal EMSA, 93% sensitivity, and 47% specificity significantly reduced the likelihood of stroke (LR- = .142, .068-0.299) versus 3I-SS (.476, .330-0.688) and C-STAT (.858, .717-1.028). EMSA was rated easy to perform by 72% (13 of 18) of paramedics versus 67% (12 of 18) for FAST-ED and 6% (1 of 18) for RACE (χ² = 27.25, P < .0001), and easy to interpret by 94% (17 of 18) versus 56% (10 of 18) for FAST-ED and 11% (2 of 18) for RACE (χ² = 21.13, P < .0001).

CONCLUSIONS

The EMSA has superior abilities to identify LVO versus 3I-SS and stroke versus 3I-SS and C-STAT. The EMSA has similar ability to triage patients with stroke compared with the FAST-ED and RACE, but is simpler to perform and interpret.