Monthly Archives: November 2018

Victor J. Del Brutto, MD

Nagel S, Bouslama M, Krause LU, Küpper C, Messer M, Petersen M, et al. Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions: A Multicenter Matched Analysis. Stroke. 2018

Over half of acute ischemic strokes in the U.S. present with mild deficits as defined by an initial NIHSS score of 5 or less. Despite having deficits perceived as “minor”, around 30% of these patients will not achieve a good functional outcome at follow-up. Large vessel occlusion (LVO) is found in 10 to 20% of patients with minor strokes. Presence of LVO has been associated with early neurological deterioration, as well as decreased likelihood of good recovery. Minor symptoms in the setting of a major occluded vessel pictures good collateral flow maintaining tissue perfusion. On the other hand, frequent early clinical deterioration and worse functional outcomes expose the potential failure of aforementioned collaterals and infarct expansion.

Mechanical thrombectomy  (MT) is the current standard of care for selected patients with LVO and initial NIHSS score ≥6; however, the benefit of MT in patients with milder symptoms remains uncertain. Recanalization is an appealing solution to prevent clinical deterioration and improve long-term functional outcome in these patients. Nonetheless, the treatment effect might not provide a significant benefit and could add potential risk for complications related to the procedure, such as hemorrhagic conversion, emboli to new vascular territories, failure of collaterals due to transient hypotension related to anesthesia, etc.

Aristeidis H. Katsanos, MD, PhD

Nagel S, Bouslama M, Krause LU, Küpper C, Messer M, Petersen M, et al. Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions: A Multicenter Matched Analysis. Stroke. 2018

Sarraj A, Hassan A, Savitz SI, Grotta JC, Cai C, Parsha KN, et al. Endovascular Thrombectomy for Mild Strokes: How Low Should We Go? A Multicenter Cohort Study. Stroke. 2018

According to the current guidelines from the American Heart Association/American Stroke Association, endovascular thrombectomy (EVT) should be implemented in the treatment of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) who have a measurable neurological deficit of at least 6 points in the National Institutes of Health Stroke Scale (NIHSS) on admission, providing however weak support for the use of EVT in AIS patients with internal carotid artery (ICA) or proximal middle cerebral artery (MCA-M1) occlusion and a baseline NIHSS score less than 6. In the October issue of Stroke, two independent multicenter study groups aimed to answer the question on the utility of EVT in patients with LVO and mild AIS severity (NIHSS <6).

Lina Palaiodimou, MD

Kim J-T, Liebeskind D, Jahan R, Menon B, Goyal M, Nogueira R, et al. Impact of Hyperglycemia According to the Collateral Status on Outcomes in Mechanical Thrombectomy. Stroke. 2018

Hyperglycemia upon admission is a common phenomenon in acute ischemic stroke and is an independent predictor of poor outcome in both diabetic and non-diabetic stroke patients. More specifically, previous studies have shown that hyperglycemia is independently associated with infarct expansion, early hemorrhagic transformation, impaired recanalization and increased rates of symptomatic intracranial hemorrhage after intravenous thrombolysis. Increased admission and fasting glucose are associated with unfavorable short-term outcome in patients with large vessel occlusion treated with endovascular reperfusion therapies, especially in the subgroup of patients not achieving complete reperfusion following mechanical thrombectomy. However, aggressive serum glucose lowering in clinical studies failed to translate into improvements in functional outcomes, indicating heterogeneity of the biological effects of glucose and the different ways that can modify prognosis in different clinical settings. Accordingly, case-specific glucose management appears to be important.

Κim et al. conducted a post-hoc analysis using data from the Triple-S database, in order to explore the potential association between poor collaterals at presentation and hyperglycemia and the interaction between pretreatment collaterals and glucose upon admission on outcomes. They obtained data from 3 prospective clinical trials (SWIFT, SWIFT PRIME and STAR) and included 309 patients who had acute ischemic stroke with moderate to severe neurological deficit and angiographically confirmed large vessel occlusion and were treated with mechanical thrombectomy within 8 hours of onset. Pretreatment collaterals grades were scored according to the American Society of Interventional and Therapeutic Neuroradiology collateral grading (AGC) system, and reperfusion was evaluated using modified TICI score.

Richard Jackson, MD

Suzuki K, Nakajima N, Kunimoto K, Hatake S, Sakamoto Y, Hokama H, et al. Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke. Stroke. 2018

Kentaro Suzuki et al. developed a new prehospital stroke scale called the Emergent Large Vessel Occlusion (ELVO) screen for use by paramedics to identify large vessel occlusions (LVO) for diversion of transport to the nearest thrombectomy-capable location.

In the introduction, they comment that transport of patients without LVO is “unwise, time consuming, and expensive” and, therefore, the need has arisen for better emergent stroke transportation systems.  They base this on data that showed, in their words, unacceptable negative predictive values (NPV) and a possible 20% of missed LVO eligibility.

They comprised their scale based on cortical symptoms with simplicity in mind. The scale consists of paramedic observation of eye deviation, a question regarding naming of eye glasses or a watch, and a question about neglect regarding naming of the number of fingers being held up for visual confrontation. A positive result was an abnormality on any of the three items.