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Brief History of Stroke Care

• 2015 – Suspected stroke: NCHCT, if onset of symptoms < 3-4.5 hours consider thrombolytics
• 2015 – IMS 3, Mr Rescue and Synthesis did not show any benefit to interventional care. Showed potential worse outcomes
• 2015 – MR CLEAN study – showed benefit in large vessel obstruction specifically anterior circulation strokes MCA, ACA and distal intracranial carotid AA.  NNT 5 for benefit
• There are 8 subsequent studies looking at the same question, all looking at patients with large vessel occlusions and 7 out of 8 found benefit to interventional therapy.

How did they identify large vessel occlusions

• MR CLEAN used NIHSS scale
• In some of the later studies they switched to perfusion imaging
• The window of time got larger and larger in the studies

Shortcomings of the studies

• All studies stopped early except for MR CLEAN
• The problem with stopping early is that it probably overestimates the benefit of the therapy
• None of the studies were blinded and all industry sponsored

All these studies have been expanding the time window for the intervention. DAWN and DEFUSE 3 trial pushing it back all the way to 24 hours.

2018 AHA/ACC Stroke Guidelines

• NCHCT within 20 minutes of arrival
• If suspicious for large vessel occlusion – order CTA
• If positive finding on CTA – get CT perfusion study or MRI perfusion study

How to identify large vessel occlusion

• NIHSS stroke scale greater than or equal to 6
• VAN score
  • Not yet externally validated but good sensitivity and specificity

Take Home Points

• Important as front line providers to know research and data behind stroke care
• Patients eligible for endovascular care are those with large vessel occlusion in the anterior circulation – anterior cerebral artery, middle cerebral artery, distal intracranial carotid artery and they have to have perfusion mismatch (small infarcted core with a large penumbra).

For More on This Topic Checkout:

• REBEL EM:  Does it Take a VAN to Identify Emergent Large Vessel Occlusion (ELVO) in Ischemic Stroke?
• REBEL EM : 2018 Stroke Workflow
• REBEL EM : Endovascular Therapy for Acute Ischemic Stroke: The New Shiny Toy in Stroke Care?
• REBEL EM : Endovascular Therapy for Acute Ischemic Stroke

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)