Eligibility and Predictors for Acute Revascularization Procedures in a Stroke Center

Abstract

Background and Purpose-Endovascular treatment (EVT) is a new standard of care for selected, large vessel occlusive strokes. We aimed to determine frequency of potentially eligible patients for intravenous thrombolysis (IVT) and EVT in comprehensive stroke centers. In addition, predictors of EVT eligibility were derived. Methods-Patients from a stroke center-based registry (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014), admitted within 24 hours of last proof of usual health, were selected if they had all data to determine IVT and EVT eligibility according to American Heart Association/American Stroke Association (AHA/ASA) guidelines (class I-IIa recommendations). Moreover, less restrictive criteria adapted from randomized controlled trials and clinical practice were tested. Maximum onset-to-door time windows for IVT eligibility were 3.5 hours (allowing door-to-needle delay of ≤60 minutes) and 4.5 hours for EVT eligibility (door-to-groin delay ≤90 minutes). Demographic and clinical information were used in logistic regression analysis to derive variables associated with EVT eligibility. Results-A total of 2704 patients with acute ischemic stroke were included, of which 26.8% were transfers. Of all patients with stroke arriving at our comprehensive stroke center, a total proportion of 12.4% patients was eligible for IVT. Frequency of EVT eligibility differed between AHA/ASA guidelines and less restrictive approach: 2.9% versus 4.9%, respectively, of all patients with acute ischemic stroke and 10.5% versus 17.7%, respectively, of all patients arriving within <6 hours. Predictors for AHA-EVT eligibility were younger, shorter onset-to-admission delays, higher National Institutes of Health Stroke Scale (NIHSS), decreased vigilance, hemineglect, absent cerebellar signs, atrial fibrillation, smoking, and decreasing glucose levels (area under the curve=0.86). Conclusions-Of patients arriving within 6 hours at a comprehensive stroke center, 10.5% are EVT eligible according to AHA/ASA criteria, 17.7% according to criteria resembling randomized controlled trials, and twice as many patients are IVT eligible (36.2% Patient SelectionEligibility for acute revascularization therapy was first determined by applying the class I and IIa recommendations stated in the latest AHA/ASA guidelines about IVT and EVT. 4,17 Following the guidelines accepted hospital arrival delays for IVT and EVT were 3.5 and 4.5 hours, respectively, allowing for door-to-needle times of ≤60 minutes for IVT and for door-to-groin times of ≤90 minutes for EVT. Additional inclusion criteria for IVT beyond 3 hours were used: age ≤80 years, NIHSS ≤25, no history of stroke and diabetes mellitus, no treatment with oral anticoagulants, and no ischemic injury involving more than one third of the middle cerebral artery territory on CT.17 Other AHA/ ASA criteria used for EVT eligibility were an admission NIHSS >6, prestroke mRS score of 0 to 1, ASPECTS of 6 to 10, and presence of an occlusion in the M1 segment of the middle cerebral artery or...

Site and Rate of Occlusive Disease in Cervicocerebral Arteries: A CT Angiography Study of 2209 Patients with Acute Ischemic Stroke

“…When adding clinical and other radiologic criteria as well as contraindications, this number may be reduced by half in the real world, however. 25 Still, improved prehospital identification and transport of patients with probable proximal intracranial occlusions 26 are likely to increase the number of endovascularly treatable patients in comprehensive stroke centers. 27 The spontaneous recanalization rate of proximal occlusions between 4.5 and 24 hours from symptom onset is approximately 9% based on the aforementioned proportions of patients with such occlusions.…”

Prehospital Scales for Large Vessel Occlusion

“…Recent figures show eligibility of ≈25% for thrombolysis and ≈10% for EVT in all AIS arriving at the hospital within 24 hours. 1 Still, paramedics, local hospitals, and primary stroke centers are struggling to clinically identify the AIS patients who are likely to have intracranial large vessel occlusions (LVO) in the anterior and posterior circulation.…”

An Appraisal of the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke

“…Real-world evidence indicates that patients who do not meet top tier evidence criteria (including tandem lesions) for EVT still demonstrate high rates of good clinical outcome and low complication rates with thrombectomy [12, 16, 17]. Depending on the sets of selection criteria, between 3% (the most restrictive criteria) and 20% (the least restrictive criteria) of patients with LVO may be potentially eligible for EVT [18, 19]. Withholding EVT from patients who do not meet all selection criteria from the recent randomized trials will negatively affect outcomes of thousands of patients with acute ischemic stroke.…”