Predictors for large vessel recanalization before stroke thrombectomy: the HALT score

Abstract

BackgroundLarge vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis.MethodsIn this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed.Results640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0–2) HALT scores.ConclusionsIVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.

DIMR Score: A Tool for Determining the Destination of LVO Patients After Thrombolysis

“…The DTA approach was higher in M1 MCA occlusions (43.2% vs. 27.4%, p=0.038) and basilar occlusions (7.6% vs. 0, p=0.026). DTA patients had a higher NIHSS at the spoke (median NIHSS 15 [9][10][11][12][13][14][15][16][17][18][19][20][21] vs. 9 [4.75-14], p<0.001) and the hub (14 [7][8][9][10][11][12][13][14][15][16][17][18][19][20] vs. 7 [3-15.75], p<0.001). There was no significant difference between the DTA and CTP groups in regards to mRS at 90 days (39% vs. 48.4%, p=0.101).…”

“…Gao et al suggested that the clinical and economic benefits of pre-MT may be increased in the drip-and-ship model 20 . Recently, Colasurdo et al suggested the HALT score as a predictor for LVO recanalization prior to thrombectomy; with one of the predictors being early thrombolysis 21 . By identifying some of these factors before arrival to the hub, we may be able to avoid unnecessary angiography activation in certain situations and transferring first to advanced imaging may be reasonable.…”

“…. Baseline characteristics between those who present to CT perfusion (CTP) vs. directly to angiography (DTA) DTA was associated with higher NIHSS both at the spoke (median NIHSS 15[9][10][11][12][13][14][15][16][17][18][19][20][21] vs. 9 [4.75-14], p<0.001) and the hub (14[7][8][9][10][11][12][13][14][15][16][17][18][19][20] vs. 7[3-15.75], p<0.001). Of those receiving thrombectomy, there was a significant difference in median door to groin time between the DTA vs. CTP group (median in minutes [IQR] 47.25 [18.75-42.5] vs. 59.5 [37-78.75], p<0.001) which was our primary time metric.…”