Take Home Points

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).

Important as front line providers to know research and data behind stroke care

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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

NNT 5 for benefit 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:

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