BACKGROUND AND PURPOSE:NGAVFs are rare vascular malformations usually presenting in infancy or childhood. We sought to identify clinical and angiographic predictors of clinical outcome for these lesions.

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Objectives: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations.Methods: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval).Results: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to 20.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites.Conclusions: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms. Neurology ® 2016;87:19-26 GLOSSARY AHA 5 American Heart Association; ASA 5 American Stroke Association; AV 5 audiovisual; BA 5 Bland-Altman; CI 5 confidence interval; EMS 5 emergency medical services; 4G 5 fourth generation; HRSA 5 Health Resources and Services Administration; iTREAT 5 Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine; LTE 5 longterm evolution; NIHSS 5 NIH Stroke Scale; TJEMS 5 Thomas

A meta-analysis of the available data concluded that none of the currently published scales are more accurate than the others. However, other studies provide insight into important qualitative features beyond accuracy. At present, only a few large vessel occlusion prediction scales have been studied in the necessary prehospital suspected stroke patient population. Among these small studies, 26-51% of patients identified by scales had large vessel occlusions and 63-84% qualified for triage to a Comprehensive Stroke Center. Valuable scale features include binary scoring, inclusion of gaze deviation and arm weakness, exclusion of neglect, and prehospital validation in a suspected stroke cohort. Patients with neurological emergencies that mimic large vessel occlusion, such as intracranial hemorrhage, may also benefit from triage to Comprehensive Stroke Centers. Prehospital triage is more complex than ever and guidelines, tools, and systems continue to evolve.

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BACKGROUND AND PURPOSE: Automated CTP software is increasingly used for extended window emergent large-vessel occlusion to quantify core infarct. We aimed to assess whether RAPID software underestimates core infarct in patients with an extended window recently receiving IV iodinated contrast. MATERIALS AND METHODS: We reviewed a prospective, single-center data base of 271 consecutive patients who underwent CTA 6 CTP for acute ischemic stroke from May 2018 through January 2019. Patients with emergent large-vessel occlusion confirmed by CTA in the extended window (.6 hours since last known well) and CTP with RAPID postprocessing were included. Two blinded raters independently assessed CT ASPECTS on NCCT performed at the time of CTP. RAPID software used relative cerebral blood flow of ,30% as a surrogate for irreversible core infarct. Patients were dichotomized on the basis of receiving recent IV iodinated contrast (,8 hours before CTP) for a separate imaging study. RESULTS: The recent IV contrast and contrast-naïve cohorts comprised 23 and 15 patients, respectively. Multivariate linear regression analysis demonstrated that recent IV contrast administration was independently associated with a decrease in the RAPID core infarct estimate (proportional increase ¼ 0.34; 95% CI, 0.12-0.96; P ¼ .04). CONCLUSIONS: Patients who received IV iodinated contrast in proximity (,8 hours) to CTA/CTP as part of a separate imaging study had a much higher likelihood of core infarct underestimation with RAPID compared with contrast-naïve patients. Over-reliance on RAPID postprocessing for treatment disposition of patients with extended window emergent large-vessel occlusion should be avoided, particularly with recent IV contrast administration. ABBREVIATIONS: ELVO ¼ emergent large-vessel occlusion; LKW ¼ last known well; MT ¼ mechanical thrombectomy; PI ¼ proportional increases; rCBF ¼ relative cerebral blood flow Q uantifying core infarction versus viable ischemic penumbra is at the crux of patient selection for mechanical thrombectomy (MT) in the setting of anterior circulation emergent largevessel occlusion (ELVO). While patients with large infarcts tend to demonstrate worse clinical outcomes following reperfusion, successful recanalization of sizable ischemic penumbra, indicative of salvageable tissue, may result in drastic clinical improvement. 1

Purpose of Review Endovascular therapy for acute ischemic stroke secondary to large vessel occlusion (LVO) is time-dependent. Prehospital patients with suspected LVO stroke should be triaged directly to specialized stroke centers for endovascular therapy. This review describes advances in LVO detection among prehospital suspected stroke patients. Recent Findings Clinical prehospital stroke severity tools have been validated in the prehospital setting. Devices including EEG, SSEPs, TCD, cranial accelerometry, and volumetric impedance phase-shift-spectroscopy have recently published data regarding LVO detection in hospital settings. Mobile stroke units bring thrombolysis and vessel imaging to patients. Summary The use of a prehospital stroke severity tool for LVO triage is now widely supported. Ease of use should be prioritized as there are no meaningful differences in diagnostic performance amongst tools. LVO diagnostic devices are promising, but none have been validated in the prehospital setting. Mobile stroke units improve patient outcomes and cost-effectiveness analyses are underway.