Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

Abstract

ObjectiveTo summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke.MethodsUsing guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy.ResultsThis review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion–perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions.ConclusionsPatients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.

Prehospital care delivery and triage of stroke with emergent large vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery

“…Stroke networks should integrate primary and associated comprehensive center notification to maximize transfer efficiency when transfer protocols dictate initial transport of patients with suspected ELVO to centers without endovascular services. This PSC/CSC pair integration8 would allow the comprehensive center to prepare for patient arrival and facilitate early communication between primary and comprehensive centers. The effect of prehospital notification may be magnified for ELVO stroke given the non-linear decay in treatment effect.…”

“…Rapid access to endovascular services depends upon optimization of prehospital stroke care and transport within stroke systems of care, focusing on the unique needs of patients with ELVO through their diagnostic investigation and treatment pathway. The Society of NeuroInterventional Surgery (SNIS) proposed process time metrics for ELVO stroke treatment, including door to IV tissue plasminogen activator (t-PA) of <30 min, comprehensive stroke center (CSC) door to puncture of <60 min, CSC door to recanalization of <90 min and primary stroke certification (PSC) picture to CSC puncture of <90 min 8. Early team awareness of the patient with potential ELVO, coupled with efficient interdisciplinary communication, triage and transport assist in meeting these ideal time metrics, and also contribute to improved clinical outcomes through efficiency gains and maximization of endovascular care delivery.…”

Endovascular treatment of ischaemic stroke patients - new evidence and old challenges

“…A door to puncture time of 60 min is still more ambitious than the target times in the ESCAPE trial which required 60 min or less from study non-contrast CT to groin puncture [6]. In addition to this infrastructural metric, there is the important physiological time to reperfusion, which is targeted at 90 min after arrival at the hospital door [49].…”

“…To achieve this, a consideration could be to bypass smaller hospitals to reduce picture to puncture and ultimately onset to reperfusion times [19,48]. Recommendations for the in-house procedure times in ischaemic stroke treatment have recently been updated [49]. For example, the time from arriving at the hospital (door time) to groin puncture in the angiography suite should be less than 60 minutes (door to puncture time).…”

Prediction of Large Vessel Occlusions in Acute Stroke: National Institute of Health Stroke Scale Is Hard to Beat*

“…These emergent LVOs are well-known predictors of poor outcome (4)(5)(6)(7), and rapid revascularization remains a primordial factor to improve clinical outcome (8,9). In the continuum of prehospital triage, choice of treatment center and revascularization method, and early intensive stroke unit care, the appropriate decisions should be based on rational choices (10). These will be best realized by a multidisciplinary stroke team composed of an well-organized emergency medical system and physicians, diagnostic and interventional neuroradiologic expertise, and neurovascular intensive care teams (11).…”