Usefulness of a single-parameter tool for the prediction of large vessel occlusion in acute stroke.

BACKGROUND: In acute stroke, large vessel occlusion (LVO) should be promptly identified to guide patient's transportation directly to comprehensive stroke centers (CSC) for mechanical thrombectomy (MT). In many cases, prehospital multi-parameter scores are used by trained emergency teams to identify patients with high probability of LVO. However, in several countries, the first aid organization without intervention of skilled staff precludes the on-site use of such scores. Here, we assessed the accuracy of LVO prediction using a single parameter (i.e. complete hemiplegia) obtained by bystander's telephone-based witnessing. PATIENTS AND METHODS: This observational, single-center study included consecutive patients who underwent intravenous thrombolysis at the primary stroke center and/or were directly transferred to a CSC for MT, from January 1, 2015 to March 1, 2020. We defined two groups: patients with initial hemiplegia (no movement in one arm and leg and facial palsy) and patients without initial hemiplegia, on the basis of a bystander's witnessing. RESULTS: During the study time, 874 patients were included [mean age 73 years (SD 13.8), 56.7% men], 320 with initial hemiplegia and 554 without. The specificity of the hemiplegia criterion to predict LVO was 0.88, but its sensitivity was only 0.53. CONCLUSION: Our results suggest that the presence of hemiplegia as witnessed by a bystander can predict LVO with high specificity. This single criterion could be used for decision-making about direct transfer to CSC for MT when the absence of emergency skilled staff precludes the patient's on-site assessment, especially in regions distant from a CSC.

Which Patients Require Physician-Led Inter-Hospital Transport in View of Endovascular Therapy?

INTRODUCTION: The current guidelines advocate the implementation of stroke networks to organize endovascular treatment (ET) for patients with acute ischemic stroke due to large vessel occlusion (LVO) after transfer from a Primary Stroke Centre (PSC) to a Comprehensive Stroke Centre (CSC). In France and in many other countries around the world, these transfers are carried out by a physician-led mobile medical team. However, with the recent broadening of ET indications, their availability is becoming more and more critical. Here, we retrospectively analysed data of patients transferred from a PSC to a CSC for potential ET to identify predictive factors of major complications (MC) at departure and during transport that absolutely require the presence of a physician during interhospital transfer. METHODS: This observational, single-centre study included patients with evidence of intracranial LVO transferred for ET from Perpignan to a 156 km-distant CSC between January 1, 2015 and -December 31, 2018. We compared 2 groups: MC group (patients who required emergency intervention by the medical team due to life-threatening complications, including need of mechanical ventilation at departure) and non-MC group (all other patients who experienced no or only minor complications that could be managed by the emergency paramedics alone). RESULTS: Among the 253 patients who were transferred to the CSC, 185 (73.1%) had no complication, 57 (22.6%) minor complications, and 11 (4.3%) had MC. In multivariate analysis, MC was associated with basilar artery (BA) occlusion (p < 0.0001), initial National Institute of Health Stroke Scale (NIHSS) score >22 (p < 0.005), and history of atrial fibrillation (p < 0.04). Among the 168 patients treated with intravenous thrombolysis (IVT), only 1 patient (0.6%) had MC due to an IVT-related adverse event during transfer. CONCLUSIONS: Physician-led inter-hospital transports are warranted for patients with BA occlusion, initial NIHSS score >22, or history of atrial fibrillation. For the other patients, transfer without a physician may be considered, even if treated with IVT.

Mechanical Recanalization after Transfer from a Distant Primary Stroke Center: Effectiveness and Future Directions.

INTRODUCTION: Little is known about the effectiveness of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) admitted to a primary stroke center (PSC). The aim of this study was to assess EVT effectiveness after transfer from a PSC to a distant (156 km apart; 1.5 hour by car) comprehensive stroke center (CSC), and to discuss perspectives to improve access to EVT, if indicated. PATIENTS AND METHOD: Analysis of the data collected in a 6-year prospective registry of patients admitted to a PSC for AIS due to LVO and selected for transfer to a distant CSC for EVT. The rate of transfer, futile transfer, EVT, reperfusion (thrombolysis in cerebral infarction score ≥2b-3), and relevant time measures were determined. RESULTS: Among the 529 patients eligible, 278 (52.6%) were transferred and 153 received EVT (55% of transferred patients) followed by reperfusion in 115 (overall reperfusion rate: 21.7%). Median times (interquartile range) were: 90 minutes (76-110) for PSC-door-in to PSC-door-out, 88 minutes (65-104) for PSC-door-out to CSC-door-in, 262 minutes (239-316) for PSC-imaging to reperfusion, and 393 minutes (332-454) for symptom onset to reperfusion. At 3 months, rates of favorable outcome (modified Rankin Scale 0-2) were not significantly different between patients eligible for EVT (42.4%), transferred patients (49.1%) and patients who underwent EVT (34.1%). DISCUSSION AND CONCLUSIONS: Our study suggests that transfer to a distant CSC is associated with reduced access to early EVT. These results argue in favor of on-site EVT at high volume PSCs that are distant from the CSC.

Futile inter-hospital transfer for mechanical thrombectomy in a semi-rural context: analysis of a 6-year prospective registry.

BACKGROUND AND PURPOSE: Inter-hospital transfer for mechanical thrombectomy (MT) might result in the transfer of patients who finally will not undergo MT (ie, futile transfers [FT]). This study evaluated FT frequency in a primary stroke center (PSC) in a semi-rural area and at 156 km from the comprehensive stroke center (CSC). METHODOLOGY: Retrospective analysis of data collected in a 6-year prospective registry concerning patients admitted to our PSC within 4.5 hours of acute ischemic stroke (AIS) symptom onset, with MR angiography indicating the presence of large vessel occlusion (LVO) without large cerebral infarction (DWI-ASPECT ≥5), and selected for transfer to the CSC to undergo MT. Futile transfer rate and reasons were determined, and the relevant time measures recorded. RESULTS: Among the 529 patients screened for MT, 278 (52.6%) were transferred to the CSC. Futile transfer rate was 45% (n=125/278) and the three main reasons for FT were: clinical improvement and reperfusion on MRI on arrival at the CSC (58.4% of FT); clinical worsening and/or infarct growth (16.8%); and longer than expected inter-hospital transfer time (11.2%). Predictive factors of FT due to clinical improvement/reperfusion on MRI could not be identified. Baseline higher NIHSS (21 vs 17; P=0.01) and lower DWI-ASPECT score (5 vs 7; P=0.001) were associated with FT due to clinical worsening/infarct growth on MRI. CONCLUSIONS: In our setting, 45% of transfers for MT were futile. None of the baseline factors could predict FT, but the initial symptom severity was associated with FT caused byclinical worsening/infarct growth.

Posterior Radioscaphoid Angle as a Predictor of Wrist Degenerative Joint Disease in Patients With Scapholunate Ligament Tears.

OBJECTIVE: The purpose of this study is to determine whether the posterior radioscaphoid angle, a marker of posterior displacement of the scaphoid, is associated with degenerative joint disease in patients with scapholunate ligament tears. MATERIALS AND METHODS: Images from 150 patients with wrist pain who underwent CT arthrography and radiography were retrospectively evaluated. Patients with and without scapholunate ligament ruptures were divided into two groups according to CT arthrography findings. The presence of degenerative changes (scapholunate advanced collapse [SLAC] wrist) was evaluated and graded on conventional radiographs. Images were evaluated by two readers independently, and an adjudicator analyzed the discordant cases. Posterior radioscaphoid angle values were correlated with CT arthrography and radiographic findings. The association between posterior radioscaphoid angle and degenerative joint disease was evaluated. Scapholunate and radiolunate angles were considered in the analysis. RESULTS: The posterior radioscaphoid angle was measurable in all patients, with substantial interobserver agreement (intraclass correlation coefficient, 0.75). The posterior radioscaphoid angle performed better than did the scapholunate and radiolunate angles in the differentiation of patients with and without SLAC wrist (p < 0.02). Posterior radioscaphoid angles greater than 114° presented an 80.0% sensitivity and 89.7% specificity for the detection of SLAC wrist. CONCLUSION: Posterior radioscaphoid angles were strongly associated with degenerative wrist disease, with potential prognostic implications in patients with wrist trauma and scapholunate ligament ruptures.

Musculoskeletal wide detector CT: principles, techniques and applications in clinical practice and research.

A progressive increase in the detector width in CT scanners has meant that advanced techniques such as dynamic, perfusion and dual-energy CT are now at the radiologist's disposal. Although these techniques may be important for the diagnosis of various musculoskeletal diseases, data acquisition and interpretation can be challenging. This article offers a practical guide for the use of these tools including acquisition protocol, post-processing options and data interpretation based on 7 years of clinical experience in a tertiary university hospital.