Treating late-presenting strokes from large vessel occlusion

Only a small minority of large vessel strokes which might be eligible for TPA thrombolysis of clot extraction removal of blockage are so treated. WOne reason is that such strokes often have a stuttering course which causes them to present to the ER only well after they have begun, or to present with changes on CT from previously begun tissue infaction even when deficits are small.

Unfortunately, many such persons with stroke worsen in the hospital. The study below offers hope for late treatment of at least some of these patients to reduce their stroke burden.

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ABSTRACT

Identifying Severe Stroke Patients Likely to Benefit From Thrombectomy Despite Delays of up to a Day

R. Gilberto González, Gisele Sampaio Silva, Julian He, Saloomeh Sadaghiani, Ona Wu, Aneesh B. Singhal

Scientific Reports, August 2022

doi: 10.1038/s41598-020-60933-3 0000005

Abstract

Selected patients with large vessel occlusions (LVO) can benefit from thrombectomy up to 24 hours after onset. Identifying patients who might benefit from late intervention after transfer from community hospitals to thrombectomy-capable centers would be valuable. We searched for presentation biomarkers to identify such patients. Frequent MR imaging over 2 days of 38 untreated LVO patients revealed logarithmic growth of the ischemic infarct core. In 24 patients with terminal internal carotid artery or the proximal middle cerebral artery occlusions we found that an infarct core growth rate (IGR) <4.1 ml/hr and initial infarct core volumes (ICV) <19.9 ml had accuracies >89% for identifying patients who would still have a core of <50ml 24 hours after stroke onset, a core size that should predict favorable outcomes with thrombectomy. Published reports indicate that up to half of all LVO stroke patients have an IGR<4.1 ml/hr. Other potentially useful biomarkers include the NIHSS and the perfusion measurements MTT and Tmax. We conclude that many LVO patients have a stroke physiology that is favorable for late intervention, and that there are biomarkers that can accurately identify them at early time points as suitable for transfer for intervention.