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Abstract
Purpose of the Review Endovascular thrombectomy (EVT) for large vessel occlusion strokes (LVOS) presents several treatment challenges. We provide a summary of existing tools for patient selection (pre-EVT tools) and for prognostication of long-term outcomes following reperfusion therapy (post-EVT tools).
Recent Findings Recently published randomized trials demonstrated superiority of EVT over medical therapy alone for LVOS. Uniform patient selection paradigms based on demographic, clinical, and radiographic variables are not completely standardized, leading to variability in patient selection for EVT for LVOS. Post-EVT, an accurate assessment of long-term prognosis is critical in the decision-making process.
Summary Prognostic scores can serve as useful adjuncts to facilitate clinical decision-making during early management of patients with ischemic stroke, particularly those with LVOS. The acute management of LVOS comprises rapid clinical assessment, triage, and cerebrovascular imaging, followed by evaluation for candidacy for thrombolysis and EVT. Pre-EVT prognostic tools that accurately predict the likelihood of benefit from EVT may guide reliable, efficient, and cost-effective patient selection. Following EVT, severe stroke deficits and subacute poststroke complications that portend a poor prognosis may warrant invasive therapies. Clinical decisions regarding these treatment options involve careful discussions between providers and patient families, and are also based on prognosis provided by the treating clinician. Reliable post-EVT prognostic tools can facilitate this by providing accurate and objective prognostic information. Several prognostic tools have been developed and validated in the literature, some of which may be applicable in the pre-EVT and post-EVT settings, although clinical utility and application varies. Validation in contemporary datasets as well as implementation and impact studies are needed before these scales can be used to guide clinical decisions for individual patients.
Glossary
- ASPECTS=
- Alberta Stroke Program Early CT Score;
- AUC=
- area under the curve;
- BAO=
- basilar artery occlusion;
- CSC=
- comprehensive stroke center;
- EVT=
- endovascular thrombectomy;
- FIV=
- final infarct volume;
- HERMES=
- Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials;
- HIAT=
- Houston Intra-Arterial Therapy;
- IMS-III=
- Interventional Management of Stroke III;
- IScore=
- Ischemic Stroke Predictive Risk Score;
- LSW=
- last seen well;
- LVOS=
- large vessel occlusion stroke;
- mRS=
- modified Rankin Scale;
- mTICI=
- modified Thrombolysis in Cerebral Infarction;
- NIHSS=
- National Institutes of Health Stroke Scale;
- NNR=
- number needed to reperfuse;
- NPV=
- negative predictive value;
- PH=
- parenchymal hemorrhage;
- POST=
- Pittsburgh Outcomes After Stroke Thrombectomy;
- POST-VB=
- Pittsburgh Outcomes After Stroke Thrombectomy Vertebrobasilar;
- PPV=
- positive predictive value;
- PRE=
- Pittsburgh Response to Endovascular Therapy;
- RCT=
- randomized controlled trial;
- ROC=
- receiver operator characteristic;
- SPAN=
- Stroke Prognostication Using Age and NIHSS;
- THRIVE=
- Totaled Health Risks in Vascular Events;
- tPA=
- tissue plasminogen activator;
- UW-mRS=
- utility-weighted modified Rankin Scale
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received June 28, 2020.
- Accepted in final form October 23, 2020.
- © 2021 American Academy of Neurology
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