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      The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department

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          A bstract

          Background

          Early identification of patients with an emergent large vessel occlusion (ELVO) ischemic stroke is crucial in the Emergency Department (ED), as they are the ideal candidates for endovascular therapy.

          With this study, we have attempted to use Vision, Aphasia, Neglect (VAN) screening tool in the ED for rapid identification of ELVO ischemic stroke and compared its performance with the National Institute of Health Stroke Severity (NIHSS) scale.

          Materials and methods

          A prospective observational study was conducted in the ED of a tertiary care hospital over 18 months among all suspected stroke patients. Vision, aphasia, neglect and NIHSS scores were calculated on arrival. Magnetic resonance imaging + magnetic resonance angiography (MRI + MRA) were taken as gold standard.

          Results

          This study found that VAN identified ELVO with 85.19% sensitivity ( p-value < 0.0001), 88.64% specificity ( p-value < 0.0001), and 87% diagnostic accuracy, with respect to the gold standard test. Vision, aphasia, neglect had a positive predictive value (PPV) and negative predictive value (NPV) of 82.14% and 90.7%, respectively. Time taken to perform VAN score in the ED was on average 2 minutes. National Institute of Health Stroke Severity detected ELVO with a sensitivity of 88%, specificity of 51.11%, a PPV of 53.33%, and a NPV of 88.4%. Diagnostic accuracy was 66%, and it took approximately 5 minutes to perform. When both scores were applied together for ELVO detection, NPV was 100%.

          Conclusion

          Vision, Aphasia, Neglect score as well as NIHSS scale are both tools for clinical prediction of ELVO with VAN having a better diagnostic accuracy and utility as a screening tool in the ED.

          How to cite this article

          Krishnan A, Srinivasarangan M, Jagadish S, Bheemanna AS, Sivasankar A. The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department. Indian J Crit Care Med 2023;27(7):475–481.

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          Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association

          Emelia Benjamin, Salim S. Virani, Clifton Callaway … (2018)
          Article 0 comments Cited 1492 times – based on 0 reviews     Review now
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            Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke

            Mayank Goyal, Andrew M Demchuk, Bijoy K. Menon … (2015)
            Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75). Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.).
            Article 0 comments Cited 913 times – based on 0 reviews     Review now
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              Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke

              Tudor G Jovin, Angel Chamorro, Erik Cobo … (2015)
              We aimed to assess the safety and efficacy of thrombectomy for the treatment of stroke in a trial embedded within a population-based stroke reperfusion registry. During a 2-year period at four centers in Catalonia, Spain, we randomly assigned 206 patients who could be treated within 8 hours after the onset of symptoms of acute ischemic stroke to receive either medical therapy (including intravenous alteplase when eligible) and endovascular therapy with the Solitaire stent retriever (thrombectomy group) or medical therapy alone (control group). All patients had confirmed proximal anterior circulation occlusion and the absence of a large infarct on neuroimaging. In all study patients, the use of alteplase either did not achieve revascularization or was contraindicated. The primary outcome was the severity of global disability at 90 days, as measured on the modified Rankin scale (ranging from 0 [no symptoms] to 6 [death]). Although the maximum planned sample size was 690, enrollment was halted early because of loss of equipoise after positive results for thrombectomy were reported from other similar trials. Thrombectomy reduced the severity of disability over the range of the modified Rankin scale (adjusted odds ratio for improvement of 1 point, 1.7; 95% confidence interval [CI], 1.05 to 2.8) and led to higher rates of functional independence (a score of 0 to 2) at 90 days (43.7% vs. 28.2%; adjusted odds ratio, 2.1; 95% CI, 1.1 to 4.0). At 90 days, the rates of symptomatic intracranial hemorrhage were 1.9% in both the thrombectomy group and the control group (P=1.00), and rates of death were 18.4% and 15.5%, respectively (P=0.60). Registry data indicated that only eight patients who met the eligibility criteria were treated outside the trial at participating hospitals. Among patients with anterior circulation stroke who could be treated within 8 hours after symptom onset, stent retriever thrombectomy reduced the severity of post-stroke disability and increased the rate of functional independence. (Funded by Fundació Ictus Malaltia Vascular through an unrestricted grant from Covidien and others; REVASCAT ClinicalTrials.gov number, NCT01692379.).
              Article 0 comments Cited 793 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Crit Care Med
                Journal ID (iso-abbrev): Indian J Crit Care Med
                Journal ID (publisher-id): IJCCM
                Title: Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Print): 0972-5229
                ISSN (Electronic): 1998-359X
                Publication date (Print): July 2023
                Volume: 27
                Issue: 7
                Pages: 475-481
                Affiliations
                [1–5 ]Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
                Author notes
                Aishwarya Krishnan, Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India, Phone: +91 8281418225, e-mail: aishwarya495@ 123456gmail.com
                Author information
                https://orcid.org/0000-0003-0558-4546
                https://orcid.org/0000-0003-3310-7018
                https://orcid.org/0000-0001-9901-4979
                https://orcid.org/0000-0002-9322-5393
                https://orcid.org/0000-0002-3010-4666
                Article
                DOI: 10.5005/jp-journals-10071-24485
                PMC ID: 10369322
                PubMed ID: 37502295
                SO-VID: 4900873b-3dcf-4d16-8a44-5c49b59d7aef
                Copyright © Copyright © 2023; The Author(s).
                License:

                © The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 18 April 2023
                Date accepted : 12 June 2023
                Date: 30 June 2023
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: aphasia,cerebrovascular accident,emergency department,emergent large vessel occlusion stroke,magnetic resonance angiography,magnetic resonance imaging,national institute of health stroke severity,neglect,vision
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: aphasia, cerebrovascular accident, emergency department, emergent large vessel occlusion stroke, magnetic resonance angiography, magnetic resonance imaging, national institute of health stroke severity, neglect, vision

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