Large arterial occlusive strokes as a medical emergency: need to accurately predict clot location

Background: Endovascular treatment for acute ischemic stroke with a large intracranial occlusion was recently shown to be effective. Timely knowledge of the presence, site, and extent of arterial occlusions in the ischemic territory has the potential to influence patient selection for endovascular treatment. We aimed to find predictors of large vessel occlusive strokes, on the basis of available demographic, clinical, radiological, and laboratory data in the emergency setting. Methods: Patients enrolled in ASTRAL registry with acute ischemic stroke and computed tomography (CT)-angiography within 12 h of stroke onset were selected and categorized according to occlusion site. Easily accessible variables were used in a multivariate analysis. Results: Of 1645 patients enrolled, a significant proportion (46.2%) had a large vessel occlusion in the ischemic territory. The main clinical predictors of any arterial occlusion were in-hospital stroke [odd ratios (OR) 2.1, 95% confidence interval 1.4–3.1], higher initial National Institute of Health Stroke Scale (OR 1.1, 1.1–1.2), presence of visual field defects (OR 1.9, 1.3–2.6), dysarthria (OR 1.4, 1.0–1.9), or hemineglect (OR 2.0, 1.4–2.8) at admission and atrial fibrillation (OR 1.7, 1.2–2.3). Further, the following radiological predictors were identified: time-to-imaging (OR 0.9, 0.9–1.0), early ischemic changes (OR 2.3, 1.7–3.2), and silent lesions on CT (OR 0.7, 0.5–1.0). The area under curve for this analysis was 0.85. Looking at different occlusion sites, National Institute of Health Stroke Scale and early ischemic changes on CT were independent predictors in all subgroups. Conclusion: Neurological deficits, stroke risk factors, and CT findings accurately identify acute ischemic stroke patients at risk of symptomatic vessel occlusion. Predicting the presence of these occlusions may impact emergency stroke care in regions with limited access to noninvasive vascular imaging.

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