VAN ELVO (Vision, Aphasia, Neglect) Emergent Large Vessel Occlusion Study Mohamed Teleb, MD Neurointerventional Surgery Stroke, & Neurocritical Care Banner Health

Introduction / Background: VAN ELVO Study Introduction / Background: Identification of large vessel occlusion (LVO) is very important with doubling of favorable outcomes with stroke thrombectomy. Delay in time to treatment has been shown to hinder outcomes.

VAN ELVO Study Introduction / Background: There are many LVO screening tools currently but non have conducted a head to head prospective evaluation on same exact patients. VAN is a LVO screening tool that has no numbers or scoring & only tool to access vision We seek to see if any tool out performs the others & to validate VAN in a larger cohort

VAN ELVO Study Methods: VAN, a screening tool designed based on neurovascular anatomy was published in JNIS last year. We used the prospectively collected NIHSS to derive RACE (Rapid Arterial oCclusion Evaluation Scale), FAST ED (Field Assessment Stroke Triage for Emergency Destination), and CPSSS (Cincinnati Pre-hospital Stroke Severity Scale) on the same patients our Nurses perform VAN exam on since it is the only one not based solely on the NIHSS (National Institute of Health Stroke Scale).

VAN ELVO Study Methods: Accuracy of RACE, FAST ED, CPSS, and VAN for identification of LVO were analyzed for positive predictive value (PPV), sensitivity, negative predictive value (NPV), specificity, and overall accuracy. Stroke mimics discovered after 24hrs were not removed. Hemorrhages and tumors were removed as stroke alerts are called off for these.

VAN ELVO Study Methods: People performing VAN underwent 1 hr lecture on why screening is important, neuro anatomy (lacunar vs large vessel strokes), how to conduct the test, and a pre post test.

Blue: TPA Green: TPA +Endovascular why Endovascular is the new standard of care Blue: TPA Green: TPA +Endovascular

VAN ELVO Study Small Vessel / Lacunar vs Large Artery anatomy Mention how a spinal cord infarct is so small but can give you arm and leg flaccid. VAN ELVO Study

How to perform VAN ELVO Study

7 case examples for training Left lacunar (severe weakness) Left MCA clot severe Left MCA minor (expressive only) Left MCA minor (receptive only) Right lacunar Right MCA clot severe Right MCA clot minor (with sensory neglect)

7 case examples for training Testing 7 case examples for training Left lacunar (severe weakness) Left MCA clot severe Left MCA minor (expressive only) Left MCA minor (receptive only) Right lacunar Right MCA clot severe Right MCA clot minor (with sensory neglect)

VAN ELVO Study Results: 303 acute stroke codes were activated during the screening period. 36 had LVOs. RACE, FAST ED, CPSSS, and VAN each had an overall accuracy of 89.4%, 92.4%, 90.4%, and 96.7% respectively. VAN out performed all other tools in PPV, Sensitivity, NPV, Specificity, and Accuracy. VAN consistently identified LVOs in patients with NIHSS less then 10 which no other tool did consistently. 5 patients with NIHSS less then 10 (3 with NIHSS of 6 or less)

Results:

Why VAN? No calculation of numerical score which potentially leads to less inter-observer differences: RACE, CPSS, LAMS, FAST ED, Uses Motor weakness as central point/triage like LAMS, Hemiparersis only screening, making it simple for 30%-50% of stroke codes. You don’t have to finish the exam if there is no arm weakness. Uses Cortical symptoms without severity/scoring allowing pick up patients with large clot despite lower NIH stroke scale score. VAN teaches what cortical symptoms are and also the medical lingo (aphasia, neglect). Pneumonic helps tester to remember aspects tested Does not over test one division of MCA ie face, arm, and leg weakness – this can lead to having many lacunar strokes being falsely positive.

VAN ELVO Conclusions: In this large cohort, the VAN screening tool has been validated and identified LVO more accurately then any other screening tool. This suggests that severity scoring is less accurate then type of stroke screening. A larger study to reproduce validation in the ED and in the field for triage is warranted.

VAN ELVO Please visit www.StrokeVAN.com for information. Update to website along with mobile Application – w teaching video, small tutorials, & GPS to be released by end of year. Please download Stroke Scales for EMS where VAN can be found as one of 5 most widely used scales.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Mohamed Teleb, MD Neurointerventional Surgery, Stroke, & Neurocritical Care Banner Health

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Introduction / Background: Identification of large vessel occlusion (LVO) is very important with publications doubling favorable outcomes with stroke thrombectomy. Delay in time to treatment has been shown to hinder outcomes.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Introduction / Background: Identification of (LVO) can be done with LVO screening or with early CTA allowing for timely activation of transfer and/or Neuroendovascular evaluation. We evaluated 5 primary stroke centers (PSCs) one year after American Stroke Association guidelines on thrombectomy are published for implementation of LVO screening. (either with tool or CTA)

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Methods: Data on LVO screening, time to CTA from Stroke alert, time to official CTA read, transfer times, as well as NIHSS were collected by our stroke center coordinators. Data for all patients with NIHSS >= 6 where evaluated for the first 9 month of 2016 after approval by IRB.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Methods: We evaluated the number of patients with NIHSS>=6, which is AHA/ASA guidelines for patient that should be screened, who got any LVO screening (including NIHSS > 6 or 10, RACE, FASTED, VAN, CPSS, LAMS), CTA of head (when completed, when read), time to transfer. We looked at read time as most PSCs do not have stroke neurologist and triage is based off of official radiology read

UPSS (Utilization of Proper imaging or Screening for Strokes) Study 2016 @PSCs % LVO screening  CTA done CTA done within 1 hr CTA done within 1/2 hr CTA read within 1 hr Transfer within 2 hrs Hospital 1   9 month data 0/111 = 0% 62/111 = 56% 28/62= 45%  12/62 = 19.4% 9/62 = 9% 3/12 = 25% Hospital 2       0/76 = 0% 29/76 = 38.2% 17/29 = 58.6% 7/29 = 24.1% 3/29 =10% 1/13 = 7.7% Hospital 3        6 month data 0/60 = 0% 27/60 = 45% 12/27 = 44.4% 2/27 = 7.4% 0/27 = 0% 1/5 = 20% Hospital 4       0/165 = 0% 36/165 = 22% 13/36 = 33% 7/36 =19.4% 4/36 = 11% Hospital 5        0/134 = 0% 64/134 = 48% 46/64 = 72% 29/64 = 45% 2/64 = 3% 0/4 = 0% Total for Current Data 0/546 = 0% 218/546 = 40% 116/218 = 53% 57/218 = 26% 18/218 = 8% 6/39 = 15%

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Results: 0% had formal LVO screening or NIHSS protocol. 40% of patients with NIHSS>= 6 eventually had CTA. (60% of patients that should have been screened, were not) Only 8% of CTAs where read within 1 hr. Of patients eventually transferred, only 15% were within 2 hours.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Discussion: Many articles have been published on worse outcomes with transfers This identifies part of the problem: no screening is done, CTA reads take long time, no urgency for transfer.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Conclusions: Despite new guidelines, patients with NIHSS>= 6 are not consistently screened, CTA interpretation is significantly delayed, and only 15% are being transferred within 2 hours. We recommend that Stroke & Neurovascular organizations should have get with the guidelines campaign for mandatory LVO screening in ED, time to CTA from door, time to CTA read, and time to transfer to endovascular stroke centers.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Future Directions: Phoenix Stroke Work group to recommend PSCs have mandatory LVO screening in ED, collect time to CTA, time to CTA read, and time to transfer. UPSS 2 – for participating centers, will implement screening & collection of metrics & compare 2016 UPSS 1 vs 2018 UPSS 2 data w mandatory screening & metrics reporting.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Recommendations: Based on these results, with 85% of transfers taking 2 hours for transfer, 60% of patients not being screened at PSCs, I would recommend bypass to CSC if driving distance is no more then 15 minutes.

UPSS (Utilization of Proper imaging or Screening for Strokes) Study Future Directions: Please contact me if you would like study protocol or want us to participate in any joint venture to make improvements in care You can’t manage what you don’t measure Please feel free to email me: Mohamed.Teleb@bannerhealth.com Or Info@strokeVAN.com