Code stroke of large vessel occlusion at triage improves candidate selection and workflow efficiency of endovascular thrombectomy

1. Incorporating acute ischemic stroke due to large vessel occlusion (LVO) screening using the Los Angeles Motor Scale (LAMS) is feasible and reduces time to computed tomography angiography (CTA) and time to endovascular thrombectomy (EVT)

Evidence Rating Level: 2 (Good)

Timely EVT for acute ischemic stroke caused by LVO is critical for patient outcomes. However, current Code Stroke protocols are not designed to identify patients with LVO, potentially delaying gold standard therapy. Conventional Code Stroke protocols recommend noncontrast CT head as initial imaging to rule out intracranial hemorrhage. However, the preferred imaging modality for LVO ischemic stroke is CTA with or without CT perfusion (CTP). This study implemented Code LVO, where patients were first triaged for LVO with LAMS. Patients with LAMS ≥ 4 underwent immediate CTA/CTP and early EVT team notification while patients with LAMS < 4 were managed with the conventional code stroke pathway. This single-center retrospective study included 1025 acute stroke patients presenting within 6 hours of onset. 808 patients (mean age ± SD, 68.0 ± 13.8; 60.4% male) were seen before Code LVO implementation and 217 patients (mean age ± SD, 68.0 ± 13.4; 64.1% male) were seen after. Code LVO patients significantly fewer patients receiving non-contrast CTA before CT (8.8% vs. 34.7%, P < 0.001), shorter door-to-CTA times (median [IQR] minutes: 19 [15–24] vs. 42 [27–61], P < 0.001), higher proportion of patients receiving EVT (24.4% vs. 11%, P < 0.001), and shorter door-to-puncture times compared to pre-Code LVO patients (median [IQR] minutes: 107.5 [97–117.25] vs. 140 [114.75–160.25], P < 0.001). Overall, incorporating LVO screening at triage is a quick and feasible strategy to expedite door-to-CTA and door-to-EVT times.

Click here to read this study in The American Journal of Emergency Medicine

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