September 2024 Pick of the Month

Large-vessel occlusion (LVO) stroke accounts for a disproportionate amount of acute ischemic stroke morbidity and mortality. Over the last decade, endovascular thrombectomy (EVT) has revolutionized the acute management of LVO strokes, but expeditious transport to EVT-capable hospitals is essential. The challenge is timely recognition of LVO stroke. The 2023 American College of Emergency Physician’s “Acute Ischemic Stroke” Clinical Policy focused on LVO strokes and could only provide a Level C recommendation in favor of the Los Angeles Motor Scale (LAMS) or Rapid Arterial Occlusion Evaluation Scale (RACE) to identify suspected stroke patients at increased risk of LVO. Suffice to say that decision instruments like LAMS and RACE are imperfect predictors of LVO stroke and lack evidence of impact in terms of improving LVO outcomes.

Cranial accelerometry measures cranial forces from cardiac contraction to recognize characteristics indicative of LVO stroke. In this issue, Paxton et al. evaluate the feasibility of a cranial accelerometry headset to improve pre-hospital recognition of LVO stroke in Headpulse measurement can reliably identify large-vessel occlusion on stroke in prehospital suspected stroke patients: Results from EPISODE-PS-COVID study. The device tested is a headband with three leads and a handheld screen that has already demonstrated good sensitivity and specificity in the emergency department and neuro-interventional suite.

The “hEad Pulse for Ischemic StrOke DEtection Prehospital Study during the COVID-19 pandemic” (EPISODE-PS-COVID) was a 23-month prospective observational study across seven Michigan and four California hospitals designed to assess the feasibility of using cranial accelerometry in the pre-hospital setting. Participating emergency medical services (EMS) received standardized training on placement and use of the cranial accelerometer but neither the length-of-time in training nor the fidelity of the device use are reported. At the discretion of EMS participants, the device was applied for a minimum of three minutes to adult patients with suspected acute ischemic stroke while they concurrently assessed the components of the LAMS score. EMS and emergency department teams were not privy to the cranial accelerometer results.

The upgraded cranial accelerometer used by investigators in the later stages of the study seemed feasible for real-world EMS use and demonstrated impressively better diagnostic properties than the LAMS score to rule-out LVO stroke. Though additional efficacy and cost-effectiveness research is certainly needed, technology may have arrived to improve LVO outcomes with efficiencies of scale to reduce our reliance on a range of imperfect prediction scores.   

Christopher R. Carpenter, MD, MSC

Mayo Clinic – Rochester