From the Guidelines
The management of a large vein occlusion stroke should prioritize rapid assessment, supportive care, and prevention of complications, with a focus on anticoagulation therapy and endovascular interventions as needed. The initial management includes immediate neuroimaging with CT or MRI to confirm diagnosis and exclude hemorrhage. Supportive measures include maintaining adequate cerebral perfusion with blood pressure management, ensuring normoglycemia, and preventing hyperthermia.
- Anticoagulation therapy is the cornerstone of treatment, typically starting with intravenous unfractionated heparin or low molecular weight heparin, followed by oral anticoagulation with warfarin or direct oral anticoagulants for at least 3-6 months 1.
- In severe cases with clinical deterioration despite anticoagulation, endovascular interventions may be considered, including catheter-directed thrombolysis or mechanical thrombectomy, with a combined endovascular therapy approach using stent-retrievers and aspiration being the most effective way to achieve fast first-pass complete reperfusion 1.
- Management of increased intracranial pressure is crucial, using head elevation, osmotic therapy with mannitol or hypertonic saline, and in severe cases, decompressive hemicraniectomy.
- The organization of existing systems of care, particularly pre-hospital transfer systems, should be optimized to facilitate rapid patient transfer, diagnosis, and treatment, with time-consuming imaging methods and overly selective treatment selection criteria being avoided 1.
- It is essential to note that the management of large vein occlusion stroke differs from arterial strokes in its pathophysiology, involving venous congestion and potential hemorrhagic transformation, which paradoxically improves with anticoagulation by preventing thrombus propagation and facilitating recanalization.
- The most recent and highest quality study 1 supports the use of anticoagulation therapy and endovascular interventions in the management of large vein occlusion stroke, with a focus on rapid assessment and treatment to improve patient outcomes.
From the Research
Management Plan for Large Vein Occlusion Stroke
The management plan for a patient with a large vein occlusion stroke involves several steps, including:
- Identification of the occlusion using imaging modalities such as noncontrast computed tomography (NCCT) or CT angiography (CTA) 2
- Assessment of the patient's eligibility for endovascular treatment, including evaluation of the National Institute of Health Stroke Scale (NIHSS) score and vessel attenuation values on NCCT 2
- Consideration of the patient's underlying condition, such as intracranial atherosclerotic disease, which may affect treatment outcomes 3
- Endovascular thrombectomy, which has been shown to be effective in improving functional outcomes in patients with large vessel occlusion stroke 3
Screening Tools for Large Vessel Occlusion
Several screening tools have been developed to identify patients with large vessel occlusion stroke, including:
- The Large Vessel Occlusion Score, which is based on NIHSS and NCCT findings 2
- The RACE score, which has been evaluated for prehospital identification of large vessel occlusion stroke 4
- The Rapid Arterial oCclusion Evaluation (RACE) scale, which has been shown to have adequate discrimination for identifying large vessel occlusion stroke in the prehospital setting 4
Treatment Outcomes
The treatment outcomes for patients with large vein occlusion stroke vary depending on several factors, including the underlying condition and the timing of treatment. Studies have shown that:
- Endovascular thrombectomy can improve functional outcomes in patients with large vessel occlusion stroke 3
- However, the benefit of endovascular treatment for medium-vessel occlusion stroke is unclear, and studies have shown mixed results 5, 6
- Patients with intracranial atherosclerotic disease may derive similar functional outcome benefits from endovascular thrombectomy, but may be at higher risk of reocclusion 3