From the Guidelines
Patients at risk for Emergent Large Vessel Occlusion (ELVO) strokes include those with atrial fibrillation, severe carotid or intracranial atherosclerosis, and hypercoagulable states, as identified in the most recent study 1. These risk factors are crucial in determining the likelihood of ELVO strokes, which can have severe consequences on morbidity, mortality, and quality of life.
Key Risk Factors
- Advanced age (particularly over 65)
- Hypertension
- Diabetes mellitus
- Smoking
- Obesity
- History of previous stroke or transient ischemic attack
- Cardiac conditions such as valvular heart disease, recent myocardial infarction, or cardiomyopathy
- Genetic disorders like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) and sickle cell disease The risk is particularly high when multiple factors coexist, as noted in 1.
Importance of Early Identification
Early identification of these high-risk patients is crucial as they may benefit from advanced interventions like mechanical thrombectomy in addition to standard thrombolytic therapy, as discussed in 1. These large vessel occlusions typically present with severe neurological deficits, including profound hemiparesis, hemisensory loss, aphasia, neglect, or visual field defects, often resulting in high National Institutes of Health Stroke Scale (NIHSS) scores. Given the time-dependent nature of treatment for ELVO strokes, as emphasized in 1, prompt recognition and management of these patients are essential to improve outcomes and reduce the risk of long-term disability and mortality.
From the Research
Patients at Risk for Emergent Large Vessel Occlusion (ELVO) Strokes
The following patients are at risk for ELVO strokes:
- Patients with atrial fibrillation, particularly those with a history of stroke, hypertension, hyperglycemia, and dyslipidemia 2, 3
- Patients with asymptomatic carotid artery stenosis, especially those with low-density lipoprotein (LDL) levels >100 mg/dL, no statin or low-potency statins, average systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg, and history of smoking 4
- Patients with non-insulin-dependent diabetes mellitus (NIDDM), particularly those with previous history of stroke, hypertension, hyperglycemia, and dyslipidemia 2
- Patients with carotid/vertebral atherosclerosis, diabetes, and hyperlipidemia, especially those on warfarin for stroke prevention 5
- Hypertensive patients with echocardiographic risk factors such as left atrium > or =4.0 cm, ejection fraction <50%, and left ventricle > or =5.6 cm, as well as clinical risk factors like congestive heart failure and coronary disease 3
- Patients undergoing carotid artery stenting, particularly those who are symptomatic or have hypercholesterolemia 6
Specific Risk Factors
Some specific risk factors that increase the risk of ELVO strokes include:
- Hyperglycemia (plasma glucose > 13.4 mmol/L) and high hemoglobin A1 (> 10.7%) 2
- Low levels of high-density lipoprotein cholesterol (< 0.90 mmol/L) and high levels of total triglyceride (> 2.30 mmol/L) 2
- History of smoking and nicotine abuse 4, 6
- Hypercholesterolemia 5, 6
- Diabetes mellitus 5, 2, 3
- Hypertension 4, 2, 3
- Carotid/vertebral atherosclerosis 5
- Left ventricular hypertrophy and diastolic dysfunction 3