Podcast 849: Large Vessel Occlusions

Contributor: Travis Barlock MD

Educational Pearls:

Large Vessel Occlusion (LVO) is a condition where a clot blocks one of the major blood vessels in the brain, leading to a stroke.

What are the vessels that can experience an LVO?

Middle Cerebral artery (MCA)

Internal Carotid Artery (ICA)

Anterior Cerebral Artery (ACA)

Posterior Cerebral Arteries (PCA)

Basilar Artery (BA)

Vertebral Arteries (VA)

What are the locations at which a mechanical thrombectomy can be performed as a treatment for an LVO?

Distal ICA, M1 or M2 segments of the MCA, A1 or A2 segments of the ACA, and some evidence for the BA.

What are the symptoms of LVO?

Use the mnemonic FANG-D to remember a few key symptoms:

Field Cut (A person loses vision in a portion of their visual field)

Aphasia (Difficulty speaking)

Neglect (A person may have difficulty paying attention to or acknowledging stimuli on the affected side of their body or in their environment. For example, a person with neglect may deny that their left hand belongs to them)

Gaze Deviation (One or both eyes are turned away from the direction of gaze)

Dense Hemiparesis (Paralysis affecting one side of the body)

What are the treatment windows for treating an LVO?

24 hours for mechanical thrombectomy

0-4.5 hours for tPA/TNK

References

1. Brain embolism, Caplan LR, Manning W (Eds), Informa Healthcare, New York 2006.

2. Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. doi: 10.1056/NEJMoa1411587. Epub 2014 Dec 17. Erratum in: N Engl J Med. 2015 Jan 22;372(4):394. PMID: 25517348.

3. Herpich, Franziska MD1,2; Rincon, Fred MD, MSc, MB.Ethics, FACP, FCCP, FCCM1,2. Management of Acute Ischemic Stroke. Critical Care Medicine 48(11):p 1654-1663, November 2020.

4. Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019 Dec;50(12):3331-3332. doi: 10.1161/STROKEAHA.119.027708. Epub 2019 Oct 30. PMID: 31662117.

5. Hoglund J, Strong D, Rhoten J, Chang B, Karamchandani R, Dunn C, Yang H, Asimos AW. Test characteristics of a 5-element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes. J Am Coll Emerg Physicians Open. 2020 Jul 24;1(5):908-917. doi: 10.1002/emp2.12188. PMID: 33145539; PMCID: PMC7593424.

Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMS1