in the voice and pantomime, but not noxious stimulation. Each limb is tested in bed by 5 seconds, but has some effort against gravity. turn, beginning with the non-paretic leg. _____ Only in the case of amputation or joint fusion at the hip, the examiner should 3 = No effort against gravity; leg falls to bed immediately. record the score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. 0 = Absent. _____ 1 = Present in one limb. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. 2 = Present in two limbs. The finger-nose-finger and heel-shin tests UN = Amputation or joint fusion, explain:________________ are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 35/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick 0 = Normal; no sensory loss. when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not pain with pinprick, but patient is aware of being touched. hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, score of 2, "severe or total sensory loss," should only be given when a severe or total and leg. _____ loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of information about comprehension will be 0 = No aphasia; normal. _____ 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of obtained during the preceding sections of the examination. For this scale item, the comprehension, without significant limitation on ideas expressed or form of patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials to read from the attached list of sentences. Comprehension is judged from responses difficult or impossible. For example, in conversation about provided materials, here, as well as to all of the commands in the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response. visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The 2 = Severe aphasia; all communication is through fragmentary expression; great need intubated patient should be asked to write. The patient in a coma (item 1a=3) will for inference, questioning, and guessing by the listener. Range of information that can automatically score 3 on this item. The examiner must choose a score for the be exchanged is limited; listener carries burden of communication. Examiner cannot patient with stupor or limited cooperation, but a score of 3 should be used only if the https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 36/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate patient is mute and follows no one-step identify materials provided from patient commands. response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be 0 = Normal. normal, an adequate sample of speech must be obtained by asking patient to read or 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be 2 = Severe dysarthria; patient's speech is so _____ slurred as to be unintelligible in the absence rated. Only if the patient is intubated or has other physical barriers to producing speech, of or out of proportion to any dysphasia, or is mute/anarthric. the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explanation for this choice. Do not tell the explain:________________ patient why he or she is being tested. 11. Extinction and inattention (formerly neglect): Sufficient information to identify 0 = No abnormality. 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to neglect may be obtained during the prior testing. If the patient has a severe visual loss bilateral simultaneous stimulation in one of the sensory modalities. preventing visual double simultaneous stimulation, and the cutaneous stimuli are 2 = Profound hemi-inattention or normal, the score is normal. If the patient _____ extinction to more than one modality; has aphasia but does appear to attend to both sides, the score is normal. The does not recognize own hand or orients to only one side of space. presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ Adapted from: Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non- neurologists in the context of a clinical trial. Stroke 1997; 28:307. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 37/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 38/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate ASPECTS study form The ASPECTS value is calculated from two standard axial CT cuts: one at the level of the thalamus and basal ganglia (left), and one just rostral to the basal ganglia (right). A: anterior circulation; P: posterior circulation; C: caudate; L: lentiform; IC: internal capsule; I: insular ribbon; MCA: middle cerebral artery; M1: anterior MCA cortex; M2: MCA cortex lateral to insular ribbon; M3: posterior MCA cortex; M4, M5, and M6 are anterior, lateral, and posterior MCA territories immediately superior to M1, M2, and M3, rostral to basal ganglia Reproduced with permission from: Barber, PA, Demchuk, AM, Zhang, J, Buchan, AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355:1670. Copyright 2000 The Lancet. Graphic 72190 Version 1.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 39/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Visual decision aid depicting the benefits and risks of endovascular thrombectomy added to IV tPA versus IV tPA alone Choice consequence matrix type visual decision aid depicting the benefits and risks of endovascular thrombectomy added to IV tPA versus IV tPA alone. Dark green, attainment of excellent outcome (mRS, 0-1) as a result of thrombectomy; light green, improved disability outcome (other than excellent outcome) as a result of thrombectomy; light red, worse disability outcome (other than severely disabled/dead) as a result of thrombectomy; open rectangle, infarct in new territory as a result of thrombectomy. https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 40/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate tPA: tissue-type plasminogen activator; IV: intravenous; mRS: modified Rankin scale; SICH: symptomatic intracranial hemorrhage. None were severely disabled or dead (mRS, 5-6) as a result of thrombectomy. No differences observed in the rate of SICH due to thrombectomy. From: Tokunboh I, Vales Montero M, Zopelaro Almeida MF, et al. Visual aids for patient, family, and physician decision making about endovascular thrombectomy for acute ischemic stroke. Stroke 2018; 49:90. DOI: 10.1161/STROKEAHA.117.018715. Copyright 2018 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 116247 Version 3.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 41/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Visual decision aid depicting the benefits and risks of endovascular thrombectomy for patients ineligible for IV tPA Choice consequence matrix type visual decision aid depicting the benefits and risks of endovascular thrombectomy among tPA-ineligible patients. Dark green, attainment of excellent outcome (mRS, 0-1) as a result of thrombectomy; light green, improved disability outcome (other than excellent outcome) as a result of thrombectomy; light red, worse disability outcome (other than severely disabled/dead) as a result of thrombectomy; open rectangle, infarct in new territory as a result of thrombectomy. https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 42/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate tPA: tissue-type plasminogen activator; IV: intravenous; mRS: modified Rankin scale; SICH: symptomatic intracranial hemorrhage. None were severely disabled or dead (mRS, 5-6) due to thrombectomy. No differences observed in the rate of SICH due to thrombectomy. From: Tokunboh I, Vales Montero M, Zopelaro Almeida MF, et al. Visual aids for patient, family, and physician decision making about endovascular thrombectomy for acute ischemic stroke. Stroke 2018; 49:90. DOI: 10.1161/STROKEAHA.117.018715. Copyright 2018 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 116248 Version 3.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 43/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Modified Treatment In Cerebral Ischemia (TICI) scale 0 No reperfusion 1 Flow beyond occlusion without distal branch reperfusion 2a Reperfusion of less than half of the downstream target arterial territory 2b Reperfusion of more than half, yet incomplete, in the downstream target arterial territory 3 Complete reperfusion of the downstream target arterial territory, including distal branches with slow flow This relates to capillary-level reperfusion as measured on catheter angiography. From: Wintermark M, Albers GW, Broderick JP, et al. Acute Stroke Imaging Research Roadmap II. Stroke 2013; 44:2628. DOI: 10.1161/STROKEAHA.113.002015. Copyright 2013 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 116431 Version 3.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 44/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Main approaches to managing cervical carotid lesions in patients with tandem occlusions undergoing thrombectomy for acute stroke Schematic summarizing the main approaches to managing cervical carotid lesions in patients with tandem occlusions undergoing thrombectomy for acute stroke. ICA: internal carotid artery; CEA: carotid endarterectomy; CAS: carotid artery stenting; EVT: endovascular therapy. Reprinted with permission of the American Society of Neuroradiology, from: Poppe AY, Jacquin G, Roy D, et al. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142; permission conveyed through Copyright Clearance Center, Inc. Copyright 2020. Graphic 133185 Version 2.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 45/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Contributor Disclosures Jamary Oliveira-Filho, MD, MS, PhD No relevant financial relationship(s) with ineligible companies to disclose. Owen B Samuels, MD No relevant financial relationship(s) with ineligible companies to disclose. Jos Biller, MD, FACP, FAAN, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator- initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 46/46