Endovascular thrombectomy (EVT) improves outcomes in acute ischemic stroke caused by large vessel occlusion. Despite successful recanalization, early neurological deterioration (END) remains frequent and is associated with poor outcomes. Transcranial Doppler (TCD) provides noninvasive, real-time assessment of cerebral blood flow velocities and may identify hemodynamic patterns associated with deterioration after EVT. PRECISE-TCD is a prospective, single-center observational study enrolling 180-300 patients undergoing EVT for anterior circulation large vessel occlusion at a tertiary academic medical center. Serial TCD examinations are performed immediately after EVT, daily for 72 hours, and as close as possible to early neurological deterioration events or clinically indicated head CT within 72 hours. The primary outcome is the association between TCD-derived hemodynamic parameters and END within 72 hours. Secondary outcomes include NIHSS at 24 hours and discharge, discharge disposition, and modified Rankin Scale at 90 days.
Anterior circulation large vessel occlusion, including ACA, MCA, or ICA stroke, treated with endovascular thrombectomy, including tandem occlusions
Age ≥ 18 years
Ability to detect an adequate acoustic window via TCD.
Inadequate acoustic windows defined as lack of bilateral MCA signal at standard depths.
Pregnancy
Incarceration
Adults with anterior circulation large vessel occlusion, including ACA, MCA, or ICA stroke, treated with endovascular thrombectomy at VCU Medical Center.
Cohort
Prospective
Transcranial Doppler (TCD) examination
Other interventionSerial non-invasive TCD monitoring will be performed as soon as possible after EVT, daily for 72 hours, and when possible, close to any neurological deterioration or head CT obtained within 72 hours after EVT. TCD parameters include PSV, EDV, MFV, and PI measured in bilateral MCA, ACA, PCA, carotid siphon, vertebrobasilar arteries, and ophthalmic artery territories. Collateralization patterns, including ACA flow reversal, ophthalmic artery flow reversal, and high-flow ACA or PCA patterns relative to MCA flow, will also be assessed.
Occurrence of early neurological deterioration (END) within 72 hours after EVT
Early neurological deterioration (END) will be assessed as a binary Yes/No outcome. A participant will be classified as having END if any of the following occurs within 72 hours after endovascular thrombectomy (EVT): an increase in total NIHSS score of ≥4 points; an increase in NIHSS item 1a score of ≥1 point; intracranial hemorrhage on CT or MRI classified using the Heidelberg Classification; or any neurological examination change prompting emergent head CT at clinician discretion. The outcome will be reported as the percentage of participants who meet the criteria for END.
Post-EVT NIHSS score at 24 hours and discharge
Post-EVT National Institutes of Health Stroke Scale (NIHSS) score will be assessed at 24 hours and at hospital discharge.
Number of participants by discharge disposition category
Discharge disposition will be obtained from the medical record and categorized as home, acute rehabilitation, long-term acute care facility, skilled nursing facility, or hospice/palliative care/death. The outcome will be reported as the number of participants in each discharge disposition category.
Functional outcome by modified Rankin Scale at 90 days
Functional outcome will be assessed by phone-based modified Rankin Scale (mRS) at 90 days. Good outcome is defined as mRS 0-2, and poor outcome is defined as mRS 3-6.
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