Combination of blood biomarkers and stroke scales improves identification of large vessel occlusions

Gaude, E.; Nogueira, B.; Graham, S.; Smith, S.; Shaw, L.; Graziadio, S.; Ladreda, G.; Sloan, P.; Bernstock, J. D.; Shekhar, S.; Gropen, T. I.; Price, C. I.

Background and Purpose. Acute ischemic stroke caused by large vessel occlusions (LVO) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. Aims. To evaluate the diagnostic accuracy of a panel of biomarkers for LVO prediction. Methods. 170 patients with suspected stroke were recruited retrospectively at one hospital. We analysed the plasma levels of D-dimer, OPN, OPG, GFAP, vWF, and ADAMTS13 in LVO vs non-LVO. Diagnostic performance was estimated by using blood biomarkers alone or in combination with NIHSS-derived stroke severity scales. Results. Our patient cohort comprised 20% stroke mimics, 11% transient ischemic attack, 11% hemorrhagic stroke, 15% LVO ischemic stroke, 28% non-LVO ischemic stroke, and 15% ischemic stroke with unknown LVO status. Multivariable analysis found that the optimal set of blood biomarkers for LVO prediction was D-dimer (OR 15.4, 95% CI 4.9 to 57.6; p-value<0.001) and GFAP (OR 0.83, 95% CI 0.90 to 0.99; p-value=0.03). The combination of D-dimer and GFAP with stroke scales significantly improved LVO prediction, compared to the stroke scales alone (p-value<0.001). The combination of biomarkers with constructed FAST-ED or EMSA scales achieved an AUC of 95% (95% CI 91-100%) or 93% (CI 95% 89-97%), a sensitivity of 91% (95% CI 71-98%) or 86 (95% CI 66-97%), and a specificity of 95% (95% CI 89-98%) or 94% (95% CI 88-98%), for LVO prediction, respectively. Conclusions. The combination of D-dimer, GFAP, and stroke scales could provide a simple and highly accurate tool for identifying LVO patients.