Abstract 118: Paramedic-Administered Los Angeles Motor Scale identifies Ischemic Stroke with Large Vessel Occlusion and Intracranial Hemorrhage for Routing to Comprehensive Stroke Centers and Compares Favorably to Other Screening Methods

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ali Reza Noorian ◽  
Nerses Sanossian ◽  
Kristina Shkirkova ◽  
David S Liebeskind ◽  
Marc Eckstein ◽  
...  
Keyword(s):  
Los Angeles ◽  
Intracranial Hemorrhage ◽  
Screening Methods ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Hospital Arrival ◽  
Academic Center ◽  
Acute Cerebral Ischemia ◽  
Los Angeles Motor Scale ◽  
Better Than

Background: Considering the recent advances in endovascular thrombectomy and advances in neurocritical care of patients with intracranial hemorrhage (ICH), there is an urgent need to develop tools for paramedics to identify patients likely to benefit from direct routing to comprehensive stroke centers (CSC). We report prospective validation of the Los Angeles Motor Scale (LAMS) performed by paramedics in the field, and compare its performance with other proposed prehospital LVO-identification scales. Methods: We analyzed all subjects enrolled in the NIH Field Administration of Stroke Therapy -Magnesium (FAST-MAG) trial transported directly to an academic center with a policy of performing immediate CTA or MRA imaging for all likely strokes. Prehospital LAMS was performed by paramedics prior to field enrollment. Hospital arrival (HA) LAMS and NIHSS were performed by trained study nurses after ED arrival. RACE, PASS, and 3i SS scales were calculated from NIHSS items. LVO in a proximal cerebral artery (ICA, MCA M1 & M2, Vertebral, Basilar and PCA P1 & 2) was determined by 3 vascular neurologists with expertise in neuroimaging. An LVO or ICH were considered as CSC appropriate patients. Results: Among 94 patients, age was 68 (±13) and 49% were female. Final diagnoses were acute cerebral ischemia in 71 (76%), intracranial hemorrhage in 18 (19%), mimic in 5 (5%). Overall, 48 patients (68%) had LVO, including MCA (30), ICA (14), basilar (1), vertebral (1) and PCA (2), and 66 (70%) were CSC-appropriate (LVO or ICH). In prediction of LVO, prehospital LAMS had the highest sensitivity (71%) and moderate specificity (54%). 3i-SS had the highest specificity (83%) but lowest sensitivity (40%). In prediction of CSC-appropriate patients, prehospital LAMS had the highest sensitivity (69%) and 3i-SS had the highest specificity (93%) but lowest sensitivity (37%). When comparing receiver operating curves, PM LAMS had AUC of 0.761, HA RACE 0.752, HA 3i SS 0.732, and HA PASS 0.712. Conclusions: Prehospital LAMS score of 4 or higher identified CSC-appropriate patients with good sensitivity and moderate specificity, and performed similar to or better than other proposed scales. LAMS is easy to administer and reproducible, and widely used currently by paramedics nationwide.

Abstract TP235: Deterioration and Improvement in the Field: Comparative Detection by Los Angeles Motor Scale and Glasgow Coma Scale in Acute, EMS-transported Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Anita Tipirneni ◽  
Kristina Shkirkova ◽  
Nerses Sanossian ◽  
Sidney Starkman ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Cerebral Ischemia ◽  
Los Angeles ◽  
Glasgow Coma Scale ◽  
Intracranial Hemorrhage ◽  
Stroke Patients ◽  
Coma Scale ◽  
Acute Cerebral Ischemia ◽  
Stroke Evolution ◽  
Global Impression Of Change ◽  
Los Angeles Motor Scale

Background: Stroke evolution after hospital arrival is well characterized for acute cerebral ischemia and intracranial hemorrhage. But with the advent of patient routing to designated stroke centers, and of prehospital stroke therapeutic trials, it is important to characterize stroke evolution in the earliest, prehospital moments of onset. Initial studies have prehospital evolution using serial Glasgow Coma Scale (GCS) assessment; however, GCS assesses level of consciousness rather than focal deficits. Methods: In the NIH FAST-MAG trial database, we analyzed patient deficit evolution from time of first paramedic assessment to early post-arrival assessment in the ED, using serial scores on the GCS, serial scores on the Los Angeles Motor Scale (LAMS) (a prehospital stroke deficit measure), and the Paramedic Global Impression of Change (PGIC) score, a 5 point Likert paramedic-clinician score. Results: Among 1632 acute, EMS-transported neurovascular disease patients, 1,245 (76.3%) had a final diagnosis of acute cerebral ischemia and 387 (23.7%) of acute intracranial hemorrhage. Time of paramedic initial assessment was median 23 mins (IQR 14-41) after onset and time of early ED assessment 58 mins (IQR 46-78). Considering score changes by 2 or more as salient, overall the LAMS and GCS indicated approximately equal frequencies of prehospital deterioration (LAMS 11.1%, GCS 12.0%), but the LAMS indicated higher frequencies of prehospital improvement (LAMS 24.5% vs GCS 5.7%, p<0.001), due to the ceiling constraint of the GCS. The LAMS correlated more strongly than the GCS with the paramedic global impression of change among all patients, r=0.31 vs 0.19, and especially in acute cerebral ischemia patients, r=0.27 vs 0.08). The prehospital course differed by stroke subtype on the LAMS: acute cerebral ischemia: improved 30.7%, worsened 7.1%, stable 62.25%; intracranial hemorrhage: improved 4.5%, worsened 24.2%, stable 71.3%. Conclusions: Focal deficit scales are superior to the GCS in characterizing prehospital stroke evolution. Change in neurologic status occurs in more than one-third of acute stroke patients during transport and the early ED, with improvement more common in acute cerebral ischemia and deterioration more common in ICH.

Abstract TMP61: Improved Routing of Comprehensive Stroke Center Appropriate Patients via Mobile Stroke Unit Conclusive Field Diagnosis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Bryan Villareal ◽  
Kevin Brown ◽  
Kenny Harrell ◽  
Jeffrey L. Saver ◽  
Mersedeh Bahr Hosseini ◽  
...  
Keyword(s):  
Cerebral Ischemia ◽  
Los Angeles ◽  
Intracranial Hemorrhage ◽  
Intravenous Thrombolysis ◽  
Patient Disposition ◽  
Mobile Stroke Unit ◽  
Acute Cerebral Ischemia ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Los Angeles Motor Scale

Background: Mobile Stroke Units (MSUs) are capable of rapid initiation of intravenous thrombolysis and have the potential to improve acute stroke patient routing by providing conclusive imaging diagnosis of LVO (arterial sequences) and intracranial hemorrhage (parenchymal/extraparenchymal sequences). However, the incremental increase in diagnostic accuracy and effect on patient disposition have not been well delineated. Methods: Consecutive transports in a regionally-deployed MSU from September 2017-August 2019) were analyzed, comparing patient routing that would have occurred under standard ambulance protocols to routing and process outcomes after CT/CTA MSU imaging. Standard ambulance regional routing policy was direct to nearest PSC if Los Angeles Motor Scale (LAMS) 0-3 and direct to nearest CSC within 30m if LAMS 4-5. Results: Among 83 MSU transports, final diagnosis was acute cerebral ischemia in 68% and intracranial hemorrhage in 10%. Among 57 acute cerebral ischemia patients, Los Angeles Motor Scale (LAMS) score was 0-3 in 65% and 4-5 in 35%. All (100%) of patients with ICA/M1 occlusions had LAMS score 4-5. However, among patients with expanded range endovascular target occlusions (M2, basilar), LAMS scores were 0-3 in 56%, and MSU imaging permitted improved routing. Among 8 intracranial hemorrhage patients (2 IPH, 5 SDH, 1 SAH), MSU imaging permitted improved direct-to-CSC routing in the 62% of patients with LAMS scores 0-3. Among all MSU admissions, 15% (13) were rerouted based solely upon in-vehicle imaging, including 7% for radiographically proven endovascularly treatable occlusion, 7% for neurosurgical/NICU intracranial hemorrhage care, and 1% for neurosurgical tumor care. Transport times for re-routed patients was median 12 minutes, compared to closest stroke center median 6 minutes. Conclusion: More than 1 in 7 MSU evaluations result in improved routing of comprehensive stroke center-appropriate patients directly to a CSC facility, including AIS patients potentially eligible for thrombectomy, intracranial hemorrhage patients, and acutely-presenting brain tumor patients. In addition to speeding start of intravenous thrombolysis, MSUs can substantially improve timely access to CSC care.

scholarly journals Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Stefanie Behnke ◽  
Thomas Schlechtriemen ◽  
Andreas Binder ◽  
Monika Bachhuber ◽  
Mark Becker ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Unsolved Problem ◽  
Standard Operating Procedure ◽  
Stroke Management ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Standard Operating ◽  
Los Angeles Motor Scale ◽  
Triage Decisions

Abstract Background The prehospital identification of stroke patients with large-vessel occlusion (LVO), that should be immediately transported to a thrombectomy capable centre is an unsolved problem. Our aim was to determine whether implementation of a state-wide standard operating procedure (SOP) using the Los Angeles Motor Scale (LAMS) is feasible and enables correct triage of stroke patients to hospitals offering (comprehensive stroke centres, CSCs) or not offering (primary stroke centres, PSCs) thrombectomy. Methods Prospective study involving all patients with suspected acute stroke treated in a 4-month period in a state-wide network of all stroke-treating hospitals (eight PSCs and two CSCs). Primary endpoint was accuracy of the triage SOP in correctly transferring patients to CSCs or PSCs. Additional endpoints included the number of secondary transfers, the accuracy of the LAMS for detection of LVO, apart from stroke management metrics. Results In 1123 patients, use of a triage SOP based on the LAMS allowed triage decisions according to LVO status with a sensitivity of 69.2% (95% confidence interval (95%-CI): 59.0–79.5%) and a specificity of 84.9% (95%-CI: 82.6–87.3%). This was more favourable than the conventional approach of transferring every patient to the nearest stroke-treating hospital, as determined by geocoding for each patient (sensitivity, 17.9% (95%-CI: 9.4–26.5%); specificity, 100% (95%-CI: 100–100%)). Secondary transfers were required for 14 of the 78 (17.9%) LVO patients. Regarding the score itself, LAMS detected LVO with a sensitivity of 67.5% (95%-CI: 57.1–78.0%) and a specificity of 83.5% (95%-CI: 81.0–86.0%). Conclusions State-wide implementation of a triage SOP requesting use of the LAMS tool is feasible and improves triage decision-making in acute stroke regarding the most appropriate target hospital.

scholarly journals The Addition of Atrial Fibrillation to the Los Angeles Motor Scale May Improve Prediction of Large Vessel Occlusion

2019 ◽  
Author(s):  
Priya Narwal ◽  
Andrew D. Chang ◽  
Brian Mac Grory ◽  
Mahesh Jayaraman ◽  
Tracy Madsen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Los Angeles ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Los Angeles Motor Scale

Abstract TMP71: The Los Angeles Motor Scale - Atrial Fibrillation (LAMS-AF) Score is Superior to LAMS in Predicting Large Vessel Occlusion

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Priya Narwal ◽  
Andrew Chang ◽  
Brian Mac Grory ◽  
Mahesh Jayaraman ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Los Angeles ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Los Angeles Motor Scale

scholarly journals 285 Predictive Value of the Los Angeles Motor Scale for Large Vessel Occlusion Strokes

2018 ◽  
Vol 72 (4) ◽  
pp. S112-S113
Author(s):  
P. Banerjee ◽  
L. Ganti ◽  
J. Rosario ◽  
M. Wallen ◽  
L. Dub ◽  
...  
Keyword(s):  
Los Angeles ◽  
Predictive Value ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Los Angeles Motor Scale

Abstract WP438: The Los Angeles Motor Scale (LAMS) is a Validated and Robust Tool for Paramedic Assessment of Stroke Severity in the Field

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Joon-Tae Kim ◽  
Pil-Wook Chung ◽  
Sidney Starkman ◽  
Nerses Sanossian ◽  
Samuel Stratton ◽  
...  
Keyword(s):  
Los Angeles ◽  
Cerebrovascular Disease ◽  
Predictive Validity ◽  
Functional Outcomes ◽  
Stroke Severity ◽  
Divergent Validity ◽  
Valid Measure ◽  
Hospital Arrival ◽  
Los Angeles Motor Scale ◽  
Rapid Quantification

Introduction: A simple, validated paramedic assessment of prehospital stroke severity would permit selective routing of more severe patients to Comprehensive Stroke Centers and a critical pretreatment deficit score in RCTs of prehospital intervention. The Los Angeles Motor Scale is a 3-item, 0-10 point motor stroke deficit scale developed for prehospital and ED use. Hypothesis: We assessed the hypothesis that the LAMS could be a valid tool for assessment of stroke severity on hospital arrival (HA) and prediction of 90D functional outcome. Methods: Among consecutive patients in the multi-ambulance, multi-hospital FAST-MAG trial, we assessed the predictive validity, concurrent, and divergent validity of the LAMS. Results: Among all 1,632 acute cerebrovascular disease patients in FAST-MAG, time from last known well (LKW) to prehospital LAMS exam was 30 mins (IQR 20 to 50), and from LKW to HA exam 147 mins (119-180). Median prehospital LAMS score was 4 (IQR 3 to 5). Concurrently performed HA LAMS and HA NIHSS correlated strongly, r=0.85, HA LAMS and GCS less so, r=0.62, as expected. Predictive validity of the prehospital LAMS was excellent. LAMS scores were higher in patients with dependency or death (mRS 0-3) at 90D, 4.2 vs 3.4, p <0.0001, and in patients with death by 90D, 4.3 vs 3.7, p<0.0001. The HA LAMS correlated with 90D mRS nearly as well as the concurrent HA NIHSS, r=0.55 vs 0.62. Each step on the LAMS scale was associated with a substantial shift to a worse distribution (Figure). Conclusion: The LAMS scale is a valid measure for paramedic use, permitting rapid quantification of prehospital stroke severity and predicting functional outcomes with accuracy comparable to the full NIH Stroke Scale.

The Los Angeles Motor Scale as a predictor of angiographically determined large vessel occlusion

2020 ◽  
Vol 15 (4) ◽  
pp. 695-700
Author(s):  
Ethan Samuel Brandler ◽  
Henry Thode ◽  
David Fiorella
Keyword(s):  
Los Angeles ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Los Angeles Motor Scale

scholarly journals Endovascular Thrombectomy for Acute Ischemic Stroke Beyond 6 Hours From Onset

Stroke ◽  
2020 ◽  
Vol 51 (7) ◽  
pp. 2051-2057 ◽  
Author(s):  
Ilaria Casetta ◽  
Enrico Fainardi ◽  
Valentina Saia ◽  
Giovanni Pracucci ◽  
Marina Padroni ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
Ct Perfusion ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: To evaluate outcome and safety of endovascular treatment beyond 6 hours of onset of ischemic stroke due to large vessel occlusion in the anterior circulation, in routine clinical practice. Methods: From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke of known onset beyond 6 hours. Additional inclusion criteria were prestroke modified Rankin Scale score ≤2 and ASPECTS score ≥6. Patients were selected on individual basis by a combination of CT perfusion mismatch (difference between total hypoperfusion and infarct core sizes) and CT collateral score. The primary outcome measure was the score on modified Rankin Scale at 90 days. Safety outcomes were 90-day mortality and the occurrence of symptomatic intracranial hemorrhage. Data were compared with those from patients treated within 6 hours. Results: Out of 3057 patients, 327 were treated beyond 6 hours. Their mean age was 66.8±14.9 years, the median baseline National Institutes of Health Stroke Scale 16, and the median onset to groin puncture time 430 minutes. The most frequent site of occlusion was middle cerebral artery (45.1%). Functional independence (90-day modified Rankin Scale score, 0–2) was achieved by 41.3% of cases. Symptomatic intracranial hemorrhage occurred in 6.7% of patients, and 3-month case fatality rate was 17.1%. The probability of surviving with modified Rankin Scale score, 0–2 (odds ratio, 0.58 [95% CI, 0.43–0.77]) was significantly lower in patients treated beyond 6 hours as compared with patients treated earlier No differences were found regarding recanalization rates and safety outcomes between patients treated within and beyond 6 hours. There were no differences in outcome between people treated 6-12 hours from onset (278 patients) and those treated 12 to 24 hours from onset (49 patients). Conclusions: This real-world study suggests that in patients with large vessel occlusion selected on the basis of CT perfusion and collateral circulation assessment, endovascular treatment beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

scholarly journals Los Angeles Motor Scale to Identify Large Vessel Occlusion

Stroke ◽  
2018 ◽  
Vol 49 (3) ◽  
pp. 565-572 ◽  
Author(s):  
Ali Reza Noorian ◽  
Nerses Sanossian ◽  
Kristina Shkirkova ◽  
David S. Liebeskind ◽  
Marc Eckstein ◽  
...  
Keyword(s):  
Los Angeles ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Los Angeles Motor Scale
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