Abstract TP253: A Novel Prehospital Scale to Predict Candidates for Acute Stroke Thrombectomy : The Fukuoka Acute Stroke ThrombEctomy pRediction (FASTER) Scale

Background: We aimed to design a prehospital scale to predict candidates for endovascular thrombectomy (CET) in patients with acute ischemic stroke (AIS). Materials and methods: In the Fukuoka Stroke Registry, we identified 3,470 patients with AIS who were transferred by emergency medical service within 24 hours of stroke onset and underwent intracranial vessel evaluation on admission from September 2007 to December 2015. CET were defined as patients with causative occlusion of internal carotid artery, middle cerebral artery, or basilar artery, and National Institute of Health Stroke Scale (NIHSS) score ≥ 6. The Fukuoka Acute Stroke ThrombEctomy pRediction (FASTER) scale was developed with NIHSS items based on the predictive importance derived from random forest analysis to predict CET. The discriminative performance was compared with other published scales for large vessel occlusion. Results: The FASTER scale was designed comprising of 4 NIHSS items : one point each was given for extinction and inattention (NIHSS subscore ≥ 1), best gaze (≥ 1), best language (≥ 1), and motor arm (≥ 2). Receiver operator curves demonstrated that the area under the curve of the FASTER scale was significantly larger than that of the Cincinnati Prehospital Stroke Severity Scale (0.907 vs 0.881, p<0.001), and not significantly different from that of the Rapid Arterial oCclusion Evaluation scale (vs 0.910, p= 0.68). The FASTER scale score ≥2 showed sensitivity of 88.4%, specificity 82.3%, positive predictive value 51.3%, and negative predictive value 97.1% for detecting CET. Conclusion: The FASTER scale is a simple and promising tool that can identify CET in the prehospital setting.

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Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings

Interventional Neurology ◽

10.1159/000486515 ◽

2018 ◽

Vol 7 (3-4) ◽

pp. 196-203 ◽

Cited By ~ 2

Author(s):

Kessarin Panichpisal ◽

Kenneth Nugent ◽

Maharaj Singh ◽

Richard Rovin ◽

Reji Babygirija ◽

...

Keyword(s):

Los Angeles ◽

Acute Stroke ◽

Predictive Value ◽

Area Under The Curve ◽

Predictive Performance ◽

Large Vessel ◽

Stroke Severity ◽

Vessel Occlusion ◽

Comparable Accuracy ◽

Score Model

Background: Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO. Method: The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS). Results: LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO. Conclusion: The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

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Are you suffering from a large arterial occlusion? Please raise your arm!

Stroke and Vascular Neurology ◽

10.1136/svn-2018-000165 ◽

2018 ◽

Vol 3 (4) ◽

pp. 215-221 ◽

Cited By ~ 2

Author(s):

Charith Cooray ◽

Michael V Mazya ◽

Matteo Bottai ◽

Jan F Scheitz ◽

Azmil H Abdul-Rahim ◽

...

Keyword(s):

Sensitivity And Specificity ◽

Motor Function ◽

Predictive Value ◽

Area Under The Curve ◽

Arterial Occlusion ◽

Artery Occlusion ◽

Large Artery ◽

Anterior Circulation ◽

Discriminative Performance ◽

Complex Models

Background and purposeTriage tools to identify candidates for thrombectomy are of utmost importance in acute stroke. No prognostic tool has yet gained any widespread use. We compared the predictive value of various models based on National Institutes of Health Stroke Scale (NIHSS) subitems, ranging from simple to more complex models, for predicting large artery occlusion (LAO) in anterior circulation stroke.MethodsPatients registered in the SITS international Stroke Register with available NIHSS and radiological arterial occlusion data were analysed. We compared 2042 patients harbouring an LAO with 2881 patients having no/distal occlusions. Using binary logistic regression, we developed models ranging from simple 1 NIHSS-subitem to full NIHSS-subitems models. Sensitivities and specificities of the models for predicting LAO were examined.ResultsThe model with highest predictive value included all NIHSS subitems for predicting LAO (area under the curve (AUC) 0.77), yielding a sensitivity and specificity of 69% and 76%, respectively. The second most predictive model (AUC 0.76) included 4-NIHSS-subitems (level of consciousness commands, gaze, facial and arm motor function) yielding a sensitivity and specificity of 67% and 75%, respectively. The simplest model included only deficits in arm motor-function (AUC 0.72) for predicting LAO, yielding a sensitivity and specificity of 67% and 72%, respectively.ConclusionsAlthough increasingly more complex models yield a higher discriminative performance for predicting LAO, differences between models are not large. Assessing grade of arm dysfunction along with an established stroke-diagnosis model may serve as a surrogate measure of arterial occlusion-status, thereby assisting in triage decisions.

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Retrospective Validation of Prehospital Acute Stroke Severity Scale to Predict Large Vessel Occlusion in Acute Stroke Patients - Single Center study in China

10.21203/rs.2.10860/v1 ◽

2019 ◽

Author(s):

Xiaoli Si ◽

Yuanjian Fang ◽

Wenqing Xia ◽

Tianwen Chen ◽

Huan Huang ◽

...

Keyword(s):

Acute Stroke ◽

Predictive Value ◽

Large Vessel ◽

Motor Deficits ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Consciousness Disorder ◽

Gaze Palsy

Abstract Background and Purpose - To date, identifying emergent large vessel occlusion (ELVO) patients in the prehospital stage is important but still challenging. We aimed to retrospectively validate a simple prehospital stroke scale——Prehospital Acute Stroke Severity (PASS) scale to identify ELVO. Methods - We retrospectively evaluated our consecutive cohort of acute ischemic stroke (AIS) who underwent CT angiography (CTA), MR angiography (MRA) or digital subtraction angiography (DSA). PASS scale was calculated based on National Institutes of Health Stroke Scale (NIHSS) items retrospectively. The comparison of diagnostic parameters between PASS scale and NIHSS scale were performed. Results - Finally, a total of 605 patients were enrolled. ELVO patients with PASS≥2 had a median NIHSS score of 14. The best predictive value of PASS≥2 showed a similar predictive value compared with NIHSS≥9. Cortical symptoms such as consciousness disorder and gaze palsy were more specific indicators for ELVO than motor deficits. Consciousness disorder was more serious in posterior circulation infarct (PIC) while gaze palsy was more common in anterior circulation infarct (AIC). Conclusions - PASS scale had both good discrimination and calibration in our retrospective cohort. It could reflect acute stroke severity well and predict ELVO in an effective and simple way. Moreover, cortical symptoms had high specificities to predict ELVO on their own.

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In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia

Cerebrovascular Diseases Extra ◽

10.1159/000478793 ◽

2017 ◽

Vol 7 (2) ◽

pp. 111-119 ◽

Cited By ~ 1

Author(s):

Cathy Cao ◽

Ashley Martinelli ◽

Brian Spoelhof ◽

Rafael H. Llinas ◽

Elisabeth B. Marsh

Keyword(s):

Atrial Fibrillation ◽

Acute Stroke ◽

Predictive Value ◽

Multivariable Analysis ◽

International Normalized Ratio ◽

Neurological Deficits ◽

Stroke Severity ◽

Stroke Registry ◽

Significant Difference ◽

Primary Stroke Center

Background: Stroke can occur in patients on warfarin despite anticoagulation. Patients with a low international normalized ratio (INR) should theoretically be at greater risk for ischemia than those who are therapeutic. Therefore, INR may be able to indicate whether new neurological deficits are more likely strokes or stroke mimics in patients on warfarin. This study evaluates the association and predictive value of INR in determining the likelihood of ischemia. Methods: Patients were identified using the acute stroke registry at a Primary Stroke Center from January 2013 through December 2014. All adult patients undergoing evaluation for acute stroke with prior documented use of warfarin and an INR level at presentation were included. Data were collected regarding patient demographics, medical comorbidities, stroke severity, reason for anticoagulation, and laboratory studies including INR. Student t tests and χ2 analysis were used to evaluate factors associated with increased likelihood of ischemia (stroke or transient ischemic attack) versus mimic. Significant results were entered into a multivariable regression analysis. Sensitivity and specificity analyses were conducted to determine the predictive value of INR for ischemic risk. Results: 116 patients were included; 46 were diagnosed with ischemia, 70 were diagnosed as mimics. 75% of patients were on warfarin for atrial fibrillation versus 25% for venous thrombosis. A statistically significant difference in mean INR for patients with ischemia (n = 46) versus mimics (n = 70) was observed (1.7 vs. 2.8; p < 0.001). In multivariable analysis, both sub-therapeutic INR (p < 0.001) and atrial fibrillation (p = 0.014) were predictors of ischemia. In patients with an INR ≥2, the predictive value of having a non-ischemic etiology was 79%. No patient with an INR of ≥3.6 was found to have ischemia. Conclusions: Sub-therapeutic INR and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients’ risk for acute ischemic stroke and guide further neurologic imaging and workup.

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Abstract TP240: The PLUMBER (Prevalence of Large Vessel Occlusion Stroke in Mecklenburg County Emergency Response) Study

Stroke ◽

10.1161/str.48.suppl_1.tp240 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Adeline R Dozois ◽

Lorrie Hampton ◽

Carlene W Kingston ◽

Gwen Lambert ◽

Thomas J Porcelli ◽

...

Keyword(s):

Acute Stroke ◽

Emergency Response ◽

Predictive Value ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Mecklenburg County ◽

Ischemic Attack ◽

Neurovascular Imaging

Introduction: Regional Emergency Medical System (EMS) protocols for acute stroke endorse routing patients with possible large vessel occlusion (LVO) acute ischemic strokes (AIS) directly to endovascular centers. These routing algorithms include prehospital stroke severity screens (PSSS) to determine the likelihood of an LVO AIS. An essential, but unreported, determinant of the predictive value of PSSS tools is the prevalence of LVO AIS stroke in the EMS population screened for stroke. Hypothesis: Among EMS patients transported to Mecklenburg county hospitals screened for stroke, acute LVO AIS prevalence ranges from 5-10%. Methods: We are conducting a prospective, observational study of all patients transported by the Mecklenburg county EMS agency who are either (1) dispatched as a possible stroke and/or (2) with a primary impression of stroke recorded by prehospital providers. We are reviewing medical records and neurovascular imaging studies to determine an acute LVO AIS diagnosis and the site(s) of occlusion. Results: Thus far, over a six-month period we have enrolled 1441 patients, of whom 33% (n=480) had a diagnosis consistent with acute stroke (ischemic stroke, hemorrhagic stroke, or transient ischemic attack), with 20% (n=287) being an AIS. Eighty-eight percent (n=253) of AIS patients underwent an intracranial CTA or MRA. The prevalence of LVO stroke in the EMS population enrolled was 5.7% (n= 82, 95% CI 4.6-7.0%), with the most common vessel occluded being M1 (n=46, 56% of LVO AIS). The prevalence of LVO AIS in patients dispatched as a possible stroke was 4.8% (n =56; 95% CI 3.6-6.1%), while the prevalence in patients with a primary impression of stroke was 10% (n=74; 95% CI 8.2-13%). Conclusions: Among patients screened for stroke by our county’s EMS agency, the prevalence of LVO AIS is low. This low LVO AIS prevalence, combined with a PSSS tool with modest accuracy, will yield poor predictive value for LVO AIS in an EMS population, resulting in a substantial rate of over-triage of non-LVO patients to endovascular centers. Data collection is ongoing to determine the accuracy of a prehospital stroke screen in identifying LVO AIS patients.

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Predictive Value of Modifications of the Prehospital Rapid Arterial Occlusion Evaluation Scale for Large Vessel Occlusion in Patients with Acute Stroke

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2016.08.032 ◽

2017 ◽

Vol 26 (1) ◽

pp. 74-77 ◽

Cited By ~ 24

Author(s):

David Carrera ◽

Bruce C.V. Campbell ◽

Jordi Cortés ◽

Montse Gorchs ◽

Marisol Querol ◽

...

Keyword(s):

Acute Stroke ◽

Predictive Value ◽

Arterial Occlusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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Dysphagia screening after intracerebral hemorrhage

International Journal of Stroke ◽

10.1177/1747493017729265 ◽

2017 ◽

Vol 13 (5) ◽

pp. 503-510 ◽

Cited By ~ 1

Author(s):

Raed A Joundi ◽

Rosemary Martino ◽

Gustavo Saposnik ◽

Vasily Giannakeas ◽

Jiming Fang ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Acute Stroke ◽

Clinical Severity ◽

Stroke Severity ◽

Stroke Registry ◽

Patients At Risk ◽

Poor Outcomes ◽

Risk Of Aspiration ◽

To Receive

Background Dysphagia screening is recommended after acute stroke to identify patients at risk of aspiration and implement appropriate care. However, little is known about the frequency and outcomes of patients undergoing dysphagia screening after intracerebral hemorrhage (ICH). Methods We used the Ontario Stroke Registry from 1 April 2010 to 31 March 2013 to identify patients hospitalized with acute stroke and to compare dysphagia screening rates in those with ICH and ischemic stroke. In patients with ICH we assessed predictors of receiving dysphagia screening, predictors of failing screening, and outcomes after failing screening. Results Among 1091 eligible patients with ICH, 354 (32.4%) patients did not have documented dysphagia screening. Patients with mild ICH were less likely to receive screening (40.4% of patients were omitted, adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI) 0.26–0.63). Older age, greater stroke severity, speech deficits, lower initial level of consciousness, and admission to intensive care unit were predictive of failing the screening test. Failing screening was associated with poor outcomes, including pneumonia (aOR 5.3, 95% CI 2.36–11.88), severe disability (aOR 4.78, 95% CI 3.08–7.41), and 1-year mortality (adjusted hazard ratio 2.1, 95% CI 1.38–3.17). When compared to patients with ischemic stroke, patients with ICH were less likely to receive dysphagia screening (aOR 0.64, 95% CI 0.54–0.76) and more likely to fail screening (aOR 1.98, 95% 1.62–2.42). Conclusion One-third of patients with ICH did not have documented dysphagia screening, increasing to 40% in patients with mild clinical severity. Failing screening was associated with poor outcomes. Patients with ICH were less like to receive screening and twice as likely to fail compared to patients with ischemic stroke, and thus efforts should be made to include ICH patients in dysphagia screening protocols whenever possible.

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Abstract WP277: Race Score is Scalable to Other Ems Systems; A Sensitivity Analysis

Stroke ◽

10.1161/str.48.suppl_1.wp277 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Sharjeel Panjwani ◽

Julie Shawver ◽

Syed F Zaidi ◽

Mouhammad A Jumaa

Keyword(s):

Hospital Setting ◽

Arterial Occlusion ◽

Final Diagnosis ◽

Medical Emergency ◽

Stroke Severity ◽

Vessel Occlusion ◽

Spanish Study ◽

Back Ground ◽

Stroke Mimic ◽

Lucas County

Back Ground: Rapid Arterial Occlusion Evaluation Scale (RACE) was first instituted in Barcelona and described in 2014 to successfully assess stroke severity and identify patients with acute stroke with large vessel occlusion (LVO) at pre-hospital setting by medical emergency technicians. Objective: We instituted Rapid Arterial Occlusion Evaluation Scale (RACE) hospital bypass protocol (RA) in Lucas county, Ohio since July 2015. Our aim in this study is to evaluate the sensitivity of our RACE protocol in identifying cerebro-vascular accidents and furthermore to identify ischemic CVAs from the cohort. Method: All county EMS personnel (N=464) underwent training in the Rapid Arterial Occlusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke symptoms, who were last seen normal less than 12 hours and had a RACE score ≥5 were taken to a facility that has neuro-interventional capacity, was implemented in July 2015. An IRB approved prospective DB was maintained during that period. Patient’s stroke characteristics, type of acute treatment and final diagnosis on discharge were reviewed for the purpose of this abstract. Our results were comparable to the Spanish study done in Barcelona in 2014. Results: Between Jul 2016-Jun 2016 186 RAs were activated. The discharge diagnoses included ischemic stroke N=91 (49%), ICH N=26 (14%) and TIA N=17(9%). The rate of stroke mimic was N=52 (28%) of the total RACE alerts. These included seizures (12%), metabolic encephalotpathy (12%) and others including sepsis and migraines. Of the patients presenting as RA, 33% underwent IV tPA treatment ± mechanical thrombectomy. Conclusion: Results from our prospective county wide data is comparable to prior studies. RACE score may be scalable to other EMS systems to triage potential LVOs for direct transfer to centers with interventional capabilities.

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Abstract TP237: Can We Improve Clinical Detection of Right Hemisphere Large Vessel Occlusion?

Stroke ◽

10.1161/str.51.suppl_1.tp237 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sana Somani ◽

Melissa Gazi ◽

Michael Minor ◽

Joe Acker ◽

Abimbola Fadairo ◽

...

Keyword(s):

Left Hemisphere ◽

Right Hemisphere ◽

Trauma System ◽

Area Under The Curve ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Emergency Medical ◽

The Right

Introduction: The Emergency Medical Stroke Assessment (EMSA) is a six point stroke severity scale with one point each for gaze preference, facial droop, arm drift, leg drift, abnormal naming, and abnormal repetition that was developed to help emergency medical services (EMS) providers identify acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We hypothesized that the EMSA would detect left hemisphere LVO with a higher sensitivity than right hemisphere LVO. Methods: We trained 24 trauma system-based emergency communication center (ECC) paramedics in the EMSA. ECC-guided EMS in performance of the EMSA on patients with suspected stroke. We compared the sensitivity, specificity, area under the curve (AUC), and 95% confidence interval (CI) of ECC-guided prehospital EMSA for right versus left hemisphere ICA or M1 occlusion. Results: We enrolled 569 patients from September 2016 through February 2018, out of which 236 had a discharge diagnosis of stroke and 173 had a diagnosis of AIS. We excluded patients with bilateral (n=21) and brainstem (n=21) AIS. There were 64 patients with left hemisphere AIS including 19 with LVO. There were 67 patients with right hemisphere AIS including 22 with LVO. A score of ≥ 4 points yielded a sensitivity of 84.2 (95% CI = 60.4-96.6) and specificity of 66.7 (51.1-80.0) for left hemisphere LVO compared to a sensitivity of 68.2 (45.1-86.1) and specificity of 73.9 (58.9-85.7) for right hemisphere LVO. For predicting a left hemisphere LVO, the AUC was 0.77 (0.65-0.90) compared to 0.66 (0.50-0.82) for right-sided LVO. Assigning 2 points for abnormal gaze yielded an AUC of 0.78 (0.66-0.91) versus 0.67 (0.52-0.83) for left and right hemisphere LVO, respectively. Conclusions: The EMSA, like the National Institutes of Health Stroke Scale (NIHSS) upon which it is based, is more sensitive to left compared to right hemisphere LVO. More heavily weighting abnormal gaze did not improve the sensitivity of the EMSA for right hemisphere LVO. There is no comparable data on the right versus left hemisphere performance of other prehospital scales. There is a need to develop sensitive tests of right hemisphere dysfunction that are suitable for use in the field.

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