Abstract WP264:
            Be Fast
            - Redefined

Introduction: Simple prehospital assessment tools for identifying patients with large vessel occlusion remains a challenge. This study evaluated the mnemonic BE FAST with modified designations for the detection of large vessel occlusion by evaluation of select symptoms ( B alance/Coordination, E ye Deviation, F acial Weakness, A rm/Leg Weakness, S lurred Speech/ S ensory Deficits, T ime of Onset). Methods: Retrospective chart review for all patients (July 2014 to June 2015) with discharge diagnosis of ischemic stroke was performed excluding hemorrhagic stroke and TIAs. Presenting symptoms, physical findings and NIH score were used to determine a BE FAST score. Imaging was evaluated for presence of large vessel occlusion (LVO) and stroke. Comorbidities and interventions were recorded. A presumptive BE FAST cut-off value for identifying LVO was made and confirmed using Two-step Cluster Technique and data dichotomized based on the cut-off. Chi-Square Tests were then used to determine if an association existed between dichotomized BE FAST scores and rates of LVO. Diagnostic sensitivity, specificity, and accuracy were then calculated using this cut-off value. Findings: 526 patient charts were identified and 455 patient charts remained after application of exclusion criteria. Of 108 patients with LVO, 18 patients had a BE FAST score <4 (16.7%) and 90 patients had a score ≥4 (83.3%). Of the 347 patients without LVO, 260 (74.9%) had a score <4 and 87 (25.1%) had a score of ≥ 4. Differences in the rates of LVO based on this cut-off were significant (p<0.001). Only atrial fibrillation and BE FAST score ≥4 were predictive of LVO, odds ratios of 1.89 (95% CI: 1.035 - 3.456; p=0.038) and 19.5 (95% CI: 10.474 - 36.293; p<0.001), respectively. The sensitivity for the BE FAST score in the detection of LVO was calculated as 83%. The diagnostic accuracy of the BE FAST score with a threshold of 4 was calculated as 77%. Conclusion: The modified BE FAST score, as defined here, may serve as a useful prehospital assessment tool for identifying patients with large vessel occlusion. The simplicity of the tool may reduce time to appropriate intervention. Prospective research is needed to confirm these findings and to determine inter- and intra-rater reliability of this modified BE FAST score.

Download Full-text

Validated pre-hospital stroke scales to predict large vessel occlusion: a systematic review

Australasian Journal of Paramedicine ◽

10.33151/ajp.16.705 ◽

2019 ◽

Vol 16 ◽

Cited By ~ 1

Author(s):

Wayne Loudon ◽

Andrew Wong ◽

Mark Disney ◽

Vivienne Tippett

Keyword(s):

Systematic Review ◽

Clinical Assessment ◽

Intravenous Thrombolysis ◽

Assessment Tools ◽

Large Vessel ◽

Hospital Environment ◽

Large Vessel Occlusion ◽

Medical Systems ◽

Vessel Occlusion ◽

Sensitivity Specificity

Background Occlusions of large cerebral vessels, including the internal carotid artery and middle cerebral artery, result in significant burden of morbidity. Treatment was previously limited to intravenous thrombolysis, however multiple studies have shown significant improvements when patients undergo endovascular clot retrieval. Early identification and triage to centres capable of delivering this is likely to contribute to improved outcomes. This systematic review aims to compare clinical assessment tools and their performance ‘in-field’ to identify usability and reliability to assist pre-hospital providers with identification of this sub-group of stroke patients. MethodsSeveral databases were reviewed to identify studies that have validated large vessel occlusion clinical assessment tools within the pre-hospital environment. Sensitivity, specificity and predictive value were compared along with any biases. Six studies met the study criteria and were included. A total of 1384 patients were involved in the studies with sensitivities ranging from 51.9% to 100% and specificities ranging from 68% to 90%.ConclusionThere is significant variation among studies and the emergency medical systems they have been performed within. It is likely that no single tool will suit every system and further research is required to determine the best tool for the Australian pre-hospital environment.

Download Full-text

Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review

The Ultrasound Journal ◽

10.1186/s13089-019-0143-6 ◽

2019 ◽

Vol 11 (1) ◽

Cited By ~ 1

Author(s):

Daria Antipova ◽

Leila Eadie ◽

Ashish Stephen Macaden ◽

Philip Wilson

Keyword(s):

Systematic Review ◽

Diagnostic Accuracy ◽

Acute Stroke ◽

Clinical Assessment ◽

Assessment Tools ◽

Large Vessel ◽

Cochrane Library ◽

Direct Transfer ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Abstract Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

Download Full-text

Abstract TMP35: Clinical Stroke Scales in Predicting Large Vessel Occlusion: A Metaanalysis

Stroke ◽

10.1161/str.48.suppl_1.tmp35 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

W Y kong ◽

Andrew Choong ◽

Nicholas Syn ◽

Vijay K Sharma ◽

Hock L Teoh ◽

...

Keyword(s):

Reference Lists ◽

Data Extraction ◽

Meta Analysis ◽

Arterial Occlusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Computed Tomography Angiogram ◽

Sensitivity Specificity ◽

Stroke Centre

Background: Identifying large vessel occlusion (LVO) is paramount in the era of endovascular therapy. This can be achieved easily by computed tomography angiogram(CTA) and magnetic resonance angiography(MRA). National Institute Health Stroke Scale(NIHSS) threshold can be used in primary stroke centre(PSC) without these facilities, to identify patients with LVO for transfer to a comprehensive stroke centre (CSC) for mechanical thrombectomy. Alternatively, simplified clinical stroke scales (CSS)can also be used by emergency medical services (EMS) to identify such patients to be directly transported to CSC. We aim to compare various CSS in predicting LVO in ischemic stroke. Methods: We searched PUBMED from January 2005 to July 2016 and screened reference lists of included studies, and included all diagnostic accuracy studies that investigate CSS and prediction of LVO confirmed with CTA or MRA. Two authors independently screened titles and abstracts and perform data extraction for analysis. Pooled sensitivity, specificity and diagnostic odd ratio (DOR) of various CSS were obtained using the random effects model. Result: 8 studies (total 8556 patients) were included for meta-analysis of 3 CSS. This includes the NIHSS≥5, ≥6, ≥10, ≥13; Cincinnati Prehospital Stroke Scale (CPSS)≥2 and Rapid Arterial oCclusion Evaluation (RACE) ≥ 5. Pooled sensivity and specificty for the respective cut off values of these CSS was metaanalysed and presented in table 1. NIHSS≥13 has the highest DOR (26.0), followed by NIHSS≥5 (16.9); whereas other NIHSS thresholds, CPSS and RACE were less predictive. NIHSS≥5 was found to have the highest sensitivity of 0.865 and NIHSS≥13 had the highest specificity of 0.934. Conclusion: We found 2 NIHSS thresholds that were most useful for identifying LVO. Depending on resources and preferences of each stroke centre, different NIHSS threshold can be utilized for purpose of ruling in LVO using a high NIHSS threshold, or ruling out LVO using a low NIHSS threshold.

Download Full-text

Abstract W P112: Natural History and Outcomes of Ischemic Stroke Patients with Mild Presenting Symptoms and Large Vessel Occlusion

Stroke ◽

10.1161/str.45.suppl_1.wp112 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Cerejo Russell ◽

Esteban Cheng-Ching ◽

M Shazam Hussain ◽

Ken Uchino ◽

Ferdinand Hui ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Large Vessel ◽

Treatment Modalities ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Acute Therapy ◽

Presenting Symptoms ◽

Significant Difference

Introduction: Large vessel occlusion (LVO) is thought to be an independent predictor of clinical outcome in acute ischemic stroke (AIS). Despite various available treatment modalities, optimal therapy for LVO patients presenting with mild symptoms is not known. These patients remain a significant challenge in clinical practice. Methods: Retrospective chart review of AIS patients admitted between January 2010 and August 2012 at a large tertiary care center. Inclusion criteria: symptom onset within 8 hours, LVO as cause of symptoms, initial NIH stroke scale (NIHSS) < 8. Patients with bilateral lesions, distal small vessel involvement or single vertebral artery disease were excluded. Tandem lesions were included. Patient demographics, administered therapies and short term clinical outcomes were analyzed. Results: A total of 51 patients (56.9% male; mean age 66.4±14.5) fulfilled our strict criteria for inclusion. MCA involvement was seen in 31 (60.8%), ICA 13 (25.5%), basilar 3 (5.9%) and tandem ICA-MCA in 4 (7.8%). A total of 15 (29.4%) received acute therapy with IV t-PA and/or endovascular intervention (TX); both were used only in 6 (11.8%). Follow-up at 30 days was available in 64.7% of patients: 58.3% with TX and 80% without. Mean NIHSS remained relatively stable showing 4.3±2.1 on admission, and 2.6±3.4 on discharge (NS), with 75.8% of patients having same or better NIHSS on follow-up. There was a significant difference in functional outcome: mRS≤2 was present in 98% of patients on admission, but only in 63.6% at follow-up. If extended the mRS range, 90.9% of patients had mRS≤3 on follow-up. Only 33.3% at follow-up had same or better mRS than on admission. Results were consistent, irrespective of receiving acute therapy. Conclusion: Acute LVO with mild presenting symptoms remains a difficult therapeutic challenge. Our data shows that despite stable gross clinical examination (by NIHSS) on follow-up, a large proportion of patients experience mild to moderately worse functional outcome, irrespective of receiving acute therapy. Our study limitations include retrospective analysis and suboptimal patient follow-up, especially in untreated patient population. We believe that a prospective, larger cohort is warranted to find optimal treatment approach.

Download Full-text

Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014519 ◽

2018 ◽

Vol 11 (8) ◽

pp. 751-756 ◽

Cited By ~ 15

Author(s):

David Carrera ◽

Montse Gorchs ◽

Marisol Querol ◽

Sònia Abilleira ◽

Marc Ribó ◽

...

Keyword(s):

Area Under The Curve ◽

Its Region ◽

Final Diagnosis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Geographical Differences ◽

Vessel Occlusion ◽

Remote Areas ◽

Direct Admission ◽

Sensitivity Specificity

Background and purposeOur aim was to revalidate the RACE scale, a prehospital tool that aims to identify patients with large vessel occlusion (LVO), after its region-wide implementation in Catalonia, and to analyze geographical differences in access to endovascular treatment (EVT).MethodsWe used data from the prospective CICAT registry (Stroke Code Catalan registry) that includes all stroke code activations. The RACE score evaluated by emergency medical services, time metrics, final diagnosis, presence of LVO, and type of revascularization treatment were registered. Sensitivity, specificity, and area under the curve (AUC) for the RACE cut-off value ≥5 for identification of both LVO and eligibility for EVT were calculated. We compared the rate of EVT and time to EVT of patients transferred from referral centers compared with those directly presenting to comprehensive stroke centers (CSC).ResultsThe RACE scale was evaluated in the field in 1822 patients, showing a strong correlation with the subsequent in-hospital evaluation of the National Institute of Health Stroke Scale evaluated at hospital (r=0.74, P<0.001). A RACE score ≥5 detected LVO with a sensitivity 0.84 and specificity 0.60 (AUC 0.77). Patients with RACE ≥5 harbored a LVO and received EVT more frequently than RACE <5 patients (LVO 35% vs 6%; EVT 20% vs 6%; all P<0.001). Direct admission at a CSC was independently associated with higher odds of receiving EVT compared with admission at a referral center (OR 2.40; 95% CI 1.66 to 3.46), and symtoms onset to groin puncture was 133 min shorter.ConclusionsThis large validation study confirms RACE accuracy to identify stroke patients eligible for EVT, and provides evidence of geographical imbalances in the access to EVT to the detriment of patients located in remote areas.

Download Full-text

Efficacy and Safety of Recanalization Therapy for Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽

10.1161/strokeaha.119.028624 ◽

2020 ◽

Vol 51 (7) ◽

pp. 2026-2035 ◽

Cited By ~ 2

Author(s):

Wen Hui ◽

Chuanjie Wu ◽

Wenbo Zhao ◽

Huan Sun ◽

Jun Hao ◽

...

Keyword(s):

Clinical Trials ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Assessment Tools ◽

Large Vessel ◽

Cochrane Central Register ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Intraarterial Thrombolysis

Background and Purpose: The optimal recanalization strategy for acute ischemic stroke with large vessel occlusion continues to be an area of active interest. Network meta-analysis can provide insight when direct comparative evidence is lacking. Methods: A systematic review of the literature using PubMed, Embase, the Cochrane Central Register of Controlled Trials, and SinoMed was performed, and a search was conducted for clinical trials on ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and StrokeCenter.org. Four independent reviewers conducted the study selection, data abstraction, and quality assessments. Results: The literature review identified 17 trials including 3236 patients and 8 ongoing clinical trials. Sample sizes ranged from 7 to 656 participants. Intravenous thrombolysis (IVT) was the most common intervention, followed by IVT plus mechanical thrombectomy (MT), IVT plus intraarterial thrombolysis, intraarterial thrombolysis alone, and MT alone. In the pooled network meta-analysis, IVT+MT was associated with a higher rate of independent functioning. In contrast, IVT was ranked as the most ineffective treatment strategy with respect to neurological functions, while direct MT was ranked as the least safe intervention with respect to all-cause mortality. Also, irrespective of assessment tools, endovascular treatment plus IVT led to higher successful recanalization rate than thrombolysis alone. Conclusions: Compared with other recanalization treatments, IVT+MT seems to be the most effective strategy, without increasing detrimental effects, for thrombolysis-eligible patients with large vessel occlusion-acute ischemic stroke. To improve the current evidentiary basis for recanalization treatment, future trials and real-world studies are warranted and should use unified definitions of symptomatic intracranial hemorrhage and recanalization.

Download Full-text

Abstract TP393: Standardization of Large Vessel Occlusion Assessment With Designated Stroke Zone Decreases Door in Door Out Times

Stroke ◽

10.1161/str.51.suppl_1.tp393 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Kimberley Duke ◽

Richelle Hartman ◽

Jeffrey Roth

Keyword(s):

Best Practices ◽

Screening Tool ◽

Assessment Tool ◽

Early Recognition ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Population ◽

Before And After ◽

Evaluation Of Data

Background and Purpose: Increased Door in door out (DIDO) times prompted a change in the “Code Stroke” process in three sister Primary Stroke Centers. It was observed that utilizing a NIHSS >6 was insufficient in recognizing potential large vessel occlusion (LVO) candidates and correlated with an increase in the DIDO times of patients presenting to the Emergency Department (ED) with large vessel symptoms. After a “pilot” of the Vision, Aphasia, and Neglect (VAN) assessment tool in 2017, all three facilities initiated changes to the “Code Stroke” process. These changes included the implementation of the VAN assessment and the designation of a “Stroke Zone”. Methods: Data was collected from 2016 through the second quarter of 2019 on all “Code Strokes” activated in the ED. This data was analyzed to determine the efficacy of implementing the VAN assessment and designation of a “Stroke Zone”. Nursing staff and ED providers were educated on the utilization of the VAN assessment tool and the inclusion of a Computed Tomography Angiography (CTA) on patients presenting with a positive VAN assessment and symptom onset less than 24 hours. The number of Mechanical Endovascular Reperfusion (MER) candidates and the average DIDO times per quarter were compared before and after the implementation of the changes. Results: Evaluation of data from the three facilities showed that implementing a standardized LVO assessment tool in conjunction with a designated “Stroke Zone” increased the identification of potential LVO candidates and decreased DIDO times. Conclusion: The standardization of an LVO screening tool and utilization of a dedicated “Stroke Zone” contributed to a decrease in DIDO times in all three facilities. Efficacy of the changes to the process will assist in supporting best practices while caring for patients in the Stroke population. In addition, the early recognition of LVO candidates will positively impact Door to Needle times.

Download Full-text