Novel Prehospital Triage Scale for Detecting Large Vessel Occlusion and Its Cause

Jianan Wang, Xiaoxian Gong, Wansi Zhong, Ying Zhou, Min Lou, Jianan Wang, Xiaoxian Gong, Wansi Zhong, Ying Zhou, Min Lou

Abstract

Background Patients with large vessel occlusion stroke (LVOS) need to be rapidly identified and transferred to comprehensive stroke centers. However, current prehospital evaluation and strategies still remain challenging. Methods and Results We retrospectively reviewed our prospectively collected database of patients with acute ischemic stroke (AIS). Based on the items of National Institutes of Health Stroke Scale and medical history that had a strong association with LVOS, we designed the 4-item Stroke Scale (4I-SS) and validated it in multi-centers. The 4I-SS incorporated gaze, level of consciousness, arm weakness, and atrial fibrillation. Receiver operating characteristic analysis was used to compare the 4I-SS with previously established prehospital prediction scales. Finally, 1630 and 11 440 patients were included in the derivation and validation cohort, respectively. In the validation cohort, Youden Index, area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the 4I-SS≥4 to predict LVOS were 0.494, 0.800, 0.657, 0.837, 0.600, 0.868, and 0.788, respectively, and that of the 4I-SS≥7 to predict basilar artery occlusion were 0.200, 0.669, 0.229, 0.971, 0.066, 0.974, and 0.899, respectively. Youden Index and area under the curve were higher than previously published scales for predicting LVOS. Further analysis showed that for predicting whether cardiogenic embolism was the cause, its accuracy was 0.922 when the 4I-SS score, including atrial fibrillation, was ≥6, and its accuracy of predicting the occluded vessel was intracranial internal carotid artery or M1 segment of the middle cerebral artery when it was ≥7 was 0.590. Conclusions The 4I-SS is an effective and simple tool that can identify LVOS and its cause. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03317639.

Keywords: 4I‐SS; LVOS; NIHSS; cardiogenic embolism.

Conflict of interest statement

None.

Figures

Figure 1. Sensitivity and specificity of different…
Figure 1. Sensitivity and specificity of different cutoff values of the 4‐Item Stroke Scale in detecting large vessel occlusion stroke in the derivation cohort.

References

    1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, American Heart Association Stroke Council , et al.; 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46–e110. doi: 10.1161/STR.0000000000000158
    1. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21. doi: 10.1056/NEJMoa1706442.
    1. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–2306. doi: 10.1056/NEJMoa1503780.
    1. Fothergill RT, Williams J, Edwards MJ, Russell IT, Gompertz P. Does use of the recognition of stroke in the emergency room stroke assessment tool enhance stroke recognition by ambulance clinicians? Stroke. 2013;44:3007–3012. doi: 10.1161/STROKEAHA.13.000851.
    1. Huwez FU. The FAST tool is effective but not for posterior fossa stroke. BMJ. 2015;350:h994. doi: 10.1136/bmj.h994.
    1. Hastrup S, Damgaard D, Johnsen SP, Andersen G. Prehospital acute stroke severity scale to predict large artery occlusion: design and comparison with other scales. Stroke. 2016;47:1772–1776. doi: 10.1161/STROKEAHA.115.012482.
    1. Katz BS, McMullan JT, Sucharew H, Adeoye O, Broderick JP. Design and validation of a prehospital scale to predict stroke severity: cincinnati prehospital stroke severity scale. Stroke. 2015;46:1508–1512. doi: 10.1161/STROKEAHA.115.008804.
    1. Vidale S, Agostoni E. Prehospital stroke scales and large vessel occlusion: a systematic review. Acta Neurol Scand. 2018;138:24–31. doi: 10.1111/ane.12908.
    1. Pérez de la Ossa N, Carrera D, Gorchs M, Querol M, Millán M, Gomis M, Dorado L, López‐Cancio E, Hernández‐Pérez M, Chicharro V, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014;45:87–91. doi: 10.1161/STROKEAHA.113.003071.
    1. Scheitz JF, Abdul‐Rahim AH, MacIsaac RL, Cooray C, Sucharew H, Kleindorfer D, Khatri P, Broderick JP, Audebert HJ, Ahmed N, et al. Clinical selection strategies to identify ischemic stroke patients with large anterior vessel occlusion: results from SITS‐ISTR (Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Registry). Stroke. 2017;48:290–297. doi: 10.1161/STROKEAHA.116.014431.
    1. Lima FO, Silva GS, Furie KL, Frankel MR, Lev MH, Camargo ÉCS, Haussen DC, Singhal AB, Koroshetz WJ, Smith WS, et al. Field assessment stroke triage for emergency destination: a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke. 2016;47:1997–2002. doi: 10.1161/STROKEAHA.116.013301.
    1. Teleb MS, Ver Hage A, Carter J, Jayaraman MV, McTaggart RA. Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J NeuroIntervent Surg. 2017;9:122–126. doi: 10.1136/neurintsurg-2015-012131.
    1. Ollikainen JP, Janhunen HV, Tynkkynen JA, Mattila KM, Halinen MM, Oksala NK, Pauniaho SK. The finnish prehospital stroke scale detects thrombectomy and thrombolysis candidates—a propensity score‐matched study. J Stroke Cerebrovasc Dis. 2018;27:771–777. doi: 10.1016/j.jstrokecerebrovasdis.2017.10.015.
    1. Singer OC, Dvorak F, du Mesnil de Rochemont R, Lanfermann H, Sitzer M, Neumann‐Haefelin T. A simple 3‐item stroke scale: comparison with the national institutes of health stroke scale and prediction of middle cerebral artery occlusion. Stroke. 2005;36:773–776. doi: 10.1161/01.STR.0000157591.61322.df.
    1. Gong X, Chen Z, Shi F, Zhang M, Xu C, Zhang R, Lou M. Conveniently‐grasped field assessment stroke triage (CG‐FAST): a modified scale to detect large vessel occlusion stroke. Front Neurol. 2019;10:390. doi: 10.3389/fneur.2019.00390.
    1. Harbison J, Hossain O, Jenkinson D, Davis J, Louw SJ, Ford GA. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke. 2003;34:71–76. doi: 10.1161/01.STR.0000044170.46643.5E.
    1. Noorian AR, Sanossian N, Shkirkova K, Liebeskind DS, Eckstein M, Stratton SJ, Pratt FD, Conwit R, Chatfield F, Sharma LK, et al. Los angeles motor scale to identify large vessel occlusion: prehospital validation and comparison with other screens. Stroke. 2018;49:565–572. doi: 10.1161/STROKEAHA.117.019228.
    1. Heldner MR, Zubler C, Mattle HP, Schroth G, Weck A, Mono M‐L, Gralla J, Jung S, El‐Koussy M, Lüdi R, et al. National institutes of health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke. 2013;44:1153–1157. doi: 10.1161/STROKEAHA.111.000604.
    1. Purrucker JC, Härtig F, Richter H, Engelbrecht A, Hartmann J, Auer J, Hametner C, Popp E, Ringleb PA, Nagel S, et al. Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH stroke scale for emergency medical services. bmj Open. 2017;7:e016893. doi: 10.1136/bmjopen-2017-016893.
    1. Beume LA, Hieber M, Kaller CP, Nitschke K, Bardutzky J, Urbach H, Weiller C, Rijntjes M. Large vessel occlusion in acute stroke. Stroke. 2018;49:2323–2329. doi: 10.1161/STROKEAHA.118.022253.
    1. Fischer U, Arnold M, Nedeltchev K, Brekenfeld C, Ballinari P, Remonda L, Schroth G, Mattle HP. NIHSS score and arteriographic findings in acute ischemic stroke. Stroke. 2005;36:2121–2125. doi: 10.1161/01.STR.0000182099.04994.fc.
    1. Maas MB, Furie KL, Lev MH, Ay H, Singhal AB, Greer DM, Harris GJ, Halpern E, Koroshetz WJ, Smith WS. National institutes of health stroke scale score is poorly predictive of proximal occlusion in acute cerebral ischemia. Stroke. 2009;40:2988–2993. doi: 10.1161/STROKEAHA.109.555664.
    1. Inoue M, Noda R, Yamaguchi S, Tamai Y, Miyahara M, Yanagisawa S, Okamoto K, Hara T, Takeuchi S, Miki K, et al. Specific factors to predict large‐vessel occlusion in acute stroke patients. J Stroke Cerebrovasc Dis. 2018;27:886–891. doi: 10.1016/j.jstrokecerebrovasdis.2017.10.021.
    1. Hendrix P, Sofoluke N, Adams MD, Kunaprayoon S, Zand R, Kolinovsky AN, Person TN, Gupta M, Goren O, Schirmer CM, et al. Risk factors for acute ischemic stroke caused by anterior large vessel occlusion. Stroke. 2019;50:1074–1080. doi: 10.1161/STROKEAHA.118.023917.
    1. Pagola J, Juega J, Francisco‐Pascual J, Bustamante A, Penalba A, Pala E, Rodriguez M, De Lera Alfonso M, Arenillas JF, Cabezas JA, et al. Large vessel occlusion is independently associated with atrial fibrillation detection. Eur J Neurol. 2020;27:1618–1624. doi: 10.1111/ene.14281.
    1. Kim B, Kim YM, Jin SC, Lee JW, Lee BI, Kim SE, Shin KJ, Park J, Park KM, Kim SE, et al. Development of a predictive scale for cardioembolic stroke using extracted thrombi and angiographic findings. J Clin Neurosci. 2020;73:224–230. doi: 10.1016/j.jocn.2020.01.089.
    1. Zhou Y, Xu C, Zhang R, Shi F, Liu C, Yan S, Ding X, Zhang M, Lou M. Longer length of delayed‐contrast filling of clot on 4‐dimensional computed tomographic angiography predicts cardiogenic embolism. Stroke. 2019;50:2568–2570. doi: 10.1161/STROKEAHA.118.024411.
    1. Zhang R, Zhou Y, Liu C, Zhang M, Yan S, Liebeskind DS, Lou M. Overestimation of susceptibility vessel sign: a predictive marker of stroke cause. Stroke. 2017;48:1993–1996. doi: 10.1161/STROKEAHA.117.016727.
    1. Ahn SH, Hong R, Choo IS, Heo JH, Nam HS, Kang HG, Kim HW, Kim JH. Histologic features of acute thrombi retrieved from stroke patients during mechanical reperfusion therapy. Int J stroke. 2016;11:1036–1044. doi: 10.1177/1747493016641965.
    1. Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol. 2011;10:1002–1014. doi: 10.1016/S1474-4422(11)70229-0.
    1. Greving JP, Schonewille WJ, Wijman CA, Michel P, Kappelle LJ, Algra A, Group BS . Predicting outcome after acute basilar artery occlusion based on admission characteristics. Neurology. 2012;78:1058–1063. doi: 10.1212/WNL.0b013e31824e8f40.
    1. Gulli G, Markus HS. The use of fast and ABCD2 scores in posterior circulation, compared with anterior circulation, stroke and transient ischemic attack. J Neurol Neurosurg Psychiatry. 2012;83:228–229. doi: 10.1136/jnnp.2010.222091.
    1. Schwamm LH, Ntaios G. Short cuts make long delays: getting it right from the start in prehospital stroke triage. Neurology. 2020;94:341–342. doi: 10.1212/WNL.0000000000008994.

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