1
|
Lakhani DA, Mehta TR, Balar AB, Koneru M, Wen S, Ozkara BB, Caplan J, Dmytriw AA, Wang R, Lu H, Hoseinyazdi M, Nabi M, Mazumdar I, Cho A, Chen K, Sepehri S, Hyson N, Xu R, Urrutia V, Luna L, Hillis AH, Heit JJ, Albers GW, Rai AT, Faizy TD, Wintermark M, Nael K, Yedavalli VS. The Los Angeles motor scale (LAMS) is independently associated with CT perfusion collateral status markers. J Clin Neurosci 2024; 125:32-37. [PMID: 38735251 DOI: 10.1016/j.jocn.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/31/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND AND AIM The Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases. MATERIALS AND METHODS In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant. RESULTS In total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05). CONCLUSION LAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS.
Collapse
Affiliation(s)
- Dhairya A Lakhani
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA.
| | - Tejas R Mehta
- Department of Neurology, University of missouri, Columbia, MO, USA
| | - Aneri B Balar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | | | - Justin Caplan
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Adam A Dmytriw
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Hanzhang Lu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ishan Mazumdar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew Cho
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Sadra Sepehri
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Nathan Hyson
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Risheng Xu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Victor Urrutia
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Argye H Hillis
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Jeremy J Heit
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Greg W Albers
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Ansaar T Rai
- Department of Neuroradiology, West Virginia University, Morgantown, WV, USA
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Division - University Medical Center Münster, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, TX
| | - Kambiz Nael
- Division of Neuroradiology, Department of Radiology, University of California San Francisco, CA, USA
| | - Vivek S Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
2
|
Paxton JH, Keenan KJ, Wilburn JM, Wise SL, Klausner HA, Ball MT, Dunne RB, Kreitel KD, Morgan LF, Fales WD, Madhok D, Barazangi N, McLean ST, Cross K, Distenfield L, Sykes J, Lovoi P, Johnson B, Smith WS. Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. Acad Emerg Med 2024. [PMID: 38643419 DOI: 10.1111/acem.14919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.
Collapse
Affiliation(s)
- James H Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, California, USA
| | - John M Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Stefanie L Wise
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Howard A Klausner
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Matthew T Ball
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - K Derek Kreitel
- Department of Radiology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Larry F Morgan
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - William D Fales
- Department of Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Debbie Madhok
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Nobl Barazangi
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | - Steven T McLean
- Department of Emergency Medicine, Ascension St. Mary's Hospital, Saginaw, Michigan, USA
| | - Katherine Cross
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | | | - Paul Lovoi
- MindRhythm, Inc., Cupertino, California, USA
| | | | - Wade S Smith
- Department of Neurology, University of California, Davis, Sacramento, California, USA
| |
Collapse
|
3
|
Habib P, Dimitrov I, Pinho J, Schürmann K, Bach JP, Wiesmann M, Schulz JB, Reich A, Nikoubashman O. Point-of-Care Ultrasound to Detect Acute Large Vessel Occlusions in Stroke Patients: A Proof-of-Concept Study. Can J Neurol Sci 2023; 50:656-661. [PMID: 35872570 DOI: 10.1017/cjn.2022.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A primary admission of patients with suspected acute ischemic stroke and large vessel occlusion (LVO) to centers capable of providing endovascular stroke therapy (EVT) may induce shorter time to treatment and better functional outcomes. One of the limitations in this strategy is the need for accurately identifying LVO patients in the prehospital setting. We aimed to study the feasibility and diagnostic performance of point-of-care ultrasound (POCUS) for the detection of LVO in patients with acute stroke. METHODS We conducted a proof-of-concept study and selected 15 acute ischemic stroke patients with angiographically confirmed LVO and 15 patients without LVO. Duplex ultrasonography (DUS) of the common carotid arteries was performed, and flow profiles compatible with LVO were scored independently by one experienced and one junior neurologist. RESULTS Among the 15 patients with LVO, 6 patients presented with an occlusion of the carotid-T and 9 patients presented with an M1 occlusion. Interobserver agreement between the junior and the experienced neurologist was excellent (kappa = 0.813, p < 0.001). Flow profiles of the CAA allowed the detection of LVO with a sensitivity of 73%, a positive predictive value of 92 and 100%, and a c-statistics of 0.83 (95%CI = 0.65-0.94) and 0.87 (95%CI = 0.69-0.94) (experienced neurologist and junior neurologist, respectively). In comparison with clinical stroke scales, DUS was associated with better trade-off between sensitivity and specificity. CONCLUSION POCUS in acute stroke setting is feasible, it may serve as a complementary tool for the detection of LVO and is potentially applicable in the prehospital phase.
Collapse
Affiliation(s)
- Pardes Habib
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Ivaylo Dimitrov
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Kolja Schürmann
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Jan Philipp Bach
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| |
Collapse
|
4
|
Aderinto N, Olatunji D, Abdulbasit M, Edun M. The essential role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa: a review. Ann Med 2023; 55:2251490. [PMID: 37643607 PMCID: PMC10496522 DOI: 10.1080/07853890.2023.2251490] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/11/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Cerebrovascular disease is a significant cause of morbidity and mortality in Africa, and using neuroimaging techniques has improved the diagnosis and management of this disease. However, there is a lack of comprehensive reviews of the role and effectiveness of neuroimaging techniques in the African context. METHODS We reviewed the literature to evaluate the role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. Our search included electronic databases such as PubMed, Scopus, and Google Scholar from 2000 to April 2023. We included peer-reviewed studies written in English that reported on the use of neuroimaging in diagnosing and managing cerebrovascular disease in African populations. We excluded non-peer-reviewed articles, letters, editorials, and studies unrelated to cerebrovascular disease, neuroimaging, or Africa. A total of 102 potential articles were identified; after applying our exclusion criteria and removing duplicated articles, 51 articles were reviewed. RESULTS Our findings suggest that neuroimaging techniques such as CT, MRI, and Skull x-ray play a crucial role in diagnosing and managing cerebrovascular disease in Africa. CT and MRI were the most commonly used techniques, with CT being more widely available and less expensive than MRI. However, challenges to using neuroimaging in Africa include the high cost of equipment and maintenance, lack of trained personnel, and inadequate infrastructure. These challenges limit the widespread use of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. CONCLUSION Neuroimaging techniques are essential for diagnosing and managing cerebrovascular disease in Africa, but challenges to their use must be addressed to improve healthcare outcomes. Our policy recommendations can help improve the availability and accessibility of neuroimaging services in Africa.
Collapse
Affiliation(s)
- Nicholas Aderinto
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Nigeria
| | - Deji Olatunji
- Department of Medicine and Surgery, University of Ilorin, Nigeria
| | - Muili Abdulbasit
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Nigeria
| | - Mariam Edun
- Department of Medicine and Surgery, University of Ilorin, Nigeria
| |
Collapse
|
5
|
Arthur KC, Huang S, Gudenkauf JC, Mohseni A, Wang R, Aslan A, Nabi M, Hoseinyazdi M, Johnson B, Patel N, Urrutia VC, Yedavalli V. Assessing the Relationship between LAMS and CT Perfusion Parameters in Acute Ischemic Stroke Secondary to Large Vessel Occlusion. J Clin Med 2023; 12:jcm12103374. [PMID: 37240480 DOI: 10.3390/jcm12103374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity which has also been shown to accurately predict large vessel occlusions (LVOs). However, to date there is no study exploring whether LAMS correlates with the computed tomography perfusion (CTP) parameters in LVOs. METHODS Patients with LVO between September 2019 and October 2021 were retrospectively reviewed and included if the CTP data and admission neurologic exams were available. The LAMS was documented based on emergency personnel exams or scored retrospectively using an admission neurologic exam. The CTP data was processed by RAPID (IschemaView, Menlo Park, CA, USA) with an ischemic core volume (relative cerebral blood flow [rCBF] < 30%), time-to-maximum (Tmax) volume (Tmax > 6 s delay), hypoperfusion index (HI), and cerebral blood volume (CBV) index. Spearman's correlations were performed between the LAMS and CTP parameters. RESULTS A total of 85 patients were included, of which there were 9 intracranial internal carotid artery (ICA), 53 proximal M1 branch middle cerebral artery M1, and 23 proximal M2 branch occlusions. Overall, 26 patients had LAMS 0-3, and 59 had LAMS 4-5. In total, LAMS positively correlated with CBF < 30% (Correlation Coefficient (CC): 0.32, p < 0.01), Tmax > 6 s (CC:0.23, p < 0.04), HI (CC:0.27, p < 0.01), and negatively correlated with the CBV index (CC:-0.24, p < 0.05). The relationships between LAMS and CBF were < 30% and the HI was more pronounced in M1 occlusions (CC:0.42, p < 0.01; 0.34, p < 0.01 respectively) and proximal M2 occlusions (CC:0.53, p < 0.01; 0.48, p < 0.03 respectively). The LAMS also correlated with a Tmax > 6 s in M1 occlusions (CC:0.42, p < 0.01), and negatively correlated with the CBV index in M2 occlusions (CC:-0.69, p < 0.01). There were no significant correlations between the LAMS and intracranial ICA occlusions. CONCLUSIONS The results of our preliminary study indicate that the LAMS is positively correlated with the estimated ischemic core, perfusion deficit, and HI, and negatively correlated with the CBV index in patients with anterior circulation LVO, with stronger relationships in the M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with the collateral status and estimated ischemic core in patients with LVO.
Collapse
Affiliation(s)
- Karissa C Arthur
- Department of Neurology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Shenwen Huang
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Julie C Gudenkauf
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Alireza Mohseni
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alperen Aslan
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mehreen Nabi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Navangi Patel
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
6
|
Sari A, Saleh Velez FG, Muntz N, Bulwa Z, Prabhakaran S. Validating Existing Scales for Identification of Acute Stroke in an Inpatient Setting. Neurohospitalist 2023; 13:137-143. [PMID: 37064928 PMCID: PMC10091444 DOI: 10.1177/19418744221144343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Background and Purpose A significant proportion of strokes occur while patients are hospitalized for other reasons. Numerous stroke scales have been developed and validated for use in pre-hospital and emergency department settings, and there is growing interest to adapt these scales for use in the inpatient setting. We aimed to validate existing stroke scales for inpatient stroke codes. Methods We retrospectively reviewed charts from inpatient stroke code activations at an urban academic medical center from January 2016 through December 2018. Receiver operating characteristic analysis was performed for each specified stroke scale including NIHSS, FAST, BE-FAST, 2CAN, FABS, TeleStroke Mimic, and LAMS. We also used logistic regression to identify independent predictors of stroke and to derive a novel scale. Results Of the 958 stroke code activations reviewed, 151 (15.8%) had a final diagnosis of ischemic or hemorrhagic stroke. The area under the curve (AUC) of existing scales varied from .465 (FABS score) to .563 (2CAN score). Four risk factors independently predicted stroke: (1) recent cardiovascular procedure, (2) platelet count less than 50 × 109 per liter, (3) gaze deviation, and (4) presence of unilateral leg weakness. Combining these 4 factors into a new score yielded an AUC of .653 (95% confidence interval [CI] .604-.702). Conclusion This study suggests that currently available stroke scales may not be sufficient to differentiate strokes from mimics in the inpatient setting. Our data suggest that novel approaches may be required to help with diagnosis in this unique population.
Collapse
Affiliation(s)
- Adriana Sari
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Faddi G. Saleh Velez
- Department of Neurology, University of Chicago, Chicago, IL, USA
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Nathan Muntz
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Zachary Bulwa
- Department of Neurology, University of Chicago, Chicago, IL, USA
- NorthShore University Health
System, Chicago, IL, USA
| | | |
Collapse
|
7
|
Balucani C, Levine SR, Sanossian N, Starkman S, Liebeskind D, Gornbein JA, Shkirkova K, Stratton S, Eckstein M, Hamilton S, Conwit R, Sharma LK, Saver JL. Neurologic Improvement in Acute Cerebral Ischemia: Frequency, Magnitude, Predictors, and Clinical Outcomes. Neurology 2023; 100:e1038-e1047. [PMID: 36878722 PMCID: PMC9990857 DOI: 10.1212/wnl.0000000000201656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 10/20/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Investigations of rapid neurologic improvement (RNI) in patients with acute cerebral ischemia (ACI) have focused on RNI occurring after hospital arrival. However, with stroke routing decisions and interventions increasingly migrating to the prehospital setting, there is a need to delineate the frequency, magnitude, predictors, and clinical outcomes of patients with ACI with ultra-early RNI (U-RNI) in the prehospital and early postarrival period. METHODS We analyzed prospectively collected data of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized clinical trial. Any U-RNI was defined as improvement by 2 or more points on the Los Angeles Motor Scale (LAMS) score between the prehospital and early post-emergency department (ED) arrival examinations and classified as moderate (2-3 point) or dramatic (4-5 point) improvement. Outcome measures included excellent recovery (modified Rankin Scale [mRS] score 0-1) and death by 90 days. RESULTS Among the 1,245 patients with ACI, the mean age was 70.9 years (SD 13.2); 45% were women; the median prehospital LAMS was 4 (interquartile range [IQR] 3-5); the median last known well to ED-LAMS time was 59 minutes (IQR 46-80 minutes), and the median prehospital LAMS to ED-LAMS time was 33 minutes (IQR 28-39 minutes). Overall, any U-RNI occurred in 31%, moderate U-RNI in 23%, and dramatic U-RNI in 8%. Any U-RNI was associated with improved outcomes, including excellent recovery (mRS score 0-1) at 90 days 65.1% (246/378) vs 35.4% (302/852), p < 0.0001; decreased mortality by 90 days 3.7% (14/378) vs 16.4% (140/852), p < 0.0001; decreased symptomatic intracranial hemorrhage 1.6% (6/384) vs 4.6% (40/861), p = 0.0112; and increased likelihood of being discharged home 56.8% (218/384) vs 30.2% (260/861), p < 0.0001. DISCUSSION U-RNI occurs in nearly 1 in 3 ambulance-transported patients with ACI and is associated with excellent recovery and decreased mortality at 90 days. Accounting for U-RNI may be useful for routing decisions and future prehospital interventions. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov. Unique identifier: NCT00059332.
Collapse
Affiliation(s)
- Clotilde Balucani
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD.
| | - Steven R Levine
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Nerses Sanossian
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Sidney Starkman
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - David Liebeskind
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Jeffrey A Gornbein
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Kristina Shkirkova
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Samuel Stratton
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Marc Eckstein
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Scott Hamilton
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Robin Conwit
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Latisha K Sharma
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Jeffrey L Saver
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| |
Collapse
|
8
|
Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
Collapse
Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
9
|
Yuksen C, Tienpratarn W, Treerasoradaj T, Jenpanitpong C, Termkijwanich P. The Clinical Predictive Score for Prehospital Large Vessel Occlusion Stroke: A Retrospective Cohort Study in the Asian Country. Open Access Emerg Med 2023; 15:53-60. [PMID: 36798910 PMCID: PMC9925388 DOI: 10.2147/oaem.s398061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Background Large vessel occlusive (LVO) stroke causes severe disabilities and occurs in more than 37% of strokes. Reperfusion therapy is the gold standard of treatment. Studies proved that endovascular thrombectomy (EVT) is more beneficial and decreases mortality. This study aimed to evaluate the factor associated with LVO stroke in an Asian population and to develop the scores to predict LVO in a prehospital setting. The score will hugely contribute to the future of stroke care in prehospital settings in the aspect of transferal suspected LVO stroke patients to appropriate EVT-capable stroke centers. Methods This study was a retrospective cohort study using an exploratory model at the emergency department of Ramathibodi Hospital, Bangkok, Thailand, between January 2018 and December 2020. We included the stroke patients aged >18 who visit ED and an available radiologic report representing LVO. Those whose stroke onset was >24 hours and no radiologic report were excluded. Multivariable logistic regression analysis developed the prediction model and score for LVO stroke. Results A total of 252 patients met the inclusion criteria; 61 cases (24%) had LVO stroke. Six independent factors were significantly predictive: comorbidity with atrial fibrillation, clinical hemineglect, gaze deviation, facial palsy, aphasia, and cerebellar sign abnormality. The predicted score had an accuracy of 92.5%. The LVO risk score was categorized into three groups: low risk (LVO score <3), moderate risk (LVO score 3-6), and high risk (LVO score >6). The positive likelihood ratio to predicting LVO stroke were 0.12 (95% CI 0.06-0.26), 2.33 (95% CI 1.53-3.53) and 45.40 (95% CI 11.16-184.78), respectively. Conclusion The Large Vessel Occlusion (LVO) Risk Score provides a screening tool for predicting LVO stroke. A clinical predictive score of ≥3 appears to be associated with LVO stroke.
Collapse
Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Welawat Tienpratarn
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,Correspondence: Welawat Tienpratarn, Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand, Email
| | - Thitibud Treerasoradaj
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Phatcha Termkijwanich
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
10
|
Scoville J, Joyce E, Harper J, Hunsaker J, Gren L, Porucznik C, Kestle JRW. A survey and analysis of pediatric stroke protocols. J Stroke Cerebrovasc Dis 2022; 31:106661. [PMID: 35896054 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/24/2022] [Accepted: 07/17/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives Despite their comparative rarity, about 10,000 ischemic strokes occur in children every year, and no standardized method of treatment exists. Protocols have been effective at increasing diagnosis accuracy and treatment efficacy in adults, but little has been done to evaluate such tools in children. A survey was developed to identify the proportion of pediatric hospitals that have stroke protocols and analyze the components used for diagnosis and treatment to identify consensus. Materials and methods Physicians at 50 pediatric hospitals that contributed to the Pediatric Hospital Inpatient Sample in specialties involved in the treatment of stroke (i.e, neurology, neurosurgery, radiology, pediatric intensive care, and emergency medicine) were invited in a purposive and referral manner to complete and 18-question survey. Consensus agreement was predefined as >75%. Results Of 264 surveys distributed, 93 (35%) were returned, accounting for 46 (92%) hospitals. Among the respondents, 76 (82%) reported the presence of a pediatric stroke protocol at their hospital. Consensus agreement was reached in 9 components, including the use of intravenous tissue plasminogen activator (90%) and mechanical thrombectomy (77%) as treatments for acute stroke. Consensus agreement was not reached in 10 components, including the use of prehospital (16%) and emergency department (59%) screening tools and a centralized contact method (57%). Conclusions Pediatric ischemic stroke is a potentially devastating disease that is potentially reversible if treated early. Most pediatric hospitals have developed stroke protocols to aid in diagnosis and treatment, but there is a lack of consensus on what the protocols should contain.
Collapse
Affiliation(s)
- Jonathan Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive, Salt Lake City, UT 84123, USA; Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive, Salt Lake City, UT 84123, USA
| | - Jonathan Harper
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Joshua Hunsaker
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lisa Gren
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Christina Porucznik
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - John R W Kestle
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive, Salt Lake City, UT 84123, USA
| |
Collapse
|
11
|
Keenan KJ, Smith WS, Cole SB, Martin C, Hemphill JC, Madhok DY. Large vessel occlusion prediction scales provide high negative but low positive predictive values in prehospital suspected stroke patients. BMJ Neurol Open 2022; 4:e000272. [PMID: 35910334 PMCID: PMC9274523 DOI: 10.1136/bmjno-2022-000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction We studied a registry of Emergency Medical Systems (EMS) identified prehospital suspected stroke patients brought to an academic endovascular capable hospital over 1 year to assess the prevalence of disease and externally validate large vessel occlusion (LVO) stroke prediction scales with a focus on predictive values. Methods All patients had last known well times within 6 hours and a positive prehospital Cincinnati Prehospital Stroke Scale. LVO prediction scale scores were retrospectively calculated from emergency department arrival National Institutes of Health Stroke Scale scores. Final diagnoses were determined by chart review. Prevalence and diagnostic performance statistics were calculated. We prespecified analyses to identify scale thresholds with positive predictive values (PPVs) ≥80% and negative predictive values (NPVs) ≥95%. A secondary analysis identified thresholds with PPVs ≥50%. Results Of 220 EMS transported patients, 13.6% had LVO stroke, 15.9% had intracranial haemorrhage, 20.5% had non-LVO stroke and 50% had stroke mimic diagnoses. LVO stroke prevalence was 15.8% among the 184 diagnostic performance study eligible patients. Only Field Assessment Stroke Triage for Emergency Destination (FAST-ED) ≥7 had a PPV ≥80%, but this threshold missed 83% of LVO strokes. FAST-ED ≥6, Prehospital Acute Severity Scale =3 and Rapid Arterial oCclusion Evaluation ≥7 had PPVs ≥50% but sensitivities were <50%. Several standard and lower alternative scale thresholds achieved NPVs ≥95%, but false positives were common. Conclusions Diagnostic performance tradeoffs of LVO prediction scales limited their ability to achieve high PPVs without missing most LVO strokes. Multiple scales provided high NPV thresholds, but these were associated with many false positives.
Collapse
Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California Davis, Sacramento, California, USA
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Wade S Smith
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Sara B Cole
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Christine Martin
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - J Claude Hemphill
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Debbie Y Madhok
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
12
|
Larsen K, Jæger HS, Hov MR, Thorsen K, Solyga V, Lund CG, Bache KG. Streamlining Acute Stroke Care by Introducing National Institutes of Health Stroke Scale in the Emergency Medical Services: A Prospective Cohort Study. Stroke 2022; 53:2050-2057. [PMID: 35291821 PMCID: PMC9126266 DOI: 10.1161/strokeaha.121.036084] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
National Institutes of Health Stroke Scale (NIHSS) is the most validated clinical scale for stroke recognition, severity grading, and symptom monitoring in acute care and hospital settings. Numerous modified prehospital stroke scales exist, but these scales contain less clinical information and lack compatibility with in-hospital stroke scales. In this real-life study, we aimed to investigate if NIHSS conducted by paramedics in the field is a feasible and accurate prehospital diagnostic tool.
Collapse
Affiliation(s)
- Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., H.S.J., K.G.B.)
| | - Henriette S Jæger
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., H.S.J., K.G.B.)
| | - Maren R Hov
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Faculty of Health Sciences, Oslo Metropolitan University, Norway (M.R.H.).,Department of Neurology, Oslo University Hospital, Norway (M.R.H., C.G.L.)
| | - Kjetil Thorsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.)
| | - Volker Solyga
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway (V.S.)
| | - Christian G Lund
- Department of Neurology, Oslo University Hospital, Norway (M.R.H., C.G.L.)
| | - Kristi G Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., H.S.J., K.G.B.)
| |
Collapse
|
13
|
Haight T, Tabaac B, Patrice KA, Phipps MS, Butler J, Johnson B, Aycock A, Toral L, Yarbrough KL, Schrier C, Lawrence E, Goldszmidt A, Marsh EB, Urrutia VC. The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke. Front Neurol 2021; 12:663472. [PMID: 34539541 PMCID: PMC8445030 DOI: 10.3389/fneur.2021.663472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min. Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window. Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed. Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time. Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.
Collapse
Affiliation(s)
- Taylor Haight
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Burton Tabaac
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kelly-Ann Patrice
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jaime Butler
- The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Anna Aycock
- Maryland Institute for Emergency Medical Services System (MIEMSS), Baltimore, MD, United States
| | - Linda Toral
- Sinai Hospital, Baltimore, MD, United States
| | | | - Chad Schrier
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Erin Lawrence
- Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | | | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
14
|
Senovilla-González L, Hernández-Ruiz Á, García-García M. [Comparison of RACE scale to other assessment scales for large vessel arterial occlusions in the out-of-hospital level: a rapid review]. An Sist Sanit Navar 2021; 44:275-289. [PMID: 34170888 PMCID: PMC10019551 DOI: 10.23938/assn.0964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/09/2020] [Accepted: 02/25/2021] [Indexed: 11/18/2022]
Abstract
A significant proportion of ischemic cerebrovascular diseases are due to large vessel arterial occlusions (LVAO). Some emergency services utilize scales to detect LVAO and determine the most appropriate treatment and medical center for the patient. The aim of this review was to compare the predictive value of the RACE scale for recognizing the presence of a LVAO with other scales used in the out-of-hospital setting. A rapid review was performed by applying the PRISMA methodology in PubMed. Twenty articles focused on the pre-hospital setting were retained. The most frequently evaluated instruments were NIHSS, CPSSS, LAMS and RACE. The scales evaluated demonstrated adequate precision in the identification of such an event, without aiming to replace imag-ing tests. The RACE showed a predictive performance comparable to the other scales, although lower than the NIHSS hospital scale, it may therefore be a useful instrument in the out-of-hospital setting.
Collapse
|
15
|
Kass-Hout T, Lee J, Tataris K, Richards CT, Markul E, Weber J, Mendelson S, O'Neill K, Sednew RM, Prabhakaran S. Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke. JAMA Neurol 2021; 78:1220-1227. [PMID: 34369969 DOI: 10.1001/jamaneurol.2021.2485] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain. Objective To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT. Design, Setting, and Participants This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019. Interventions Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers. Main Outcomes and Measures Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset. Results Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window. Conclusions and Relevance Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.
Collapse
Affiliation(s)
- Tareq Kass-Hout
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Jungwha Lee
- Department of Preventive Medicine (Biostatistics), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katie Tataris
- Section of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois.,Chicago EMS System, Chicago, Illinois
| | - Christopher T Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eddie Markul
- Chicago EMS System, Chicago, Illinois.,Department of Emergency Medicine, University of lllinois College of Medicine, Advocate Illinois Masonic Hospital, Chicago, Illinois
| | - Joseph Weber
- Chicago EMS System, Chicago, Illinois.,Department of Emergency Medicine, Cook County Health, Chicago, Illinois
| | - Scott Mendelson
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | | | - Renee M Sednew
- American Heart Association, Midwest Region, Chicago, Illinois
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| |
Collapse
|
16
|
Thomas S, de la Pena P, Butler L, Akbilgic O, Heiferman DM, Garg R, Gill R, Serrone JC. Machine learning models improve prediction of large vessel occlusion and mechanical thrombectomy candidacy in acute ischemic stroke. J Clin Neurosci 2021; 91:383-390. [PMID: 34373056 DOI: 10.1016/j.jocn.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Early identification of large vessel occlusions (LVO) and timely recanalization are paramount to improved clinical outcomes in acute ischemic stroke. A stroke assessment that maximizes sensitivity and specificity for LVOs is needed to identify these cases and not overburden the health system with unnecessary transfers. Machine learning techniques are being used for predictive modeling in many aspects of stroke care and may have potential in predicting LVO presence and mechanical thrombectomy (MT) candidacy. METHODS Ischemic stroke patients treated at Loyola University Medical Center from July 2018 to June 2019 (N = 286) were included. Thirty-five clinical and demographic variables were analyzed using machine learning algorithms, including logistic regression, extreme gradient boosting, random forest (RF), and decision trees to build models predictive of LVO presence and MT candidacy by area of the curve (AUC) analysis. The best performing model was compared with prior stroke scales. RESULTS When using all 35 variables, RF best predicted LVO presence (AUC = 0.907 ± 0.856-0.957) while logistic regression best predicted MT candidacy (AUC = 0.930 ± 0.886-0.974). When compact models were evaluated, a 10-feature RF model best predicted LVO (AUC = 0.841 ± 0.778-0.904) and an 8-feature RF model best predicted MT candidacy (AUC = 0.862 ± 0.782-0.942). The compact RF models had sensitivity, specificity, negative predictive value and positive predictive value of 0.81, 0.87, 0.92, 0.72 for LVO and 0.87, 0.97, 0.97, 0.86 for MT, respectively. The 10-feature RF model was superior at predicting LVO to all previous stroke scales (AUC 0.944 vs 0.759-0.878) and the 8-feature RF model was superior at predicting MT (AUC 0.970 vs 0.746-0.834). CONCLUSION Random forest machine learning models utilizing clinical and demographic variables predicts LVO presence and MT candidacy with a high degree of accuracy in an ischemic stroke cohort. Further validation of this strategy for triage of stroke patients requires prospective and external validation.
Collapse
|
17
|
Modified Prehospital Acute Stroke Severity (mPASS) Scale to Predict Emergent Large Arterial Occlusion. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5568696. [PMID: 34337028 PMCID: PMC8315848 DOI: 10.1155/2021/5568696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 06/21/2021] [Accepted: 07/06/2021] [Indexed: 11/17/2022]
Abstract
Introduction To date, identifying emergent large vessel occlusion (ELVO) patients in the prehospital stage is important but still challenging. In this present study, we aimed to design a modified prehospital acute stroke severity (mPASS) scale to identify ELVO patients and compared the scale to the PASS scale which has been published. Methods We retrospectively evaluated a consecutive cohort of acute ischemic stroke (AIS) in our stroke unit who visited the emergercy department. These patients underwent CT angiography (CTA), MR angiography (MRA), or digital subtraction angiography (DSA) at admission. The mPASS scale was calculated based on the National Institutes of Health Stroke Scale (NIHSS) items retrospectively, including the level of consciousness commands, gaze, arm weakness, and aphasia/dysarthria. Receiver operating characteristic (ROC) analysis was used to obtain the area under the curve (AUC) of the mPASS scale, NIHSS, and PASS scale. U-statistics was used to compare the AUC of the mPASS scale to the NIHSS and PASS scale. Results A total of 382 AIS patients were enrolled. The AUC and specificity of the mPASS scale (0.92, 84.4) were all higher than those of the PASS scale. Cortical symptoms such as gaze palsy and consciousness disorder were more specific indicators for ELVO than motor deficits. Conclusions The mPASS scale had a better discrimination for identifying ELVO than the PASS scale in our retrospective cohort. It might predict ELVO in an effective and simple way for paramedics in the prehospital triage stage or emergency stage. Moreover, cortical symptoms might have relatively high specificities to predict ELVO on their own.
Collapse
|
18
|
Javed K, Boyke A, Naidu I, Ryvlin J, Dardick J, Kadaba D, Altschul DJ, Haranhalli N. Re-Evaluating Stroke Systems of Care: Association of Transfer Status With Thrombectomy Outcomes at an Urban Comprehensive Stroke Center. Cureus 2021; 13:e16732. [PMID: 34513363 PMCID: PMC8405356 DOI: 10.7759/cureus.16732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction Given the efficacy of mechanical thrombectomies (MT) for large vessel occlusions (LVO), there is concern that the Hub and Spoke model of stroke care, which prioritizes initial assessment of the acute ischemic stroke (AIS) patient at a primary stroke center, would cause a delay in arterial reperfusion, thus leading to worse outcomes. In this study that occurred at our comprehensive stroke center in New York, we compared the clinical outcomes of patients that were either directly admitted for thrombectomy versus those who were transferred from another institution. Methods Retrospective review of the electronic medical record (EMR) was performed on all adult patients treated with endovascular therapy for ischemic stroke between January 2016 and February 2020. A bivariate analysis was performed to compare patients in the direct admit versus transfer group. A multivariable logistic regression model was developed to determine which factors affect 90-day modified Rankin score (mRS) and to evaluate if transfer status was an independent predictor in this model. Results Three hundred and twenty-five patients were included in this study; 127 patients belonged to the direct admit group while 198 were in the transfer group. Thirteen patients (20%) in the direct admit group had a 90-day mRS score of 0-2 and so did 29 patients (25.2%) in the transfer group; thus, no statistically significant difference found in clinical outcomes between both groups (p-value = 0.427). In a multivariable logistic regression model that accounts for age, gender, smoking status, baseline mRS, presenting National Institute of Health Stroke Scale (NIHSS), procedure duration, thrombolysis in cerebral infarction (TICI) score, post-NIHSS and decompressive hemicraniectomy, transfer status was not found to be predictive of clinical outcomes (OR 0.727 95% CI 0.349-1.516; p-value = 0.396). Conclusion Transfer status is not significantly associated with 90-day outcome. Since Hub and Spoke is not associated with worse outcomes compared to direct admit, it remains a viable model for providing effective care to stroke patients in an urban setting.
Collapse
Affiliation(s)
- Kainaat Javed
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| | - Andre Boyke
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| | - Ishan Naidu
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| | - Jessica Ryvlin
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| | - Joseph Dardick
- Neurosurgery, Johns Hopkins Medical Institute, Baltimore, USA
| | - Devikarani Kadaba
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| | - David J Altschul
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| | - Neil Haranhalli
- Neurological Surgery, Montefiore Medical Center Moses Campus, New York, USA
| |
Collapse
|
19
|
Nehme A, Rivet S, Choisi TJ, Dallaire M, de Montigny L, Deschaintre Y, Daneault N, Jacquin G, Legault C, Levy JP, Neves Briard J, Odier C, Poppe AY, Segal E, Stapf C, Gioia LC. Prospective Evaluation of a Two-Scale Protocol for Prehospital Large Vessel Occlusion Detection. PREHOSP EMERG CARE 2021; 26:348-354. [PMID: 33689555 DOI: 10.1080/10903127.2021.1901164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background and purposes: Stroke severity scales may expedite prehospital large vessel occlusion (LVO) stroke detection, but few are validated for paramedic use. We evaluated the feasibility of introducing the Cincinnati Stroke Triage Assessment Tool (C-STAT) in the field and its capacity to detect LVO stroke.Methods: We performed a prospective paramedic-based study assessing C-STAT in the field on patients currently redirected to two comprehensive stroke centers (CSC), based on a Cincinnati Prehospital Stroke Scale (CPSS) score of 3/3. C-STAT was administered by on-site paramedics with telephone guidance from trained centralized clinical support paramedics.Results: Between October 2018 and November 2019, C-STAT scores were obtained in 188/218 (86.2%) patients, among which 118/188 (62.8%) were positive. Paramedics reported performing the C-STAT in less than 5 minutes on 170/188 (90.4%) patients and noted no difficulties administering the scale in 151/188 (80.3%). A positive C-STAT identified 51/68 (75%) LVO strokes in the cohort, demonstrating a 43% (95% CI: 38%-48%) positive and 76% (95% CI: 66%-83%) negative predictive value for LVO stroke diagnosis. In a cohort of 100 patients with CPSS 3/3, requiring a positive C-STAT for redirection would decrease CSC patient volume by 37 but miss 9 of 36 LVO strokes.Conclusion: Prehospital administration of the C-STAT was feasible, using a model of minimal paramedic training and real-time telephone guidance. A protocol based on both a CPSS 3/3 and a positive C-STAT would decrease CSC redirected patient volume by one-third but would miss one-quarter of LVO strokes when compared to a CPSS-based protocol.
Collapse
|
20
|
Lopez-Rivera V, Salazar-Marioni S, Abdelkhaleq R, Savitz SI, Czap A, Alderazi Y, Chen PR, Grotta JC, Blackburn S, Jones W, Spiegel G, Dannenbaum MJ, Wu TC, Cochran J, Kim DH, Day AL, Farquhar G, McCullough LD, Sheth SA. Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes. Stroke 2021; 52:1022-1029. [PMID: 33535778 PMCID: PMC7902449 DOI: 10.1161/strokeaha.120.032710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. METHODS We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. RESULTS Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. CONCLUSIONS In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.
Collapse
Affiliation(s)
| | | | - Rania Abdelkhaleq
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Sean I. Savitz
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| | - Alexandra Czap
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Yazan Alderazi
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Peng R. Chen
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Spiros Blackburn
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Wesley Jones
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Gary Spiegel
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Mark J. Dannenbaum
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Tzu-Ching Wu
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Joseph Cochran
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Dong H. Kim
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Arthur L. Day
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | | | | | - Sunil A. Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| |
Collapse
|
21
|
Li Q, Deng L, Huang C, Zhang WY, Zou N, Cao D, Wei X, Qin XY. A Novel Scale for Assessment of Stroke Severity at Symptom Onset: Correlation With Neurological Deterioration and Outcome. Front Neurol 2021; 11:602839. [PMID: 33551962 PMCID: PMC7862557 DOI: 10.3389/fneur.2020.602839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/11/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: To propose a novel scale for the assessment of stroke severity at symptom onset and to investigate whether it is associated with ultra-early neurological deterioration (UND) and functional outcomes. Methods: The Chongqing Stroke Scale (CQSS) was constructed based on key aspects of history, emphasizing language, motor function, and level of consciousness to yield a total 0–11 scale. The diagnostic performance of the CQSS was assessed in 215 ischemic stroke patients between June 2017 and October 2017 in a tertiary hospital. Patients were included if they presented within 24 h after onset of symptoms and they or their witness can recall the scenario at symptom onset. UND was defined as an increase ≥2 points on the CQSS between symptom onset and admission. Functional outcomes were assessed using the 3-month modified Rankin scale. The correlation between the CQSS score and baseline National Institutes of Health Stroke Scale (NIHSS) score was assessed. The sensitivity, specificity, and positive and negative predictive values of CQSS for the outcomes were calculated. Logistic regression was used to test the association between the CQSS score and functional outcomes. Results: A total of 215 patients with available CQSS scores were included. Baseline CQSS scores at symptom onset were correlated with the admission NIHSS score (r = 0.56, p < 0.001) and functional outcome at 3 months (r = 0.47, p < 0.001). Baseline CQSS ≥ 6 was an independent predictor of functional outcome at 3 months (odds ratio, 12.61; 95% confidence interval 5.68–27.97, p < 0.001). UND was observed in 20 (9.30%) patients. The 90-day mortality was significantly higher in patients with UND than those without UND (25.0 vs. 8.2%, p < 0.001). After adjusting for age, admission systolic blood pressure, hypertension, and diabetes, UND independently predicted poor functional outcome in the multivariate logistic regression model (odds ratio, 9.69; 95% confidence interval 3.19–29.45, p < 0.001). Conclusions: The newly developed CQSS is a simple and easy-to-perform scale that allows a quantitative evaluation of the stroke severity at symptom onset and an assessment of UND before hospital admission. It is associated with NIHSS and predicts functional outcome in patients with acute ischemic stroke.
Collapse
Affiliation(s)
- Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Huang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen-Yu Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurology, Panzhihua Municipal Central Hospital, Panzhihua, China
| | - Ning Zou
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Du Cao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Wei
- Department of Traditional Chinese Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Xin-Yue Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
22
|
Ernst M, Psychogios MN, Schlemm E, Holodinsky JK, Kamal N, Rodt T, Henningsen H, Kraemer C, Thomalla G, Fiehler J, Brekenfeld C. Modeling the Optimal Transportation for Acute Stroke Treatment : Impact of Diurnal Variations in Traffic Rate. Clin Neuroradiol 2020; 31:729-736. [PMID: 32676698 PMCID: PMC8463378 DOI: 10.1007/s00062-020-00933-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 11/26/2022]
Abstract
Purpose Prolonged transfer times between the primary stroke center (PSC) and the comprehensive stroke center (CSC) are one of the major causes of treatment delay for endovascular stroke treatment. We aimed to analyze the effect of the diurnal variations in traffic rates at weekdays and weekends on the catchment area size of three transportation paradigms, i.e. mothership, drip-and-ship (DS) and drip-and-drive (DD). Methods A conditional probability model that predicts the probability of good outcome for patients with suspected large vessel occlusion was used to analyze the prehospital stroke triage in northwest Germany and produce catchment area maps. Transportation times were calculated during each hour of a weekday and a Sunday using Google Maps. For comparison, real DD transportation times from our CSC in Hamburg-Eppendorf (blinded for review) to a PSC in Lüneburg were prospectively recorded. Result On weekdays, the mothership catchment area was the largest (≥40,000 km2, 63%) except for a decrease during morning rush hours, when the DD catchment area was highest (30,879 km2, 48%). The DS catchment area was higher than the DD catchment area during the afternoon rush hours both during the week as well as on Sundays. Conclusion Our study showed a considerable impact of the diurnal variations in traffic rate and direction of travel on optimal stroke transportation. Stroke systems of care should take real time traffic information into account. Electronic supplementary material The online version of this article (10.1007/s00062-020-00933-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany.
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada
| | - Thomas Rodt
- Department of Diagnostic and Interventional Radiology, Klinikum Lüneburg, Lüneburg, Germany
| | | | | | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
23
|
Koka A, Suppan L, Cottet P, Carrera E, Stuby L, Suppan M. Teaching the National Institutes of Health Stroke Scale to Paramedics (E-Learning vs Video): Randomized Controlled Trial. J Med Internet Res 2020; 22:e18358. [PMID: 32299792 PMCID: PMC7312264 DOI: 10.2196/18358] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/01/2020] [Accepted: 04/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background Prompt and accurate identification of stroke victims is essential to reduce time from symptom onset to adequate treatment and to improve neurological outcomes. Most neurologists evaluate the extent of neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), but the use of this scale by paramedics, the first healthcare providers to usually take care of stroke victims, has proven unreliable. This might be, at least in part, due to the teaching method. The video used to teach NIHSS lacks interactivity, while more engaging electronic learning (e-learning) methods might improve knowledge acquisition. Objective This study was designed to evaluate whether a highly interactive e-learning module could enhance NIHSS knowledge acquisition in paramedics. Methods A randomized controlled trial comparing a specially designed e-learning module with the original NIHSS video was performed with paramedics working in Geneva, Switzerland. A registration number was not required as our study does not come into the scope of the Swiss federal law on human research. The protocol was nevertheless submitted to the local ethics committee (Project ID 2017-00847), which issued a “Declaration of no objection.” Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. The primary outcome was overall performance in the study quiz, which contained 50 questions. Secondary outcomes were performance by NIHSS item, time to course and quiz completion, user satisfaction regarding the learning method, user perception of the course duration, and probability the user would recommend the course to a colleague. Results The study was completed by 39 paramedics. There was a better overall median score (36/50 vs 33/50, P=.04) and a higher degree of satisfaction regarding the learning method in the e-learning group (90% vs 37%, P=.002). Users who had followed the e-learning module were more likely to recommend the course to a colleague (95% vs 63%, P=.02). Paramedics in the e-learning group took more time to complete the course (93 vs 59 minutes, P<.001), but considered the duration to be more adequate (75% vs 32%, P=.01). Time to quiz completion was similar between groups (25 vs 38 minutes, P=.12). Conclusions Use of an e-learning module shows promising results in teaching the NIHSS to paramedics.
Collapse
Affiliation(s)
- Avinash Koka
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Cottet
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Emmanuel Carrera
- Stroke Center, Department of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Mélanie Suppan
- Division of Anesthesiology, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
24
|
Brandler ES, Thode H, Fiorella D. The Los Angeles Motor Scale as a predictor of angiographically determined large vessel occlusion. Intern Emerg Med 2020; 15:695-700. [PMID: 31927683 DOI: 10.1007/s11739-019-02272-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
Recent advances in time-sensitive mechanical thrombectomy for the treatment of emergent large vessel occlusion (ELVO) have changed the role of prehospital providers from simply identifying a stroke to identifying the likely presence of ELVO. No one method for identifying ELVO in the field has been demonstrated to be superior. We sought to describe how this might be best accomplished using the Los Angeles Motor Scale (LAMS) in concert with other physical exam findings by paramedics and emergency medical technicians (EMTs). We had paramedics and EMTs examine patients with suspected stroke in the hospital. We compared their exams to the standard neurologist exams and to the results of angiography. We performed multiple analyses to identify the exam elements that would best identify large vessel occlusions. Using LAMS with a threshold score of 4, sensitivity for stroke and ELVO, respectively, was 27% (95% CI 20-36%) and 42% (95% CI 30-55%). When a LAMS of 3 was used in concert with speech abnormality, sensitivity improved to 36% (95% CI 28-45%) and 61% (95% CI 48-73%). Specificity of this model was 70%, (95% CI 64-75%). Most striking was the negative predictive value of this model for ELVO: 90% (95% CI 85-93%) The LAMS or LAMS plus speech can be used to decrease the number of missed large vessel occlusions and to route suspected large vessel occlusions to thrombectomy-capable centers. Other, more complicated scales may have little additional benefit. This derivation data set is the first to use paramedics and EMTs as examiners prospectively and supports prehospital protocol change underway in New York City.
Collapse
Affiliation(s)
- Ethan Samuel Brandler
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, USA.
| | - Henry Thode
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, USA
| | - David Fiorella
- Department of Neurological Surgery, State University of New York at Stony Brook, Stony Brook, USA
| |
Collapse
|
25
|
Crowe RP, Myers JB, Fernandez AR, Bourn S, McMullan JT. The Cincinnati Prehospital Stroke Scale Compared to Stroke Severity Tools for Large Vessel Occlusion Stroke Prediction. PREHOSP EMERG CARE 2020; 25:67-75. [PMID: 32017644 DOI: 10.1080/10903127.2020.1725198] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Various screening tools, ranging in complexity, have been developed to predict large vessel occlusion (LVO) stroke in the prehospital setting. Our objective was to determine whether newly-developed LVO stroke scales offer a clinically-meaningful advantage over the Cincinnati Prehospital Stroke Scale (CPSS). METHODS We retrospectively analyzed prehospital patient care records linked with hospital data from 151 EMS agencies in the United States, between January 1, 2018 and December 31, 2018. We compared the CPSS to the Rapid Arterial Occlusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), and the Vision, Aphasia, Neglect (VAN) assessment for LVO prediction. For each stroke scale, we used the intersection of sensitivity and specificity curves to determine optimal prediction cut-points. We used area under the ROC curve and 95% confidence intervals to assess for differences in discriminative ability between scales. RESULTS We identified 13,596 prehospital records with one or more documented stroke scales of interest. Among these, 4,228 patients were diagnosed with stroke. Over half (57%, n = 2,415) of patients diagnosed with stroke experienced an acute ischemic stroke. Of patients with ischemic stroke, 26% (n = 628) were diagnosed with LVO. A CPSS score of 2 or higher demonstrated sensitivity = 69% and specificity = 78% for LVO. A RACE score of 4 or higher demonstrated sensitivity = 63%, specificity = 73%. A LAMS score of 3 or higher demonstrated sensitivity = 63%, specificity = 72% and a positive VAN score demonstrated sensitivity = 86%, specificity = 65%. Comparing the area under the ROC curve for each scale revealed no statistically significant differences in discriminative ability for LVO stroke. CONCLUSIONS In this large sample of real-world prehospital patient encounters, the CPSS demonstrated similar predictive performance characteristics compared to the RACE, LAMS, and VAN for detecting LVO stroke. Prior to implementing a specific screening tool, EMS agencies should evaluate ease of use and associated implementation costs. Scored 0-3, the simple, widely-used CPSS may serve as a favorable prehospital screening instrument for LVO detection with a cut-point of 2 or higher maximizing the tradeoff between sensitivity and specificity.
Collapse
|
26
|
Shkirkova K, Wang TT, Vartanyan L, Liebeskind DS, Eckstein M, Starkman S, Stratton S, Pratt FD, Hamilton S, Kim-Tenser M, Conwit R, Saver JL, Sanossian N. Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals. Front Neurol 2020; 10:1396. [PMID: 32038463 PMCID: PMC6987385 DOI: 10.3389/fneur.2019.01396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose: Primary stroke center (PSC) certification is associated with improvements in stroke care and outcome. However, these improvements may reflect a higher baseline level of care delivery in hospitals eventually achieving certification. This study examines whether advancements in acute stroke care at PSCs are due to certification or factors intrinsic to the hospital. Methods: Data was obtained from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial with participation of 40 Emergency Medical System agencies, 315 ambulances, and 60 acute receiving hospitals in Los Angeles and Orange Counties. Subjects were transported to one of three types of destinations: PSC certified hospitals (PSCs), hospitals that were not PSCs at time of enrollment but would later become certified (pre-PSCs), and hospitals that would never be certified (non-PSCs). Metrics of acute stroke care quality included time arrival to imaging, use of intravenous tPA, and arrival to treatment. Results: Of 1,700 cases, 856(50%) were at certified PSCs, 529(31%) were at pre-PSCs, and 315 (19%) were at non-PSCs. Mean (SD) was 33min (±76.1) at PSCs, 47(±86.6) at pre-PSCs, and 49(±71.7) at non-PSCs. Of 1,223 cerebral ischemia cases, rate of tPA utilization was 43% at PSCs, 27% at pre-PSCs, and 28% at non-PSCs. Mean ED arrival to thrombolysis was 71(±32.7) at PSC, 98(±37.6) at pre-PSC, and 95(±45.0) at non-PSCs. PSCs had improved time to imaging (p = 0.014), percent tPA use (p < 0.001), and time to treatment (p = 0.003). Conclusions: Stroke care at hospitals prior to PSC certification is equivalent to care at non-PSCs. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
Collapse
Affiliation(s)
- Kristina Shkirkova
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Theodore T Wang
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Lily Vartanyan
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Marc Eckstein
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, United States
| | - Sidney Starkman
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Samuel Stratton
- Department of Community Health Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Franklin D Pratt
- Los Angeles County Department of Public Health, Los Angeles, CA, United States
| | - Scott Hamilton
- Department of Neurology, Stanford Stroke Center, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - May Kim-Tenser
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robin Conwit
- National Institutes of Health, Bethesda, MD, United States
| | - Jeffrey L Saver
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Nerses Sanossian
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
27
|
Shkirkova K, Schuberg S, Balouzian E, Starkman S, Eckstein M, Stratton S, Pratt FD, Hamilton S, Sharma L, Liebeskind DS, Conwit R, Saver JL, Sanossian N. Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke. Stroke 2020; 51:784-791. [PMID: 31955642 DOI: 10.1161/strokeaha.119.026392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.
Collapse
Affiliation(s)
- Kristina Shkirkova
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles
| | - Samuel Schuberg
- Department of Emergency Medicine (S. Schuberg, M.E.), University of Southern California, Los Angeles
| | - Emma Balouzian
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles
| | - Sidney Starkman
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Emergency Medicine (S. Starkman, S. Stratton), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - Marc Eckstein
- Department of Emergency Medicine (S. Schuberg, M.E.), University of Southern California, Los Angeles
| | - Samuel Stratton
- Department of Emergency Medicine (S. Starkman, S. Stratton), University of California Los Angeles
| | | | - Scott Hamilton
- School of Public Health (S.H.), University of California Los Angeles.,Stanford University, CA (S.H.)
| | - Latisha Sharma
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - David S Liebeskind
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Neurovascular Imaging Core (D.S.L.), University of California Los Angeles
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke (R.C.)
| | - Jeffrey L Saver
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - Nerses Sanossian
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles.,Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S.), University of Southern California, Los Angeles
| | | |
Collapse
|
28
|
Brandler ES, Baksh N. Emergency management of stroke in the era of mechanical thrombectomy. Clin Exp Emerg Med 2019; 6:273-287. [PMID: 31910498 PMCID: PMC6952636 DOI: 10.15441/ceem.18.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/13/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023] Open
Abstract
Emergency management of stroke has been directed at the delivery of recombinant tissue plasminogen activator (tPA) in a timely fashion. Because of the many limitations attached to the delivery of tPA and the perceived benefits accrued to tPA, its use has been limited. Mechanical thrombectomy, a far superior therapy for the largest and most disabling strokes, large vessel occlusions (LVOs), has changed the way acute strokes are managed. Aside from the rush to deliver tPA, there is now a need to identify LVO and refer those patients with LVO to physicians and facilities capable of delivering urgent thrombectomy. Other parts of emergency department management of stroke are directed at identifying and mitigating risk factors for future strokes and at preventing further damage from occurring. We review here the most recent literature supporting these advances in stroke care and present a framework for understanding the role that emergency physicians play in acute stroke care.
Collapse
Affiliation(s)
- Ethan S. Brandler
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Nayeem Baksh
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| |
Collapse
|
29
|
Ernst M, Schlemm E, Holodinsky JK, Kamal N, Thomalla G, Fiehler J, Brekenfeld C. Modeling the Optimal Transportation for Acute Stroke Treatment: The Impact of the Drip-and-Drive Paradigm. Stroke 2019; 51:275-281. [PMID: 31735142 DOI: 10.1161/strokeaha.119.027493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose- Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods- Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km2 with a population of 12 703 561 in 2017 (198 persons per km2). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results- The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain <40 minutes each. A slowed workflow in the DD paradigm resulted in a decrease of the DD catchment area to 1221 km2 (2%). Conclusions- Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.
Collapse
Affiliation(s)
- Marielle Ernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Eckhard Schlemm
- Department of Neurology (E.S., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.K.H.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada (N.K.)
| | - Götz Thomalla
- Department of Neurology (E.S., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
30
|
Campbell BCV, De Silva DA, Macleod MR, Coutts SB, Schwamm LH, Davis SM, Donnan GA. Ischaemic stroke. Nat Rev Dis Primers 2019; 5:70. [PMID: 31601801 DOI: 10.1038/s41572-019-0118-8] [Citation(s) in RCA: 851] [Impact Index Per Article: 170.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Stroke is the second highest cause of death globally and a leading cause of disability, with an increasing incidence in developing countries. Ischaemic stroke caused by arterial occlusion is responsible for the majority of strokes. Management focuses on rapid reperfusion with intravenous thrombolysis and endovascular thrombectomy, which both reduce disability but are time-critical. Accordingly, improving the system of care to reduce treatment delays is key to maximizing the benefits of reperfusion therapies. Intravenous thrombolysis reduces disability when administered within 4.5 h of the onset of stroke. Thrombolysis also benefits selected patients with evidence from perfusion imaging of salvageable brain tissue for up to 9 h and in patients who awake with stroke symptoms. Endovascular thrombectomy reduces disability in a broad group of patients with large vessel occlusion when performed within 6 h of stroke onset and in patients selected by perfusion imaging up to 24 h following stroke onset. Secondary prevention of ischaemic stroke shares many common elements with cardiovascular risk management in other fields, including blood pressure control, cholesterol management and antithrombotic medications. Other preventative interventions are tailored to the mechanism of stroke, such as anticoagulation for atrial fibrillation and carotid endarterectomy for severe symptomatic carotid artery stenosis.
Collapse
Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia. .,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia.
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital campus, National Neuroscience Institute, Singapore, Singapore
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
31
|
Schlechtriemen T, Becker M, Hoor L. [Prehospital management of acute stroke : Using the example of Saarland ambulance services]. Radiologe 2019; 59:596-602. [PMID: 31165174 DOI: 10.1007/s00117-019-0550-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The preclinical care strategy was changed after reevaluation of endovascular thrombectomy in the S2k guideline of the German Neurological Society (DGN). Severe strokes should be directly transferred to neurovascular centers (model "mothership"). The severity of a stroke should be determined using the LAMS (Los Angeles Motor Scale) score. MATERIALS AND METHODS The general conditions of preclinical care of patients with stroke in the Saarland are presented. The key figures and statistical data of clinic assignments in the adapted care strategy are evaluated. RESULTS The 2018 data from the Saarland Ambulance Services indicate that 9.1% of all preclinical emergencies are diagnosed with "transient ischemic attack (TIA)/insult/bleeding"; 97.1% of these patients were admitted to one of the 10 hospitals in Saarland with a stroke unit. A care time at the emergency site of 20 min was observed in 78.2%, a prehospital time of 60 min in 90.1% of the missions. Preclinically, severe strokes with LAMS score ≥4 were detected in 19.2% of all stroke patients; 71.6% of these severe strokes were assigned to one of two neurovascular centers in the Saarland. CONCLUSIONS With good traffic and hospital infrastructure in Saarland, severe strokes can be treated primarily in neurovascular centers. Differentiated care requirements with monitoring of key figures in medical quality management and clear agreements with the target hospitals in the implementation of a common care strategy are essential.
Collapse
Affiliation(s)
- T Schlechtriemen
- Zweckverband für Rettungsdienst und Feuerwehralarmierung Saar, Saarpfalz-Park 9, 66450, Bexbach, Deutschland.
| | - M Becker
- Klinik für Anästhesiologie, Marienhausklinikum Saarlouis-Dillingen, Saarlouis-Dillingen, Deutschland
| | - L Hoor
- Zweckverband für Rettungsdienst und Feuerwehralarmierung Saar, Saarpfalz-Park 9, 66450, Bexbach, Deutschland
| |
Collapse
|
32
|
Aghaebrahim A, Granja MF, Agnoletto GJ, Aguilar-Salinas P, Cortez GM, Santos R, Monteiro A, Camp W, Day J, Dellorso S, Naval N, Chmayssani M, Stromberg R, Rill MC, Sauvageau E, Hanel R. Workflow Optimization for Ischemic Stroke in a Community-Based Stroke Center. World Neurosurg 2019; 129:e273-e278. [DOI: 10.1016/j.wneu.2019.05.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 11/30/2022]
|
33
|
Venema E, Duvekot MHC, Lingsma HF, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, van der Lugt A, Kerkhoff H, Dippel DWJ, Roozenbeek B. Prehospital triage of patients with suspected stroke symptoms (PRESTO): protocol of a prospective observational study. BMJ Open 2019; 9:e028810. [PMID: 31289083 PMCID: PMC6615792 DOI: 10.1136/bmjopen-2018-028810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting. METHODS AND ANALYSIS Prehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve. ETHICS AND DISSEMINATION The Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients. TRIAL REGISTRATION NUMBER NTR7595.
Collapse
Affiliation(s)
- Esmee Venema
- Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Martijne H C Duvekot
- Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Hester F Lingsma
- Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Anouk D Rozeman
- Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Walid Moudrous
- Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Marileen Biekart
- Ambulance Service Rotterdam-Rijnmond, Barendrecht, The Netherlands
| | - Aad van der Lugt
- Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Henk Kerkhoff
- Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Bob Roozenbeek
- Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
34
|
Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Syst Rev 2019; 4:CD011427. [PMID: 30964558 PMCID: PMC6455894 DOI: 10.1002/14651858.cd011427.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Rapid and accurate detection of stroke by paramedics or other emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage. However, their accuracy remains uncertain and there is no agreement which of the scales perform better. OBJECTIVES To systematically identify and review the evidence pertaining to the test accuracy of validated stroke recognition scales, as used in a prehospital or emergency room (ER) setting to screen people suspected of having stroke. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and the Science Citation Index to 30 January 2018. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data. SELECTION CRITERIA We included studies evaluating the accuracy of stroke recognition scales used in a prehospital or ER setting to identify stroke and transient Ischemic attack (TIA) in people suspected of stroke. The scales had to be applied to actual people and the results compared to a final diagnosis of stroke or TIA. We excluded studies that applied scales to patient records; enrolled only screen-positive participants and without complete 2 × 2 data. DATA COLLECTION AND ANALYSIS Two review authors independently conducted a two-stage screening of all publications identified by the searches, extracted data and assessed the methodologic quality of the included studies using a tailored version of QUADAS-2. A third review author acted as an arbiter. We recalculated study-level sensitivity and specificity with 95% confidence intervals (CI), and presented them in forest plots and in the receiver operating characteristics (ROC) space. When a sufficient number of studies reported the accuracy of the test in the same setting (prehospital or ER) and the level of heterogeneity was relatively low, we pooled the results using the bivariate random-effects model. We plotted the results in the summary ROC (SROC) space presenting an estimate point (mean sensitivity and specificity) with 95% CI and prediction regions. Because of the small number of studies, we did not conduct meta-regression to investigate between-study heterogeneity and the relative accuracy of the scales. Instead, we summarized the results in tables and diagrams, and presented our findings narratively. MAIN RESULTS We selected 23 studies for inclusion (22 journal articles and one conference abstract). We evaluated the following scales: Cincinnati Prehospital Stroke Scale (CPSS; 11 studies), Recognition of Stroke in the Emergency Room (ROSIER; eight studies), Face Arm Speech Time (FAST; five studies), Los Angeles Prehospital Stroke Scale (LAPSS; five studies), Melbourne Ambulance Stroke Scale (MASS; three studies), Ontario Prehospital Stroke Screening Tool (OPSST; one study), Medic Prehospital Assessment for Code Stroke (MedPACS; one study) and PreHospital Ambulance Stroke Test (PreHAST; one study). Nine studies compared the accuracy of two or more scales. We considered 12 studies at high risk of bias and one with applicability concerns in the patient selection domain; 14 at unclear risk of bias and one with applicability concerns in the reference standard domain; and the risk of bias in the flow and timing domain was high in one study and unclear in another 16.We pooled the results from five studies evaluating ROSIER in the ER and five studies evaluating LAPSS in a prehospital setting. The studies included in the meta-analysis of ROSIER were of relatively good methodologic quality and produced a summary sensitivity of 0.88 (95% CI 0.84 to 0.91), with the prediction interval ranging from approximately 0.75 to 0.95. This means that the test will miss on average 12% of people with stroke/TIA which, depending on the circumstances, could range from 5% to 25%. We could not obtain a reliable summary estimate of specificity due to extreme heterogeneity in study-level results. The summary sensitivity of LAPSS was 0.83 (95% CI 0.75 to 0.89) and summary specificity 0.93 (95% CI 0.88 to 0.96). However, we were uncertain in the validity of these results as four of the studies were at high and one at uncertain risk of bias. We did not report summary estimates for the rest of the scales, as the number of studies per test per setting was small, the risk of bias was high or uncertain, the results were highly heterogenous, or a combination of these.Studies comparing two or more scales in the same participants reported that ROSIER and FAST had similar accuracy when used in the ER. In the field, CPSS was more sensitive than MedPACS and LAPSS, but had similar sensitivity to that of MASS; and MASS was more sensitive than LAPSS. In contrast, MASS, ROSIER and MedPACS were more specific than CPSS; and the difference in the specificities of MASS and LAPSS was not statistically significant. AUTHORS' CONCLUSIONS In the field, CPSS had consistently the highest sensitivity and, therefore, should be preferred to other scales. Further evidence is needed to determine its absolute accuracy and whether alternatives scales, such as MASS and ROSIER, which might have comparable sensitivity but higher specificity, should be used instead, to achieve better overall accuracy. In the ER, ROSIER should be the test of choice, as it was evaluated in more studies than FAST and showed consistently high sensitivity. In a cohort of 100 people of whom 62 have stroke/TIA, the test will miss on average seven people with stroke/TIA (ranging from three to 16). We were unable to obtain an estimate of its summary specificity. Because of the small number of studies per test per setting, high risk of bias, substantial differences in study characteristics and large between-study heterogeneity, these findings should be treated as provisional hypotheses that need further verification in better-designed studies.
Collapse
Affiliation(s)
- Zhivko Zhelev
- University of ExeterNIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical SchoolSt Luke's CampusSouth Cloisters (Room 3.09)ExeterDevonUKEX1 2LU
| | - Greg Walker
- University of British ColumbiaDepartment of NeurologyVancouver General HospitalVancouverBCCanada
| | | | - Jonathan Fridhandler
- University of British ColumbiaDepartment of NeurologyVancouver General HospitalVancouverBCCanada
| | - Samuel Yip
- University of British ColumbiaDepartment of NeurologyVancouver General HospitalVancouverBCCanada
| | | |
Collapse
|
35
|
Almekhlafi MA, Kunz WG, Menon BK, McTaggart RA, Jayaraman MV, Baxter BW, Heck D, Frei D, Derdeyn CP, Takagi T, Aamodt AH, Fragata IMR, Hill MD, Demchuk AM, Goyal M. Imaging of Patients with Suspected Large-Vessel Occlusion at Primary Stroke Centers: Available Modalities and a Suggested Approach. AJNR Am J Neuroradiol 2019; 40:396-400. [PMID: 30705072 DOI: 10.3174/ajnr.a5971] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/06/2018] [Indexed: 12/24/2022]
Abstract
The overwhelming benefit of endovascular therapy in patients with large-vessel occlusions suggests that more patients will be screened than treated. Some of those patients will be evaluated first at primary stroke centers; this type of evaluation calls for standardizing the imaging approach to minimize delays in assessing, transferring, and treating these patients. Here, we propose that CT angiography (performed at the same time as head CT) should be the minimum imaging approach for all patients with stroke with suspected large-vessel occlusion presenting to primary stroke centers. We discuss some of the implications of this approach and how to facilitate them.
Collapse
Affiliation(s)
- M A Almekhlafi
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - W G Kunz
- Department of Radiology (W.G.K.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - B K Menon
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R A McTaggart
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M V Jayaraman
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - B W Baxter
- Department of Radiology (B.W.B.), Erlanger Medical Center, Chattanooga, Tennessee
| | - D Heck
- Department of Radiology (D.H.), Forsyth Medical Center, Winston Salem, North Carolina
| | - D Frei
- Swedish Medical Center (D.F.), Denver, Colorado
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - T Takagi
- Department of Neurosurgery (T.T.), Hyogo College of Medicine, Nishinomiya, Hyögo, Japan
| | - A H Aamodt
- Department of Neurology (A.H.A.), Oslo University Hospital, Oslo, Norway
| | - I M R Fragata
- Department of Neuroradiology (I.M.R.F.), Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - M D Hill
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
36
|
Middleton S, McElduff P, Drury P, D’Este C, Cadilhac DA, Dale S, Grimshaw JM, Ward J, Quinn C, Cheung NW, Levi C. Vital sign monitoring following stroke associated with 90-day independence: A secondary analysis of the QASC cluster randomized trial. Int J Nurs Stud 2019; 89:72-79. [DOI: 10.1016/j.ijnurstu.2018.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 01/04/2023]
|
37
|
Neves Briard J, Zewude RT, Kate MP, Rowe BH, Buck B, Butcher K, Gioia LC. Stroke Mimics Transported by Emergency Medical Services to a Comprehensive Stroke Center: The Magnitude of the Problem. J Stroke Cerebrovasc Dis 2018; 27:2738-2745. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/22/2018] [Accepted: 05/28/2018] [Indexed: 11/29/2022] Open
|
38
|
Prehospital Prediction of Large Vessel Occlusion in Suspected Stroke Patients. Curr Atheroscler Rep 2018; 20:34. [DOI: 10.1007/s11883-018-0734-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
39
|
Analysis of the new code stroke protocol in Asturias after one year. Experience at one hospital. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
40
|
Noorian AR, Sanossian N, Shkirkova K, Liebeskind DS, Eckstein M, Stratton SJ, Pratt FD, Conwit R, Chatfield F, Sharma LK, Restrepo L, Valdes-Sueiras M, Kim-Tenser M, Starkman S, Saver JL. Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens. Stroke 2018; 49:565-572. [PMID: 29459391 DOI: 10.1161/strokeaha.117.019228] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/14/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Prehospital scales have been developed to identify patients with acute cerebral ischemia (ACI) because of large vessel occlusion (LVO) for direct routing to Comprehensive Stroke Centers (CSCs), but few have been validated in the prehospital setting, and their impact on routing of patients with intracranial hemorrhage has not been delineated. The purpose of this study was to validate the Los Angeles Motor Scale (LAMS) for LVO and CSC-appropriate (LVO ACI and intracranial hemorrhage patients) recognition and compare the LAMS to other scales. METHODS The performance of the LAMS, administered prehospital by paramedics to consecutive ambulance trial patients, was assessed in identifying (1) LVOs among all patients with ACI and (2) CSC-appropriate patients among all suspected strokes. Additionally, the LAMS administered postarrival was compared concurrently with 6 other scales proposed for paramedic use and the full National Institutes of Health Stroke Scale. RESULTS Among 94 patients, age was 70 (±13) and 49% female. Final diagnoses were ACI in 76% (because of LVO in 48% and non-LVO in 28%), intracranial hemorrhage in 19%, and neurovascular mimic in 5%. The LAMS administered by paramedics in the field performed moderately well in identifying LVO among patients with ACI (C statistic, 0.79; accuracy, 0.72) and CSC-appropriate among all suspected stroke transports (C statistic, 0.80; accuracy, 0.72). When concurrently performed in the emergency department postarrival, the LAMS showed comparable or better accuracy versus the 7 comparator scales, for LVO among ACI (accuracies LAMS, 0.70; other scales, 0.62-0.68) and CSC-appropriate (accuracies LAMS, 0.73; other scales, 0.56-0.73). CONCLUSIONS The LAMS performed in the field by paramedics identifies LVO and CSC-appropriate patients with good accuracy. The LAMS performs comparably or better than more extended prehospital scales and the full National Institutes of Health Stroke Scale.
Collapse
Affiliation(s)
- Ali Reza Noorian
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.).
| | - Nerses Sanossian
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Kristina Shkirkova
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - David S Liebeskind
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Marc Eckstein
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Samuel J Stratton
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Franklin D Pratt
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Robin Conwit
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Fiona Chatfield
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Latisha K Sharma
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Lucas Restrepo
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Miguel Valdes-Sueiras
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - May Kim-Tenser
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Sidney Starkman
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Jeffrey L Saver
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | | |
Collapse
|
41
|
Purrucker JC, Härtig F, Richter H, Engelbrecht A, Hartmann J, Auer J, Hametner C, Popp E, Ringleb PA, Nagel S, Poli S. 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. [PMID: 28864702 PMCID: PMC5589005 DOI: 10.1136/bmjopen-2017-016893] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To develop an NIH Stroke Scale (NIHSS)-compatible, all-in-one scale for rapid and comprehensive prehospital stroke assessment including stroke recognition, severity grading and progression monitoring as well as prediction of large vessel occlusion (LVO). METHODS Emergency medical services (EMS) personnel and stroke physicians (n=326) rated each item of the NIHSS regarding suitability for prehospital use; best rated items were included. Stroke recognition was evaluated retrospectively in 689 consecutive patients with acute stroke or stroke mimics, prediction of LVO in 741 consecutive patients with ischaemic stroke with acute vessel imaging independent of admission NIHSS score. RESULTS Nine of the NIHSS items were rated as 'suitable for prehospital use.' After excluding two items in order to increase specificity, the final scale (termed shortened NIHSS for EMS, sNIHSS-EMS) consists of 'level of consciousness', 'facial palsy', 'motor arm/leg', 'sensory', 'language' and 'dysarthria'. Sensitivity for stroke recognition of the sNIHSS-EMS is 91% (95% CI 86 to 94), specificity 52% (95% CI 47 to 56). Receiver operating curve analysis revealed an optimal cut-off point for LVO prediction of ≥6 (sensitivity 70% (95% CI 65 to 76), specificity 81% (95% CI 76 to 84), positive predictive value 70 (95% CI 65 to 75), area under the curve 0.81 (95% CI 0.78 to 0.84)). Test characteristics were non-inferior to non-comprehensive scales. CONCLUSIONS The sNIHSS-EMS may overcome the sequential use of multiple emergency stroke scales by permitting parallel stroke recognition, severity grading and LVO prediction. Full NIHSS-item compatibility allows for evaluation of stroke progression starting at the prehospital phase.
Collapse
Affiliation(s)
| | - Florian Härtig
- Department of Neurology and Stroke, Hertie Institute for Clinical Brain Research, Tuebingen University Hospital, Tuebingen, Germany
| | - Hardy Richter
- Department of Neurology and Stroke, Hertie Institute for Clinical Brain Research, Tuebingen University Hospital, Tuebingen, Germany
| | - Andreas Engelbrecht
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Hartmann
- Department of Medical Informatics, University of Tuebingen, Tuebingen, Germany
| | - Jonas Auer
- Department of Computer Science and Software Engineering, University of Stuttgart, Stuttgart, Germany
| | - Christian Hametner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Erik Popp
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Hertie Institute for Clinical Brain Research, Tuebingen University Hospital, Tuebingen, Germany
| |
Collapse
|
42
|
Nogueira RG, Silva GS, Lima FO, Yeh YC, Fleming C, Branco D, Yancey AH, Ratcliff JJ, Wages RK, Doss E, Bouslama M, Grossberg JA, Haussen DC, Sakano T, Frankel MR. The FAST-ED App: A Smartphone Platform for the Field Triage of Patients With Stroke. Stroke 2017; 48:1278-1284. [PMID: 28411260 DOI: 10.1161/strokeaha.116.016026] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 02/16/2017] [Accepted: 02/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Emergency Medical Services field triage to stroke centers has gained considerable complexity with the recent demonstration of clinical benefit of endovascular treatment for acute ischemic stroke. We sought to describe a new smartphone freeware application designed to assist Emergency Medical Services professionals with the field assessment and destination triage of patients with acute ischemic stroke. METHODS Review of the application's platform and its development as well as the different variables, assessments, algorithms, and assumptions involved. RESULTS The FAST-ED (Field Assessment Stroke Triage for Emergency Destination) application is based on a built-in automated decision-making algorithm that relies on (1) a brief series of questions assessing patient's age, anticoagulant usage, time last known normal, motor weakness, gaze deviation, aphasia, and hemineglect; (2) a database of all regional stroke centers according to their capability to provide endovascular treatment; and (3) Global Positioning System technology with real-time traffic information to compute the patient's eligibility for intravenous tissue-type plasminogen activator or endovascular treatment as well as the distances/transportation times to the different neighboring stroke centers in order to assist Emergency Medical Services professionals with the decision about the most suitable destination for any given patient with acute ischemic stroke. CONCLUSIONS The FAST-ED smartphone application has great potential to improve the triage of patients with acute ischemic stroke, as it seems capable to optimize resources, reduce hospital arrivals times, and maximize the use of both intravenous tissue-type plasminogen activator and endovascular treatment ultimately leading to better clinical outcomes. Future field studies are needed to properly evaluate the impact of this tool in stroke outcomes and resource utilization.
Collapse
Affiliation(s)
- Raul G Nogueira
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.).
| | - Gisele S Silva
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Fabricio O Lima
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Yu-Chih Yeh
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Carol Fleming
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Daniel Branco
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Arthur H Yancey
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Jonathan J Ratcliff
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Robert Keith Wages
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Earnest Doss
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Mehdi Bouslama
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Jonathan A Grossberg
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Teppei Sakano
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| | - Michael R Frankel
- Marcus Stroke and Neuroscience Center (R.G.N., C.F., J.J.R., M.B., J.A.G., D.C.H., M.R.F.) and Department of Emergency Medicine (A.H.Y., J.J.R.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Neurology, Federal University of São Paulo/UNIFESP and Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, Brazil (G.S.S.); Ciências da Saúde, Curso de Medicina, Universidade de Fortaleza, Brazil (F.O.L.); Allm Group, Tokyo, Japan (Y.-C.Y., T.S.); Medicinia, Sao Paulo, Brazil (D.B.); and Georgia Office of EMS and Trauma, Brookhaven (R.K.W., E.D.)
| |
Collapse
|
43
|
Kim JT, Chung PW, Starkman S, Sanossian N, Stratton SJ, Eckstein M, Pratt FD, Conwit R, Liebeskind DS, Sharma L, Restrepo L, Tenser MK, Valdes-Sueiras M, Gornbein J, Hamilton S, Saver JL. Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity. Stroke 2017; 48:298-306. [DOI: 10.1161/strokeaha.116.015247] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/21/2016] [Accepted: 12/02/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region.
Methods—
We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy–Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals.
Results—
Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20–50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119–180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120–180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were
r
=0.49 for the prehospital LAMS and
r
=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale,
r
=−0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74–0.78); EPA LAMS, 0.85 (95% confidence interval 0.83–0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85–0.88).
Conclusions—
In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.
Collapse
Affiliation(s)
- Joon-Tae Kim
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Pil-Wook Chung
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Sidney Starkman
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Nerses Sanossian
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Samuel J. Stratton
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Marc Eckstein
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Frank D. Pratt
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Robin Conwit
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - David S. Liebeskind
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Latisha Sharma
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Lucas Restrepo
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - May-Kim Tenser
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Miguel Valdes-Sueiras
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Jeffrey Gornbein
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Scott Hamilton
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Jeffrey L. Saver
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| |
Collapse
|
44
|
McMullan JT, Katz B, Broderick J, Schmit P, Sucharew H, Adeoye O. Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool. PREHOSP EMERG CARE 2017; 21:481-488. [DOI: 10.1080/10903127.2016.1274349] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
45
|
Rodríguez-Pardo J, Fuentes B, Alonso de Leciñana M, Ximénez-Carrillo Á, Zapata-Wainberg G, Álvarez-Fraga J, Barriga FJ, Castillo L, Carneado-Ruiz J, Díaz-Guzman J, Egido-Herrero J, de Felipe A, Fernández-Ferro J, Frade-Pardo L, García-Gallardo Á, García-Pastor A, Gil-Núñez A, Gómez-Escalonilla C, Guillán M, Herrero-Infante Y, Masjuan-Vallejo J, Ortega-Casarrubios MÁ, Vivancos-Mora J, Díez-Tejedor E. The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network. Eur J Neurol 2017; 24:509-515. [DOI: 10.1111/ene.13233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/24/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | - B. Fuentes
- Department of Neurology; La Paz University Hospital; Madrid Spain
| | | | | | | | - J. Álvarez-Fraga
- Department of Neurology; La Paz University Hospital; Madrid Spain
| | - F. J. Barriga
- Department of Neurology; Alcorcon University Hospital Foundation; Madrid Spain
| | - L. Castillo
- Department of Neurology; Alcorcon University Hospital Foundation; Madrid Spain
| | - J. Carneado-Ruiz
- Department of Neurology; Puerta de Hierro-Majadahonda University Hospital; Madrid Spain
| | - J. Díaz-Guzman
- Department of Neurology; 12 de Octubre University Hospital; Madrid Spain
| | - J. Egido-Herrero
- Department of Neurology; San Carlos University Hospital; Madrid Spain
| | - A. de Felipe
- Department of Neurology; Ramón y Cajal University Hospital; Madrid Spain
| | - J. Fernández-Ferro
- Department of Neurology; Rey Juan Carlos University Hospital; Madrid Spain
| | - L. Frade-Pardo
- Department of Neurology; La Paz University Hospital; Madrid Spain
| | | | - A. García-Pastor
- Department of Neurology; Gregorio Marañón University Hospital; Madrid Spain
| | - A. Gil-Núñez
- Department of Neurology; Gregorio Marañón University Hospital; Madrid Spain
| | | | - M. Guillán
- Department of Neurology; Rey Juan Carlos University Hospital; Madrid Spain
| | | | - J. Masjuan-Vallejo
- Department of Neurology; Ramón y Cajal University Hospital; Madrid Spain
| | | | - J. Vivancos-Mora
- Department of Neurology; La Princesa University Hospital; Madrid Spain
| | - E. Díez-Tejedor
- Department of Neurology; La Paz University Hospital; Madrid Spain
| | | |
Collapse
|
46
|
Analysis of the new code stroke protocol in Asturias after one year. Experience at one hospital. Neurologia 2016; 33:92-97. [PMID: 27469579 DOI: 10.1016/j.nrl.2016.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Prehospital code stroke (CS) systems have been proved effective for improving access to specialised medical care in acute stroke cases. They also improve the prognosis of this disease, which is one of the leading causes of death and disability in our setting. The aim of this study is to analyse results one year after implementation of the new code stroke protocol at one hospital in Asturias. PATIENTS AND METHODS We prospectively included patients who were admitted to our tertiary care centre as per the code stroke protocol for the period of one year. RESULTS We analysed 363 patients. Mean age was 69 years and 54% of the cases were men. During the same period in the previous year, there were 236 non-hospital CS activations. One hundred forty-seven recanalisation treatments were performed (66 fibrinolysis and 81 mechanical thrombectomies or combined treatments), representing a 25% increase with regard to the previous year. CONCLUSIONS Recent advances in the management of acute stroke call for coordinated code stroke protocols that are adapted to the needs of each specific region. This may result in an increased number of patients receiving early care, as well as revascularisation treatments.
Collapse
|
47
|
Neville K, Lo W. Sensitivity and Specificity of an Adult Stroke Screening Tool in Childhood Ischemic Stroke. Pediatr Neurol 2016; 58:53-6. [PMID: 26973299 DOI: 10.1016/j.pediatrneurol.2016.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/15/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND There are frequent delays in the diagnosis of acute pediatric ischemic stroke. A screening tool that could increase the suspicion of acute ischemic stroke could aid early recognition and might improve initial care. An earlier study reported that children with acute ischemic stroke have signs that can be recognized with two adult stroke scales. We tested the hypothesis that an adult stroke scale could distinguish children with acute ischemic stroke from children with acute focal neurological deficits not due to stroke. METHODS We retrospectively applied an adult stroke scale to the recorded examinations of 53 children with acute symptomatic acute ischemic stroke and 53 age-matched control subjects who presented with focal neurological deficits. We examined the sensitivity and specificity of the stroke scale and the occurrence of acute seizures as predictors of stroke status. RESULTS The total stroke scale did not differentiate children with acute ischemic stroke from those who had acute deficits from nonstroke causes; however, the presence of arm weakness was significantly associated with stroke cases. Acute seizures were significantly associated with stroke cases. CONCLUSIONS An adult stroke scale is not sensitive or specific to distinguish children with acute ischemic stroke from those with nonstroke focal neurological deficits. The development of a pediatric acute ischemic stroke screening tool should include arm weakness and perhaps acute seizures as core elements. Such a scale must account for the limitations of language in young or intellectually disabled children.
Collapse
Affiliation(s)
- Kerri Neville
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio
| | - Warren Lo
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio; Department of Neurology, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio.
| |
Collapse
|
48
|
Glober NK, Sporer KA, Guluma KZ, Serra JP, Barger JA, Brown JF, Gilbert GH, Koenig KL, Rudnick EM, Salvucci AA. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2016; 17:104-28. [PMID: 26973735 PMCID: PMC4786229 DOI: 10.5811/westjem.2015.12.28995] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
Collapse
Affiliation(s)
- Nancy K Glober
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kama Z Guluma
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - John P Serra
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Joe A Barger
- EMS Medical Directors Association of California, California
| | - John F Brown
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California, California; Stanford University, Department of Emergency Medicine, Stanford, California
| | - Kristi L Koenig
- EMS Medical Directors Association of California, California; University of California Irvine, Center for Disaster Medical Sciences, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California, California
| | | |
Collapse
|
49
|
Zuckerman SL, Sivaganesan A, Zhang C, Dewan MC, Morone PJ, Ganesh Kumar N, Mocco J. Maximizing efficiency and diagnostic accuracy triage of acute stroke patients: A case-control study. Interv Neuroradiol 2016; 22:304-9. [PMID: 26842606 DOI: 10.1177/1591019915622167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recent data have demonstrated that mechanical thrombectomy (MT) is beneficial for patients presenting within zero to six hours of symptom onset after stroke. However, transferring all patients with possible strokes for endovascular therapy and MT would be inefficient and costly. We conducted a case-control study to identify a subset of the National Institutes of Health Stroke Scale (NIHSS) to identify patients with large-vessel occlusion (LVO) to a high degree of specificity, in order to select those patients for whom transfer is most appropriate. METHODS Acute code stroke alerts presenting to a comprehensive stroke center from 2012 to 2013 (779) and corresponding NIHSS were collected. All patients had vascular imaging and 125 demonstrated LVO (cases) and were compared to 272 small-vessel strokes and stroke mimics (controls). Demographics of both groups and modified receiver operating characteristic (ROC) curves were generated for each combination of three NIHSS items to optimize specificity of LVO for those who would benefit from MT. RESULTS The average NIHSS of cases was higher than controls (12.5 vs. 6.5, p < 0.0001). The subset of three NIHSS items with the largest modified AUC (optimized for specificity) was maximum "Arm," "Sensory," and "Extinction." Using a cutoff of seven out of a total 10 possible points, the sum score for these items has 90.2% specificity and 16.0% sensitivity for LVO. CONCLUSION We present a validated three-question subset of the NIHSS for those who would benefit from MT with a high degree of specificity.
Collapse
Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - Chi Zhang
- Vanderbilt University School of Medicine, USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - J Mocco
- Mt. Sinai Health System, Department of Neurological Surgery, USA
| |
Collapse
|
50
|
Sanossian N, Liebeskind DS, Eckstein M, Starkman S, Stratton S, Pratt FD, Koenig W, Hamilton S, Kim-Tenser M, Conwit R, Saver JL. Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research. Stroke 2015; 46:2886-90. [PMID: 26265130 PMCID: PMC4920547 DOI: 10.1161/strokeaha.115.010264] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/16/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE Emergency medical services routing of patients with acute stroke to designated centers may increase the proportion of patients receiving care at facilities meeting national standards and augment recruitment for prehospital stroke research. METHODS We analyzed consecutive patients enrolled within 2 hours of symptom onset in a prehospital stroke trial, before and after regional Los Angeles County Emergency Medical Services implementation of preferentially routing patients with acute stroke to approved stroke centers (ASCs). From January 2005 to mid-November 2009, patients were transported to the nearest emergency department, whereas from mid-November 2009 to December 2012, patients were preferentially transported to first 9, and eventually 29, ASCs. RESULTS There were 863 subjects enrolled before and 764 after emergency medical service preferential routing, with implementation leading to an increase in the proportion cared for at an ASC from 10% to 91% (P<0.0001), with a slight decrease in paramedic on-scene to emergency department arrival time (34.5 [SD, 9.1] minutes versus 33.5 [SD, 10.3] minutes; P=0.045). The effects of routing were immediate and included an increase in proportion of receiving ASC care (from 17% to 88%; P<0.001) and a greater number of enrollments (18.6% increase) when comparing 12 months before and after regional stroke system implementation. CONCLUSIONS The establishment of a regionalized emergency medical services system of acute stroke care dramatically increased the proportion of patients with acute stroke cared for at ASCs, from 1 in 10 to >9 in 10, with no clinically significant increase in prehospital care times and enhanced recruitment of patients into a prehospital treatment trial. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
Collapse
Affiliation(s)
- Nerses Sanossian
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
| | - David S Liebeskind
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Marc Eckstein
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Sidney Starkman
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Samuel Stratton
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Franklin D Pratt
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - William Koenig
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Scott Hamilton
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - May Kim-Tenser
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Robin Conwit
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Jeffrey L Saver
- From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| |
Collapse
|