Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion

Background: Endovascular treatment was shown to drastically improve stroke patient outcomes but earlier identification of eligible patients is crucial. First responders are instrumental to the rapid identification and transportation of stroke patients to the nearest appropriate facility for acute stroke care especially when endovascular intervention is an option. Purpose: To develop and evaluate the effectiveness of an algorithm for first responders to use to differentiate which stroke patients should be transported to the closest Interventional Stroke Center for treatment. Method: We revised the County-Level Emergency Medical Services (EMS) protocol and algorithm to include the Rapid Arterial oCclusion Evaluation (RACE) scale in addition to the Cincinnati Prehospital Stroke Scale (CPPS). Together these simple in-the-field scales assess stroke severity and identify patients with acute stroke and large artery occlusion in a prehospital setting. Lucas County EMS staff received a four hour block of continuing education with credit on acute stroke, the updated protocol and algorithm, and use of the new RACE scale in addition to the CPPS. Effectiveness of the training and use of the RACE alert was measured by the percent of patients accurately identified with and without large artery occlusion. Results: Training was provided to 450 EMS staff in several in-person sessions in June 2015. The RACE protocol went citywide on July first. Of the 18 patients brought in to our hospital by EMS in July using the RACE protocol, 72% were identified correctly using the tool. Of these, 6 were identified correctly as having large vessel occlusions and 7 were correctly identified as not having large vessel occlusions. The remaining 5 patients transported by EMS were identified as large vessel occlusions, but were not found to have strokes (seizures, intoxication, and conversion disorders). Conclusion: Our data suggests that first responders can accurately differentiate between which stroke patients could benefit from endovascular treatment using a simple algorithm. Future evaluation could measure the relationship between accurate pre-hospital identification and treatment rates.

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Abstract 71: Refining the CT Angiography Collaterals Scoring System to Better Predict Outcome in Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.71 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Amrou Sarraj ◽

Clark W Sitton ◽

Amelia K Boehme ◽

Emilio P Supsupin ◽

Wafi Bibars ◽

...

Keyword(s):

Roc Analysis ◽

Operating Characteristic ◽

Artery Occlusion ◽

Stroke Severity ◽

Large Artery ◽

Acute Setting ◽

Good Outcome ◽

Poor Outcome ◽

Specificity And Sensitivity ◽

Baseline Characteristics

Background: Collateral circulation profile is an important determinant of outcome in patients with large artery occlusion (LAO). We sought to refine the collateral score (CS) to better identify patients with potential for good outcome after AIS. Methods: We studied 342 patients presenting to our center with AIS and LAO (MCA or ICA) from 03/05 to 04/13. We modified the CS to a 5 point scale (mCS) (fig 1). We dichotomized the score into unfavorable (0-2A) and favorable (2B-3) profiles. Logistic regression model with good and poor discharge outcome (mRS 0-2 and 4-6, respectively) was used. We performed receiver-operating characteristic (ROC) analysis to compare the mCS with the CS and with ASPECTS. Results: Table 1 shows the baseline characteristics. Patients with favorable mCS had a significantly higher odds of a good outcome (OR 9.61, 95%CI 2.78-33.2, p=0.0003). Moreover, patients with unfavorable profile mCS (0-2A) had greater odds of poor outcome at discharge (4-6), and this association was maintained when using more stringent criteria for poor outcome (mRS 5-6) (table 2). These results persisted after adjustment for CT early ischemic changes (ASPECTS) and stroke severity (NIHSS). The modified scale was more precise than the original CS in predicting patients’ clinical outcomes (table 2). Importantly, patients treated with IV tPA who had good collaterals showed better odds of good outcome (OR 7.07, 95%CI 1.39-35.9, p=0.02). Furthermore, mCS showed more specificity and sensitivity than the original CS and ASPECTS as illustrated on ROCs (AUC: 0.73 compared to CS 0.669 and ASPECTS 0.667) in fig 2. Conclusion: The modified collateral CTA score (mCS) which gives a finer gradation of the collaterals discriminates better those who have potential for good outcome compared with the CS and ASPECTS. A simple score that does not require sophisticated radiology expertise may help physicians triage patients in the acute setting by identifying patients who may achieve a good outcome.

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Abstract TMP74: Evaluation of NIHSS-Onset to Groin Time and Prehospital Acute Stroke Severity Scale-onset to Groin Time Scores in Prediction of Outcomes After Endovascular Treatment in Acute Ischemic Stroke Patients: A Retrospective Single-center Study

Stroke ◽

10.1161/str.48.suppl_1.tmp74 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Muhammad H Niazi ◽

Mohammad El-Ghanem ◽

Kevin Cockroft ◽

Kathy Morrison ◽

Alicia Richardson ◽

...

Keyword(s):

Endovascular Treatment ◽

Acute Stroke ◽

Sensitivity And Specificity ◽

Symptom Onset ◽

Odds Ratio ◽

Small Sample Size ◽

Diagnostic Odds Ratio ◽

Small Sample ◽

Stroke Severity ◽

Severity Scale

Background: Prehospital triage tools are essential to identify large vessel occlusion (LVO) in order to triage patients to a comprehensive stroke center for timely endovascular treatment (ET). Prehospital Acute Stroke Severity Scale (PASS) (score range 0-3) was recently identified as a valuable tool to predict LVO. Several studies have shown that in patients treated with IV tPA, a score calculated by multiplying admission NIHSS by the time from symptom onset to tPA treatment (in hours) can predict outcome. In our study, we applied similar concept for patients with LVO who underwent successful ET. Methods: We retrospectively reviewed all LVO patients between January 2015 and June 2016 who received ET. We analyzed the association of time of symptom onset to groin time (OGT), NIHSS, PASS, NIHSS-OGT, and PASS-OGT with modified Rankin scale (mRS) at the time of discharge. Results: Fifty-four patients underwent ET during the study period. Patients with posterior circulation LVO and those treated after 6 hours from last known normal were excluded. A total of 34 patients were left for final analysis. Patients with a good outcome (mRS ≤2) had an average NIHSS-OGT score of 43.2 (95% CI: 29.7-56.8) and PASS-OGT score of 5.52 (95% CI: 4.48-6.56). Patient’s with poor to miserable outcomes (mRS 3-6) average NIHSS-OGT 84.7 (95% CI: 72.8-96.6) and PASS-OGT average 9.8 (95% CI: 8.3-11.2). For NIHSS-OGT cut off of 55 the sensitivity and specificity was 0.75 and 0.85 respectively; diagnostic odds ratio 16.5 (96% CI: 2.41-112.83). For PASS-OGT cut off of 6.5 the sensitivity and specificity were 0.88 and 0.76 respectively; diagnostic odds ratio 23.33 (95% CI: 2.37-229.33). The wide confidence intervals can be attributed to small sample size. Conclusion: Our study indicates NIHSS–OGT and PASS-OGT scores have a linear relationship with discharge mRS and can reliably predict early clinical outcomes after ET. Further confirmation with randomized control trials is needed.

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Thrombectomy in acute ischemic stroke: estimations of increasing demands

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012575 ◽

2016 ◽

Vol 9 (9) ◽

pp. 830-833 ◽

Cited By ~ 7

Author(s):

Åsa Kuntze Söderqvist ◽

Tommy Andersson ◽

Niaz Ahmed ◽

Nils Wahlgren ◽

Magnus Kaijser

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Artery Occlusion ◽

University Hospital ◽

Stroke Severity ◽

Large Artery ◽

Anterior Circulation ◽

Stroke Treatment ◽

Stroke Registry ◽

New Treatment

BackgroundNew recommendations for mechanical thrombectomy in acute ischemic stroke suggest that thrombectomy should be considered for eligible patients with a large artery occlusion in the anterior circulation within 6 hours of stroke onset. The resources are unevenly spread and, in order to be able to meet a potentially increased demand, we have estimated the future need for thrombectomy.MethodsThe new treatment recommendations are similar to those that have been in use at the Karolinska University Hospital since 2007. Using our local thrombectomy data (2009–2011), we calculated the proportion of thrombectomies performed at our hospital by level of stroke severity according to the National Institutes of Health Stroke Scale score (0–5, 6–11, 12–19, and 20–35). We then estimated the total number of potential thrombectomies expected in Sweden by extrapolating our treatment proportions to the rest of Sweden through the use of data from the Swedish National Stroke Registry.ResultsThe number of potential thrombectomies would have been more than five times higher (1268 estimated compared with 232 actually reported in the National Stroke Registry) if the new recommendations for thrombectomy in acute ischemic stroke had been implemented in 2013 (the year from which we had the most recent available data from the Swedish Stroke Registry).ConclusionsWhen the new recommendations are implemented broadly, there may be a substantial increase in demand for thrombectomies. Our study highlights the need for policymakers and healthcare professionals to prepare for the increasing demands for advanced endovascular stroke treatment.

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