Henry Zhao1, Skye Coote2, Lauren Pesavento2, Leonid Churilov2, Helen M Dewey2, Stephen M Davis2, Bruce C V Campbell2. 1. From the Department of Medicine and Neurology, Royal Melbourne Hospital (H.Z., L.P., S.M.D., B.C.V.C.), and The Florey Institute of Neuroscience and Mental Health (L.C.), University of Melbourne, Parkville, Australia; and Eastern Health Clinical School, Eastern Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia (S.C., H.M.D.). zhaohdr@live.com. 2. From the Department of Medicine and Neurology, Royal Melbourne Hospital (H.Z., L.P., S.M.D., B.C.V.C.), and The Florey Institute of Neuroscience and Mental Health (L.C.), University of Melbourne, Parkville, Australia; and Eastern Health Clinical School, Eastern Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia (S.C., H.M.D.).
Abstract
BACKGROUND AND PURPOSE: Clinical large vessel occlusion (LVO) triage scales were developed to identify and bypass LVO to endovascular centers. However, there are concerns that scale misclassification of patients may cause excessive harm. We studied the settings where misclassifications were likely to occur and the consequences of these misclassifications in a representative stroke population. METHODS: Prospective data were collected from consecutive ambulance-initiated stroke alerts at 2 stroke centers, with patients stratified into typical (LVO with predefined severe syndrome and non-LVO without) or atypical presentations (opposite situations). Five scales (Rapid Arterial Occlusion Evaluation [RACE], Los Angeles Motor Scale [LAMS], Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Prehospital Acute Stroke Severity scale [PASS], and Cincinnati Prehospital Stroke Severity Scale [CPSSS]) were derived from the baseline National Institutes of Health Stroke Scale scored by doctors and analyzed for diagnostic performance compared with imaging. RESULTS: Of a total of 565 patients, atypical presentations occurred in 31 LVO (38% of LVO) and 50 non-LVO cases (10%). Most scales correctly identified >95% of typical presentations but <20% of atypical presentations. Misclassification attributable to atypical presentations would have resulted in 4 M1/internal carotid artery occlusions, with National Institutes of Health Stroke Scale score ≥6 (5% of LVO) being missed and 9 non-LVO infarcts (5%) bypassing the nearest thrombolysis center. CONCLUSIONS: Atypical presentations accounted for the bulk of scale misclassifications, but the majority of these misclassifications were not detrimental, and use of LVO scales would significantly increase timely delivery to endovascular centers, with only a small proportion of non-LVO infarcts bypassing the nearest thrombolysis center. Our findings, however, would require paramedics to score as accurately as doctors, and this translation is made difficult by weaknesses in current scales that need to be addressed before widespread adoption.
BACKGROUND AND PURPOSE: Clinical large vessel occlusion (LVO) triage scales were developed to identify and bypass LVO to endovascular centers. However, there are concerns that scale misclassification of patients may cause excessive harm. We studied the settings where misclassifications were likely to occur and the consequences of these misclassifications in a representative stroke population. METHODS: Prospective data were collected from consecutive ambulance-initiated stroke alerts at 2 stroke centers, with patients stratified into typical (LVO with predefined severe syndrome and non-LVO without) or atypical presentations (opposite situations). Five scales (Rapid Arterial Occlusion Evaluation [RACE], Los Angeles Motor Scale [LAMS], Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Prehospital Acute Stroke Severity scale [PASS], and Cincinnati Prehospital Stroke Severity Scale [CPSSS]) were derived from the baseline National Institutes of Health Stroke Scale scored by doctors and analyzed for diagnostic performance compared with imaging. RESULTS: Of a total of 565 patients, atypical presentations occurred in 31 LVO (38% of LVO) and 50 non-LVO cases (10%). Most scales correctly identified >95% of typical presentations but <20% of atypical presentations. Misclassification attributable to atypical presentations would have resulted in 4 M1/internal carotid artery occlusions, with National Institutes of Health Stroke Scale score ≥6 (5% of LVO) being missed and 9 non-LVO infarcts (5%) bypassing the nearest thrombolysis center. CONCLUSIONS: Atypical presentations accounted for the bulk of scale misclassifications, but the majority of these misclassifications were not detrimental, and use of LVO scales would significantly increase timely delivery to endovascular centers, with only a small proportion of non-LVO infarcts bypassing the nearest thrombolysis center. Our findings, however, would require paramedics to score as accurately as doctors, and this translation is made difficult by weaknesses in current scales that need to be addressed before widespread adoption.
Authors: Radoslav I Raychev; Dana Stradling; Nirav Patel; Joey R Gee; David A Lombardi; Johnson L Moon; David M Brown; Mayank Pathak; Wengui Yu; Samuel J Stratton; Steven C Cramer Journal: Stroke Date: 2018-04-06 Impact factor: 7.914
Authors: Laurent Pierot; Mahesh V Jayaraman; Istvan Szikora; Joshua A Hirsch; Blaise Baxter; Shigeru Miyachi; Jeyaledchumy Mahadevan; Winston Chong; Peter J Mitchell; Alan Coulthard; Howard A Rowley; Pina C Sanelli; Donatella Tampieri; Patrick A Brouwer; Jens Fiehler; Naci Kocer; Pedro Vilela; Alex Rovira; Urs Fischer; Valeria Caso; Bart van der Worp; Nobuyuki Sakai; Yuji Matsumaru; Shin-Ichi Yoshimura; Rene Anxionnat; Hubert Desal; Luisa Biscoito; José Manuel Pumar; Orlando Diaz; Justin F Fraser; Italo Linfante; David S Liebeskind; Raul G Nogueira; Werner Hacke; Michael Brainin; Bernard Yan; Michael Soderman; Allan Taylor; Sirintara Pongpech; Michihiro Tanaka; Terbrugge Karel Journal: Interv Neuroradiol Date: 2018-10-23 Impact factor: 1.610
Authors: Laurent Pierot; Mahesh V Jayaraman; Istvan Szikora; Joshua A Hirsch; Blaise Baxter; Shigeru Miyachi; Jeyaledchumy Mahadevan; Winston Chong; Peter J Mitchell; Alan Coulthard; Howard A Rowley; Pina C Sanelli; Donatella Tampieri; Patrick A Brouwer; Jens Fiehler; Naci Kocer; Pedro Vilela; Alex Rovira; Urs Fischer; Valeria Caso; Bart van der Worp; Nobuyuki Sakai; Yuji Matsumaru; Shin-Ichi Yoshimura; Rene Anxionnat; Hubert Desal; Luisa Biscoito; José Manuel Pumar; Orlando Diaz; Justin F Fraser; Italo Linfante; David S Liebeskind; Raul G Nogueira; Werner Hacke; Michael Brainin; Bernard Yan; Michael Soderman; Allan Taylor; Sirintara Pongpech; Michihiro Tanaka; Karel Terbrugge Journal: AJNR Am J Neuroradiol Date: 2018-11 Impact factor: 3.825
Authors: Jessalyn K Holodinsky; Tyler S Williamson; Andrew M Demchuk; Henry Zhao; Luke Zhu; Michael J Francis; Mayank Goyal; Michael D Hill; Noreen Kamal Journal: JAMA Neurol Date: 2018-12-01 Impact factor: 18.302
Authors: Y Mayasi; R P Goddeau; M Moonis; B Silver; A H Jun-O'Connell; A S Puri; N Henninger Journal: AJNR Am J Neuroradiol Date: 2017-11-23 Impact factor: 3.825
Authors: Christopher T Richards; Ryan Huebinger; Katie L Tataris; Joseph M Weber; Laura Eggers; Eddie Markul; Leslee Stein-Spencer; Kenneth S Pearlman; Jane L Holl; Shyam Prabhakaran Journal: Prehosp Emerg Care Date: 2018-01-03 Impact factor: 3.077
Authors: Mohammad Anadani; Eyad Almallouhi; Amy E Wahlquist; Ellen Debenham; Christine A Holmstedt Journal: Telemed J E Health Date: 2019-02-12 Impact factor: 3.536
Authors: Ali Reza Noorian; Nerses Sanossian; Kristina Shkirkova; David S Liebeskind; Marc Eckstein; Samuel J Stratton; Franklin D Pratt; Robin Conwit; Fiona Chatfield; Latisha K Sharma; Lucas Restrepo; Miguel Valdes-Sueiras; May Kim-Tenser; Sidney Starkman; Jeffrey L Saver Journal: Stroke Date: 2018-02-19 Impact factor: 7.914