Henry Zhao1, Lauren Pesavento2, Skye Coote2, Edrich Rodrigues2, Patrick Salvaris2, Karen Smith2, Stephen Bernard2, Michael Stephenson2, Leonid Churilov2, Nawaf Yassi2, Stephen M Davis2, Bruce C V Campbell2. 1. From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of Emergency Medicine, University of Western Australia, Australia (K.S., S.B.). zhaohdr@live.com. 2. From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of Emergency Medicine, University of Western Australia, Australia (K.S., S.B.).
Abstract
BACKGROUND AND PURPOSE: Clinical triage scales for prehospital recognition of large vessel occlusion (LVO) are limited by low specificity when applied by paramedics. We created the 3-step ambulance clinical triage for acute stroke treatment (ACT-FAST) as the first algorithmic LVO identification tool, designed to improve specificity by recognizing only severe clinical syndromes and optimizing paramedic usability and reliability. METHODS: The ACT-FAST algorithm consists of (1) unilateral arm drift to stretcher <10 seconds, (2) severe language deficit (if right arm is weak) or gaze deviation/hemineglect assessed by simple shoulder tap test (if left arm is weak), and (3) eligibility and stroke mimic screen. ACT-FAST examination steps were retrospectively validated, and then prospectively validated by paramedics transporting culturally and linguistically diverse patients with suspected stroke in the emergency department, for the identification of internal carotid or proximal middle cerebral artery occlusion. The diagnostic performance of the full ACT-FAST algorithm was then validated for patients accepted for thrombectomy. RESULTS: In retrospective (n=565) and prospective paramedic (n=104) validation, ACT-FAST displayed higher overall accuracy and specificity, when compared with existing LVO triage scales. Agreement of ACT-FAST between paramedics and doctors was excellent (κ=0.91; 95% confidence interval, 0.79-1.0). The full ACT-FAST algorithm (n=60) assessed by paramedics showed high overall accuracy (91.7%), sensitivity (85.7%), specificity (93.5%), and positive predictive value (80%) for recognition of endovascular-eligible LVO. CONCLUSIONS: The 3-step ACT-FAST algorithm shows higher specificity and reliability than existing scales for clinical LVO recognition, despite requiring just 2 examination steps. The inclusion of an eligibility step allowed recognition of endovascular-eligible patients with high accuracy. Using a sequential algorithmic approach eliminates scoring confusion and reduces assessment time. Future studies will test whether field application of ACT-FAST by paramedics to bypass suspected patients with LVO directly to endovascular-capable centers can reduce delays to endovascular thrombectomy.
BACKGROUND AND PURPOSE: Clinical triage scales for prehospital recognition of large vessel occlusion (LVO) are limited by low specificity when applied by paramedics. We created the 3-step ambulance clinical triage for acute stroke treatment (ACT-FAST) as the first algorithmic LVO identification tool, designed to improve specificity by recognizing only severe clinical syndromes and optimizing paramedic usability and reliability. METHODS: The ACT-FAST algorithm consists of (1) unilateral arm drift to stretcher <10 seconds, (2) severe language deficit (if right arm is weak) or gaze deviation/hemineglect assessed by simple shoulder tap test (if left arm is weak), and (3) eligibility and stroke mimic screen. ACT-FAST examination steps were retrospectively validated, and then prospectively validated by paramedics transporting culturally and linguistically diverse patients with suspected stroke in the emergency department, for the identification of internal carotid or proximal middle cerebral artery occlusion. The diagnostic performance of the full ACT-FAST algorithm was then validated for patients accepted for thrombectomy. RESULTS: In retrospective (n=565) and prospective paramedic (n=104) validation, ACT-FAST displayed higher overall accuracy and specificity, when compared with existing LVO triage scales. Agreement of ACT-FAST between paramedics and doctors was excellent (κ=0.91; 95% confidence interval, 0.79-1.0). The full ACT-FAST algorithm (n=60) assessed by paramedics showed high overall accuracy (91.7%), sensitivity (85.7%), specificity (93.5%), and positive predictive value (80%) for recognition of endovascular-eligible LVO. CONCLUSIONS: The 3-step ACT-FAST algorithm shows higher specificity and reliability than existing scales for clinical LVO recognition, despite requiring just 2 examination steps. The inclusion of an eligibility step allowed recognition of endovascular-eligible patients with high accuracy. Using a sequential algorithmic approach eliminates scoring confusion and reduces assessment time. Future studies will test whether field application of ACT-FAST by paramedics to bypass suspected patients with LVO directly to endovascular-capable centers can reduce delays to endovascular thrombectomy.
Authors: Michael V Mazya; Annika Berglund; Niaz Ahmed; Mia von Euler; Staffan Holmin; Ann-Charlotte Laska; Jan M Mathé; Christina Sjöstrand; Einar E Eriksson Journal: JAMA Neurol Date: 2020-06-01 Impact factor: 18.302
Authors: Boris Keselman; Annika Berglund; Niaz Ahmed; David Grannas; Mia von Euler; Staffan Holmin; Ann-Charlotte Laska; Jan M Mathé; Christina Sjöstrand; Einar E Eriksson; Michael V Mazya Journal: Eur Stroke J Date: 2022-02-23
Authors: T Truc My Nguyen; Ido R van den Wijngaard; Jan Bosch; Eduard van Belle; Erik W van Zwet; Tamara Dofferhoff-Vermeulen; Dion Duijndam; Gaia T Koster; Els L L M de Schryver; Loet M H Kloos; Karlijn F de Laat; Leo A M Aerden; Stas A Zylicz; Marieke J H Wermer; Nyika D Kruyt Journal: JAMA Neurol Date: 2021-02-01 Impact factor: 18.302
Authors: Stefanie Behnke; Thomas Schlechtriemen; Andreas Binder; Monika Bachhuber; Mark Becker; Benedikt Trauth; Martin Lesmeister; Elmar Spüntrup; Silke Walter; Lukas Hoor; Andreas Ragoschke-Schumm; Fatma Merzou; Luca Tarantini; Thomas Bertsch; Jürgen Guldner; Achim Magull-Seltenreich; Frank Maier; Christoph Massing; Volkmar Fischer; Michael Gawlitza; Katrin Donnevert; Hans-Michael Lamberty; Stefan Jung; Matthias Strittmatter; Silke Tonner; Johannes Schuler; Robert Liszka; Stefan Wagenpfeil; Iris Q Grunwald; Wolfgang Reith; Klaus Fassbender Journal: Neurol Res Pract Date: 2021-06-01