Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion

Ossa, Natàlia Pérez de la; Carrera, David; Gorchs, Montse; Querol, Marisol; Millán, Mònica; Gomis, Meritxell; Dorado, Laura; López‐Cancio, Elena; Hernández‐Pérez, María; Chicharro, Vicente; Escalada, Xavier; Jiménez, Xavier F.; Dávalos, Antoni

doi:10.1161/strokeaha.113.003071

Cited by 401 publications

(391 citation statements)

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“…The presented test has a higher sensitivity and NPV than other tests (Table 4) (Hastrup et al., 2016; Katz et al., 2015; Lima et al., 2016; McMullan et al., 2017; Nazliel et al., 2008; Pérez de la Ossa et al., 2014; Scheitz et al., 2017; Singer et al., 2005). We found that the FAST PLUS test had a high sensitivity of 93% and high NPV of 94%.…”

Section: Discussionmentioning

confidence: 99%

“…We enrolled 435 patients with median NIHSS scores of 8 into our study. The number of patients and NIHSS scores is comparable to the RACE study (Pérez de la Ossa et al., 2014). …”

Section: Discussionmentioning

confidence: 99%

“…The LAMS test has been used in prehospital care for stroke identification, but not for predicting LVO (Nazliel et al., 2008). In a pilot study of the Cincinnati test, untrained paramedics tested only 58 patients (Table 4) (McMullan et al., 2017; Pérez de la Ossa et al., 2014). …”

Section: Discussionmentioning

confidence: 99%

“…This is comparable to the RACE study (McMullan et al., 2017) Other studies were performed retrospectively or with small numbers of patients (Hastrup et al., 2016; Katz et al., 2015; Lima et al., 2016; McMullan et al., 2017; Nazliel et al., 2008; Pérez de la Ossa et al., 2014; Singer et al., 2005). …”

Section: Discussionmentioning

confidence: 99%

“…Only the RACE and Cincinnati tests for LVO have been performed at a prehospital level (McMullan et al., 2017; Pérez de la Ossa et al., 2014). …”

Section: Introductionmentioning

confidence: 99%

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Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

et al. 2018

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Background and PurposeMechanical thrombectomy (MT) is indicated for the treatment of large vessel occlusion (LVO) stroke. MT should be provided as quickly as possible; therefore, a test identifying suspected LVO in the prehospitalization stage is needed to ensure direct transport to a comprehensive stroke center (CSC). We assume that patients with clinically severe hemiparesis have a high probability of LVO stroke. We modified the FAST test into the FAST PLUS test: The first part is the FAST test and the second part evaluates the presence of severe arm or leg motor deficit. This prospective multicenter study evaluates the specificity and sensitivity of the FAST PLUS test in detecting LVO stroke.MethodsParamedics were trained through e‐learning to conduct the FAST PLUS test.All prehospital suspected stroke patients who were administered the FAST PLUS test were included. Demographics, National Institutes of Health Stroke Scale (NIHSS) score, brain computed tomography (CT), and CT angiography (CTA) were recorded. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating curve (ROC) area for LVO were calculated.ResultsThe study included 435 patients. LVO were found in 124 patients (28%). Sensitivity was 93%, specificity was 47%, PPV was 41%, NPV was 94%, and ROC area for ICA/MCA occlusion was 0.65. Intracerebral hemorrhage (ICH) was identified in 48 patients (11%).ConclusionWe found that the FAST PLUS test had a high sensitivity for LVO stroke. Of the 435 patients, 41% were all directly transported to a CSC based on positive FAST PLUS test scores and were potential candidates for MT.

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Section: Discussionmentioning

confidence: 99%

“…We enrolled 435 patients with median NIHSS scores of 8 into our study. The number of patients and NIHSS scores is comparable to the RACE study (Pérez de la Ossa et al., 2014). …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…Only the RACE and Cincinnati tests for LVO have been performed at a prehospital level (McMullan et al., 2017; Pérez de la Ossa et al., 2014). …”

Section: Introductionmentioning

confidence: 99%

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Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

et al. 2018

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Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas

Ossa

Abilleira

Jovin

et al. 2022

JAMA

122

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In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. OBJECTIVE To determine whether, in nonurban areas, direct transport to a thrombectomycapable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURESThe primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTSEnrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR,[65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83] years; median National Institutes of Health Stroke Scale score, 17 [IQR,[11][12][13][14][15][16][17][18][19][20][21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCEIn nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings.

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Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes

et al. 2017

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IMPORTANCE While prehospital triage to the closest comprehensive stroke center (CSC) may improve the delivery of care for patients with suspected emergent large-vessel occlusion (ELVO), efficient systems of care must also exist for patients with ELVO who first present to a primary stroke center (PSC). OBJECTIVE To describe the association of a PSC protocol focused on 3 key steps (early CSC notification based on clinical severity, vessel imaging at the PSC, and cloud-based image sharing) with the efficiency of care and the outcomes of patients with suspected ELVO who first present to a PSC. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, 14 regional PSCs unfamiliar with the management of patients with ELVO were instructed on the use of the following protocol for patients presenting with a Los Angeles Motor Scale score 4 or higher: (1) notify the CSC on arrival, (2) perform computed tomographic angiography concurrently with noncontract computed tomography of the brain and within 30 minutes of arrival, and (3) share imaging data with the CSC using a cloud-based platform. A total of 101 patients were transferred from regional PSCs to the CSC between July 1, 2015, and May 31, 2016, and received mechanical thrombectomy for acute ischemic stroke. The CSC serves approximately 1.7 million people and partners with 14 PSCs located between 6.4 and 73.6 km away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred over an 11-month period were reviewed, and they were divided into 2 groups based on whether the PSC protocol was partially or fully executed. MAIN OUTCOMES AND MEASURES The primary outcomes were efficiency measures including time from PSC door in to PSC door out, time from PSC door to CSC groin puncture, and 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome). RESULTS Although 101 patients were transferred, only 70 patients met the inclusion criteria during the study period. The protocol was partially executed for 48 patients (68.6%) (mean age, 77 years [interquartile range, 65-84 years]; 22 of the 48 patients [45.0%] were women) and fully executed for 22 patients (31.4%) (mean age, 76 years [interquartile range, 59-86 years]; 13 of the 22 patients [59.1%] were women). When fully executed, the protocol was associated with a reduction in the median time for PSC arrival to CSC groin puncture (from 151 minutes [95% CI, 141-166 minutes] to 111 minutes [95% CI, 88-130 minutes]; P < .001). This was primarily related to an improvement in the time from PSC door in to door out that reduced from a median time of 104 minutes (95% CI, 82-112 minutes) to a median time of 64 minutes (95% CI, 51-71.0 minutes) (P < .001). When the protocol was fully executed, patients were twice as likely to have a favorable outcome (50% vs 25%, P < .04). CONCLUSIONS AND RELEVANCE When fully implemented, a standardized protocol at PSCs for patients with suspected ELVO consisting of early CSC notification, computed tomographic angiography on ar...

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Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion

Abstract: The RACE scale is a simple tool that can accurately assess stroke severity and identify patients with acute stroke with large artery occlusion at prehospital setting by medical emergency technicians.

Cited by 401 publications

References 29 publications

Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas

Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes

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