Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review

Krebs, William; Sharkey-Toppen, Travis; Cheek, Fern; Cortez, Eric; Larrimore, Ashley; Keseg, David; Panchal, Ashish R.

doi:10.1080/10903127.2017.1371263

Cited by 30 publications

(22 citation statements)

References 26 publications

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“…Several stroke LVO scales have been validated1 14–16 20 21; however, few have been prospectively applied by the EMS in a prehospital setting within the USA 18 19. Our 3-year experience demonstrates the long-term feasibility of implementing a countywide EMS-based prehospital AIS triage protocol using the RACE Scale.…”

Section: Discussionmentioning

confidence: 90%

“…The accuracy of stroke severity-based triage may not be generalizable to EMS agencies that rely on volunteers or may not have similar rigorous training and feedback processes. As our EMS personnel are trained only on the RACE scale, we were unable to prospectively compare other prehospital LVO scales, such as vision, aphasia, and neglect (VAN) and the Los Angeles Motor Scale (LAMS), in our current study 15 22. Physician involvement via tele-stroke technology may reduce the number of stroke mimics, which accounted for 27.8% in our RACE cohort.…”

Section: Discussionmentioning

confidence: 99%

“…Prehospital stroke severity scales may aid in identifying patients with AIS with suspected LVOs13; however, there is a paucity of data on the long-term implementation of prehospital LVO scales in a ’real-world' setting 14 15. The Rapid Arterial oCclusion Evaluation (RACE) Scale is one of the few prehospital scales that have been prospectively validated in the field, and has been recently revalidated in a large cohort in Catalonia 16 17.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Jumaa

Castonguay

Salahuddin

et al. 2019

J NeuroIntervent Surg

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BackgroundData on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA.ObjectiveTo report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score.MethodsOur prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated.ResultsBetween July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively.ConclusionsWe have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Jumaa

Castonguay

Salahuddin

et al. 2019

J NeuroIntervent Surg

View full text Add to dashboard Cite

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“…Despite derivation of more than 30 different stroke severity tools for this purpose, most have not been prospectively validated in the field, and diagnostic performance has been highly variable . The most rigorously studied LVO prediction tools include the Cincinnati Prehospital Stroke Severity Scale (CP‐SSS), the Los Angeles Motor Score (LAMS), and Rapid Arterial Occlusion Evaluation (RACE) .…”

Section: The Expanded Treatment Window's Impact On Prehospital Strokementioning

confidence: 99%

The Extended Treatment Window's Impact on Emergency Systems of Care for Acute Stroke

Miller

Heitsch

Madsen

et al. 2019

Academic Emergency Medicine

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The window for acute ischemic stroke treatment was previously limited to 4.5 hours for intravenous tissue plasminogen activator and to 6 hours for thrombectomy. Recent studies using advanced imaging selection expand this window for select patients up to 24 hours from last known well. These studies directly affect emergency stroke management, including prehospital triage and emergency department (ED) management of suspected stroke patients. This narrative review summarizes the data expanding the treatment window for ischemic stroke to 24 hours and discusses these implications on stroke systems of care. It analyzes the implications on prehospital protocols to identify and transfer large-vessel occlusion stroke patients, on issues of distributive justice, and on ED management to provide advanced imaging and access to thrombectomy centers. The creation of high-performing systems of care to manage acute ischemic stroke patients requires academic emergency physician leadership attentive to the rapidly changing science of stroke care.A cute ischemic stroke in the United States is the fifth leading cause of death and the leading cause of preventable disability and has an incidence of over 700,000 annual events. 1 The treatment of acute ischemic stroke changed dramatically following the publication of the National Institute of Neurological Disorders and Stroke (NINDS) trials in 1995, 2 which demonstrated improved outcomes for patients treated with intravenous tissue plasminogen activator (IV t-PA). Since then, national quality improvement efforts such as Get With The Guidelines -Stroke have sought to promote rapid stroke evaluation and IV t-PA delivery to appropriate patients. 3Patients with acute ischemic stroke and large-vessel occlusion (LVO) are at especially high risk of poor outcomes. They represent only one-third of all ischemic stroke cases, but LVO strokes are responsible for over 95% of acute ischemic stroke-related mortality and 60% of acute ischemic stroke-related death or permanent dependency. 4 Without emergent recanalization, 60% to 80% of LVO strokes result in death or permanent disability. 5,6 Landmark trials published in 2015 used clinical and imaging-based criteria to select LVO stroke patients for endovascular therapy and significantly changed the treatment landscape for acute ischemic

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“…Prehospital clinical stroke severity scales have been implemented in several regions across the USA. The sensitivity of prehospital stroke scales used by emergency medical services (EMS) for detection of ELVO ranges from 49% to 91% and specificity from 40% to 94% 18. To improve the accuracy of prehospital ELVO detection, prehospital technologies, such as portable, non-invasive ELVO detection devices and mobile CT scanners, have emerged akin to field electrocardiography for acute myocardial infarction 19.…”

Section: Advances In Prehospital Screening Toolsmentioning

confidence: 99%

In the thrombectomy era, triage in the field improves care

Fifi

Dabus

Mack

et al. 2018

J NeuroIntervent Surg

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Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review

Abstract: At this time, further evaluations must be done in the prehospital setting to determine the ease of use and true sensitivity and specificity of these scales in identifying LVOs.

Cited by 30 publications

References 26 publications

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

The Extended Treatment Window's Impact on Emergency Systems of Care for Acute Stroke

In the thrombectomy era, triage in the field improves care

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