Large Vessel Occlusion Scales Increase Delivery to Endovascular Centers Without Excessive Harm From Misclassifications

  title={Large Vessel Occlusion Scales Increase Delivery to Endovascular Centers Without Excessive Harm From Misclassifications},
  author={Henry Zhao and Skye Coote and Lauren Pesavento and Leonid P. Churilov and Helen M. Dewey and Stephen M. Davis and Bruce C.V. Campbell},
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… 

Tables from this paper

Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting.
All 7 sLAVO prediction scales found had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales, and feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.
Sensitivity of prehospital stroke scales for different intracranial large vessel occlusion locations
Although prehospital stroke scales are generally sensitive for proximal large vessel occlusion, they are less sensitive to detect more distal occlusions.
Leukoaraiosis Attenuates Diagnostic Accuracy of Large-Vessel Occlusion Scales
The diagnostic accuracy of the tested large-vessel occlusion scales was attenuated in the presence of moderate-to-severe leukoaraiosis, and this information may aid the design of future studies that require large- Vessel Occlusion scale screening of patients who are likely to have concomitant leukoARaiosis.
Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke
A CPSS score of 3 reliably identifies LVO in AIS patients, and EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.
PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response)
The prevalence of LVO acute ischemic stroke in the EMS population screened for stroke was low, an important consideration for any EMS stroke severity-based triage protocol and should be considered in predicting the rates of overtriage to endovascular stroke centers.
The Cincinnati Prehospital Stroke Scale Compared to Stroke Severity Tools for Large Vessel Occlusion Stroke Prediction
In this large sample of real-world prehospital patient encounters, the Cincinnati Prehospital Stroke Scale demonstrated similar predictive performance characteristics compared to the RACE, LAMS, and VAN for detecting LVO stroke.
Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens
The Los Angeles Motor Scale for LVO and CSC-appropriate (LVO ACI and intracranial hemorrhage patients) recognition is validated and performs comparably or better than more extended prehospital scales and the full National Institutes of Health Stroke Scale.
Distribution of Diagnoses and Clinical and Imaging Characteristics in 1,322 Consecutive Suspected Stroke Patients
The results help to plan resources in thrombectomy-capable centers in times of expanding indications for EVT where resources will have to be adjusted to patients with low-NIHSS, low-ASPECTS, and distal occlusions, and patients presenting in the extended time window, which may altogether account for an additional 20% of all ischemic stroke patients.
Utility of Severity-Based Prehospital Triage for Endovascular Thrombectomy
The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.
The Finnish Prehospital Stroke Scale Detects Thrombectomy and Thrombolysis Candidates-A Propensity Score-Matched Study.


Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes
FAST-ED is a simple scale that if successfully validated in the field, it may be used by medical emergency professionals to identify LVOS in the prehospital setting enabling rapid triage of patients.
Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion: Design and Comparison With Other Scales
A simple prehospital stroke scale to identify emergent large vessel occlusion (ELVO) in patients with acute ischemic stroke is designed and validated and has promising accuracy for prediction of ELVO in the field.
A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions
The LAMS is a promising instrument for use by prehospital personnel to identify select stroke patients for direct transport to Comprehensive Stroke Centers capable of endovascular interventions.
Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion: The Rapid Arterial Occlusion Evaluation Scale
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.
Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion
Intacranial arterial imaging should be performed in all patients with acute ischemic stroke presenting within 6 hours of symptom onset, and published cutoffs would result in a loss of opportunity for ≥20% of patients with large-artery occlusion who would be inappropriately sent to a center lacking neurointerventional facilities.
Prehospital Scales to Identify Patients With Large Vessel Occlusion: It Is Time for Action.
The advent of the endovascular treatment (EVT) for acute ischemic strokes caused by large artery occlusions and the evidence that EVT benefit declines with increasing time after symptom onset force us to consider and favor systems of care that prioritizes rapid access to EVT in an equitable way.
Abstract 83: Field Validation of Prehospital LAMS Score to Identify Large Vessel Occlusion Ischemic Stroke Patients for Direct Routing to Emergency Neuroendovascular Centers
The Los Angeles Motor Scale score identifies LVO in acute cerebral ischemia patients as well as the current gold standard NIHSS, and in prospective field validation testing, a positive paramedic LAMS increased the likelihood ofLVO by 76% and a negative cut the chance of LVO by more than half.
Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?
There is a significant correlation between clinical scores based on the NIHSS score and LVO on arteriography, however, if clinically relevant thresholds are applied to the scores, a sizable number of LVOs are missed and clinical scores cannot replace vessel imaging.
Response by Lima et al to Letter Regarding Article, "Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes".
We would like to thank Heldner et al1 for taking an interest on our work and applying the Field Assessment Stroke Triage for Emergency Destination scale (FAST-ED) to their large patient cohort.
Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis.
The period in which endovascular thrombectomy is associated with benefit, and the extent to which treatment delay is related to functional outcomes, mortality, and symptomatic intracranial hemorrhage are characterized are characterized.