DISCLOSURES• ANDREW HARRELL MD FAEMS

• UNM DEPARTMENT OF EMERGENCY MEDICINEUNM EMS MEDICAL

DIRECTION CONSORTIUM

• MEDICAL DIRECTOR, ALBUQUERQUE FIRE DEPARTMENT

• MEDICAL DIRECTOR, GRAND CANYON NATIONAL PARK

• TEMS PHYSICIAN & MEDICAL DIRECTOR, BERNALILLO CO. SHERIFF'S

DEPARTMENT

• STAKEHOLDER OWNERSHIP SHARE IN CPR/AED/FIRST AID TRAINING

COMPANY

• HUY TRAN MD

• UNM DEPARTMENT OF NEUROLOGY AND NEUROSURGERY

• NO DISCLOSURES

OBJECTIVES

REVIEW PRE-HOSPITAL LVO SCREENS

RACE

C-STAT

LAMS

2014 – A REVOLUTION IN STROKE• DEC 2014 – MR CLEAN

• FEBRUARY 2015: AT ISC

• ESCAPE

• SWIFT-PRIME

• EXTEND-IA

• REVASCAT

• MECHANICAL THROMBECTOMY PROVEN BENEFICIAL

FOR STROKES DUE TO ANTERIOR LARGE VESSEL

OCCLUSION (LVO)

TIME TO TREATMENT

• STILL IMPORTANT AS W IV TPA

• EVERY 30 MINUTES DELAY 10%

DECREASE IN THE CHANCE OF GOOD

OUTCOME

• EARLIER ENDOVASCULAR THERAPY

SUBSTANTIALLY BETTER OUTCOMES

Khatri P, Abruzzo T, Yeatts SD, et al. Good clinical outcome after ischemic

stroke with successful revascularization is time-dependent. Neurology 2009;73:

1066–72.

Vagal AS, Khatri P, Broderick JP, et al. Time to angiographic reperfusion in

acute

ischemic stroke: decision analysis. Stroke 2014;45:3625–30.

Sheth SA, Jahan R, Gralla J, et al. Time to endovascular reperfusion and

degree of disability in acute stroke. Ann Neurol 2015;78:584-593.

Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al;

HERMES Collaborators. Time to treatment with endovascular thrombectomy

and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316:1279–

1288. doi: 10.1001/jama.2016.13647

INTERFACILITY TRANSFERS

• CAUSE DELAY AND RESULT IN WORSE OUTCOMES

• COMPARED TO DIRECT TRANSPORT TO AND ENDOVASCULAR FACILITY.

• SUN CH, NOGUEIRA RG, GLENN BA, ET AL. “PICTURE TO PUNCTURE”: A NOVEL TIME METRIC TO ENHANCE OUTCOMES IN PATIENTS TRANSFERRED FOR

ENDOVASCULAR REPERFUSION IN ACUTE ISCHEMIC STROKE. CIRCULATION 2013;127:1139-1148.

• MOHAMAD NF, HASTRUP S, RASMUSSEN M, ANDERSEN MS, JOHNSEN SP, ANDERSEN G, ET AL. BYPASSING PRIMARY STROKE CENTRE REDUCES DELAY AND

IMPROVES OUTCOMES FOR PATIENTS WITH LARGE VESSEL OCCLUSION. EUR STROKE J. 2016;1:85–92. DOI: 10.1177/2396987316647857

SYSTEMS OF CARE

• NEED TO BE RE-ORGANIZED TO PROVIDE OPTIMAL CARE TO ALL STROKE PATIENTS

• ELVO SHOULD GO TO ENDOVASCULAR TREATMENT FACILITY

• NO ELVO SHOULD GO TO NEAREST PSC

HOW TO PREDICT WHO HAS LVO

ASSESSING STROKE SEVERITY SCALES

• A HIGH NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) SCORE IS STRONGLY

ASSOCIATED WITH THE PRESENCE OF LVO

• NIHSS ≥11 IS PRETTY ACCURATE FOR PREDICTING LVO

• 42 ITEM SCALE

Heldner MR, Zubler C, Mattle HP, Schroth G, Weck A, Mono ML, et al. National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke.

2013;44:1153–1157. doi: 10.1161/STROKEAHA.111.000604.

Vanacker P, Heldner MR, Amiguet M, Faouzi M, Cras P, Ntaios G, et al. Prediction of large vessel occlusions in acute stroke: National Institute of Health Stroke Scale is hard to beat. Crit Care Med.

2016;44:e336–e343. doi: 10.1097/CCM.0000000000001630

STROKE SEVERITY 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]) = CSTAT

• MARIA PREHOSPITAL STROKE SCALE (MPSS)

• RECOGNITION OF STROKE IN THE EMERGENCY ROOM (ROSIER)

• 3-ITEM STROKE SCALE (31-SS)

• VAN

• SHORTENED VERSIONS OF THE NIHSS (SNIHSS-1, SNIHSS-5, AND SNIHSS-8)

• G-FAST

• MELBOURNE AMBULANCE STROKE SCREEN (MASS)

• MEDIC PREHOSPITAL ASSESSMENT FOR CODE STROKE (MED PACS)

• ONTARIO PREHOSPITAL STROKE SCREENING (OPSS)

HOW DO YOU CHOOSE A SCALE

• KEEP IT SIMPLE

• EXTERNAL VALIDATION

• VALIDATED IN PRE-HOSPITAL SETTING IS

PARAMOUNT

VALIDATED SCALES

RACE C STAT LAMS

CPSSS

formerly

RACE RAPID ARTERIAL OCCLUSION EVALUATION SCALE

Ossa et al. Stroke. 2014;45:87-91

RACE

• RACE ≥ 5

• SEN 85%, SPEC 68%

• CORRECTLY CLASSIFIED

71% OF PATIENTS

RACE ≥5

n Sensitivity Specificity AUC

Ossa et al. Stroke. 2014;45:87-

91 357 85% 68% ND

Turc et al. Stroke.

2016;47:1466-1472 1004 67% 85% 0.79

Harstrup et al. Stroke.

2016;47:00-00 3127 59% 86% 0.72

Lima et al. Stroke. 2016;47:00-

00 741 55% 87% 0.77

Zhao et al . Stroke.

2017;48:568-573 565 66% 90% 0.78

Carrera et al.J. Stroke

cerebrovasdis.;2017; 26:74 - 77 341 84% 68%

Shietz et al. Stroke.

2017;48:290-297 3505 71% 68%

C-STAT CINCINNATI PREHOSPITAL STROKE SEVERITY SCALE

Katz et al. Stroke. 2015;46:1508-1512

C-STAT

C-STAT ≥ 2

OBJECTIVE: ABSENT OR

PRESENT

FAST < 1 MINUTE

EMS APPROVED

C-STAT ≥ 2

n Sensitivity Specificity AUC

Katz et al. Stroke. 2015;46:1508-1512 303 83% 40% 0.67

Turc et al. Stroke. 2016;47:1466-1472 1004 65% 84% 0.78

Kummer et al. J Stroke and Cerebrovasc Disease. 25:5 (May),

2016: 1270-1274664 70% 87% ND

Harstrup et al. Stroke. 2016;47:00-00 3127 59% 86% 0.72

Lima et al. Stroke. 2016;47:00-00 741 56% 85% 0.75

McMullen et al. Pre-hospital Emerg Care. 2017; 1-8 58 71% 70%

Zhao et al . Stroke.

2017;48:568-573 565 56% 86% 0.71

Shietz et al. Stroke.

2017;48:290-297 3505 71% 67%

LAMS

• IS A VALIDATED, 3-ITEM, 0- TO 5-POINT MOTOR

STROKE DEFICIT SCALE, DEVELOPED FOR

PREHOSPITAL AND ED USE, THAT TAKES 20 TO

30 SECONDS TO PERFORM.

•

• THE LAMS HAS GOOD INTERRATER RELIABILITY,

CORRELATES STRONGLY WITH THE FULL NIHSS

(CONCURRENT VALIDITY), AND PREDICTS FINAL

STROKE FUNCTIONAL OUTCOMES AS WELL AS

THE NIHSS (PREDICTIVE VALIDITY).

The Los Angeles Motor Scale (LAMS)

LAMSLAMS ≥ 4

n Sensitivity Specificity AUC

Nazliel et al. Stroke. 2008;39:2264-2267 119 81% 89% 0.854

Harstrup et al. Stroke. 2016;47:00-00 3127 57% 84% 0.7

Noorian et al. Stroke. 2016;47:A83 190 74% 58% 0.7

Zhao et al . Stroke.

2017;48:568-573 565 66% 86% 0.78

AUC• SCALES ARE PRETTY EQUIVALENT

• MODERATELY GOOD PERFORMANCE

• MATTER OF CHOOSING WHICH ONE IS EASIEST

WHY YOU CAN’T HAVE A PERFECT SCALE

• UP TO 29% OF PATIENTS W BASELINE NIHSS OF 0 HAD PROXIMAL OCCLUSION ON CTA

• MOST SCORES ARE SUBSETS OF NIHSS SCORES

• PATIENTS WITH ICH, POST SEIZURE PARALYSIS, HYPERGLYCEMIA IN THE FIELD CAN HAVE HIGH

NIHSS

Maas MB, Furie KL, Lev MH, Ay H, Singhal AB, Greer DM, et al. National Institutes of Health Stroke Scale score is poorly predictive of

proximal occlusion in acute cerebral ischemia. Stroke. 2009;40:2988– 2993. doi: 10.1161/STROKEAHA.109.555664

TYPICAL VS ATYPICAL PRESENTATION

TYPICAL PRESENTATION

• PROMINENT ARM WEAKNESS (NIHSS

MOTOR ARM ≥2)

• PLUS AN ADDITIONAL CORTICAL SIGN:

• EITHER SEVERE SPEECH DISTURBANCE

• PROMINENT INATTENTION

• GAZE DEVIATION

ATYPICAL PRESENTATION

• LVO WHO DID NOT PRESENT WITH THE

DEFINED SEVERE MCA SYNDROME

• PATIENTS WHO PRESENTED WITH THE

SEVERE MCA SYNDROME DESPITE NOT

HAVING AN LVO (NON-LVO)

Zhao et al . Stroke. 2017;48:568-573

THE GOOD NEWS• AMONG NON-LVO W ATYPICAL

PRESENTATIONS

• 64% WERE ICH

• SPECIFICITY ~80%; FPR 20%

• 20% * 36%* = 7.2% FUTILE TRANSFERS

• AMONG LVO

• 58% WERE M2 OCCLUSION

• SENSITIVITY ~66%; FNR 33%

• 33%*16% = 5.3% MISSED

THROMBECTOMY CANDIDATE

FINAL THOUGHTS

• STATE-WIDE PROTOCOL