BACKGROUND: It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians. METHODS: We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (r _s ) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference. RESULTS: We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (r _s =0.70 [95% CI, 0.68–0.72]). Concerning individual items, prehospital assessment of arm (r _s =0.68) and leg (r _s =0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (r _s =0.31), abnormal speech (r _s =0.50), and gaze deviation (r _s =0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%). CONCLUSIONS: The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.

BACKGROUND: Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. METHODS: We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. RESULTS: Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65–0.75) to 0.77 (95% CI, 0.73–0.82) in women versus 0.69 (95% CI, 0.64–0.73) to 0.75 (95% CI, 0.71–0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20–0.27) to 0.29 (95% CI, 0.26–0.31) in women versus 0.29 (95% CI, 0.24–0.33) to 0.37 (95% CI, 0.32–0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94–0.96] to 0.98 [95% CI, 0.97–0.98] in women versus 0.94 [95% CI, 0.93–0.95] to 0.96 [95% CI, 0.94–0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43–0.63] to 0.76 [95% CI, 0.68–0.84] versus 0.49 [95% CI, 0.40–0.57] to 0.63 [95% CI, 0.55–0.73]), whereas specificity was lower (0.79 [95% CI, 0.76–0.81] to 0.87 [95% CI, 0.84–0.89] versus 0.82 [95% CI, 0.79–0.84] to 0.90 [95% CI, 0.88–0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. CONCLUSIONS: aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.

Various prehospital scales have been developed to detect patients with anterior-circulation large-vessel occlusion (aLVO) ischemic stroke to enable direct transportation to a thrombectomy-capable stroke center. To guide implementation, a head-to-head comparison of aLVO stroke detection scales is needed to determine which scale is most useful for prehospital triage in different regional contexts. We aimed to systematically identify and compare these scales. Published prehospital aLVO stroke scales were identified with a systematic literature search. Scales were reconstructed from individual patient data of 2 large prospective observational cohort studies conducted between 2018 and 2019, the Leiden Prehospital Stroke Study and PREhospital triage of patients with suspected STrOke symptoms study. Both studies included consecutive adult patients suspected by paramedics of having a stroke within 6 hours of symptom onset, from 4 Dutch ambulance regions, encompassing 15 stroke centers and serving 3.7 million people. All data used for the reconstruction of scales were acquired by paramedics in the field before hospital arrival. Scales' diagnostic performance to detect aLVO stroke was compared with the area under the receiver operating characteristic curve (AUROC) of the full scale and sensitivity and specificity at the scales' original cut-point. Decision curve analysis was used to evaluate harm-benefit trade-offs between delaying IV thrombolysis and expediting endovascular thrombectomy with direct transportation of patients to a thrombectomy-capable center. We identified 63 aLVO scales, of which 14 could be reconstructed. Of 2,358 included patients (mean age 70 years; 47% female), 231 (9.8%) had aLVO stroke. The AUROC was highest for Rapid Arterial oCclusion Evaluation (RACE) (0.81, 95% CI 0.78-0.84), Los Angeles Motor Scale (LAMS) (0.80, 95% CI 0.77-0.83), Gaze-Face-Arm-Speech-Time (G-FAST) (0.80, 95% CI 0.77-0.83), and modified Gaze-Face-Arm-Speech-Time (mG-FAST) (0.79, 95% CI 0.76-0.82). The Emergency Medical Stroke Assessment had highest sensitivity (85%, 95% CI 80%-90%) but lowest specificity (58%, 95% CI 56%-61%) while Cincinnati Prehospital Stroke Scale with an adjusted cut-point of 3 + gaze had highest specificity (94%, 95% CI 93%-95%) but lowest sensitivity (35%, 95% CI 29%-41%). In decision curve analysis, RACE had the highest benefit across a clinically reasonable range of harm-benefit trade-offs. RACE, LAMS, G-FAST, and mG-FAST are the best-performing scales, with RACE being preferred in most triage settings. Our findings may support policymakers with implementing a scale suitable for their region.

: Introduction: Computed tomography perfusion (CTP) is variably considered to assess eligibility for endovascular thrombectomy (EVT) in acute ischemic (AIS) stroke patients. Although CTP is recommended for patient selection in later (6–24 h) time window, it is currently not recommended in the earlier (0–6 h) time window and the costs and health effects of including CTP for EVT selection remain unknown. We aim to estimate the costs and health effects of using CTP for EVT selection in AIS patients compared to conventional selection. Patients and methods: CLEOPATRA is a healthcare evaluation study using clinical and imaging data from multiple, prospective EVT trials and registries in both the earlier and later time windows. To study the long-term health and cost effects, we will construct a (“Markov”) health state transition model simulating the clinical outcome over a 5-year follow-up period for CTP-based and conventional selection for EVT. Clinical data acquired within the current study and estimates from the literature will be used as input for probabilities of events, costs, and Quality-Adjusted Life Years (QALYs) per modified Rankin Scale (mRS) subscore. Primary outcome for the cost-effectiveness analysis will be the Incremental Cost-Effectiveness Ratio (ICER) in terms of costs per QALY gained over the simulated follow-up period. Study outcomes: Outcome measures will be reported as cumulative values over a 5-year follow-up period. Discussion: This study will provide preliminary insight into costs and health effects of including CTP in the selection for EVT for AIS patients, presenting between 0 and 24 h after time last known well. The results may be used to develop recommendations and inform further implementation projects and studies.

Purpose: Intravenous alteplase (IVT) prior to endovascular treatment (EVT) is neither superior nor noninferior to EVT alone in acute ischemic stroke patients. We aim to assess whether the effect of IVT prior to EVT differs according to CT perfusion (CTP)–based imaging parameters. Methods: In this retrospective post hoc analysis, we included patients from the MR CLEAN-NO IV with available CTP data. CTP data were processed using syngo.via (version VB40). We performed multivariable logistic regression to obtain the effect size estimates (adjusted common odds ratio a[c]OR) on 90-day functional outcome (modified Rankin Scale [mRS]) and functional independence (mRS 0-2) for CTP parameters with two-way multiplicative interaction terms between IVT administration and the studied parameters. Results: In 227 patients, median CTP-estimated core volume was 13 (IQR 5–35) mL. The treatment effect of IVT prior to EVT on outcome was not altered by CTP-estimated ischemic core volume, penumbral volume, mismatch ratio, and presence of a target mismatch profile. None of the CTP parameters was significantly associated with functional outcome after adjusting for confounders. Conclusion: In directly admitted patients with limited CTP-estimated ischemic core volumes who presented within 4.5 h after symptom onset, CTP parameters did not statistically significantly alter the treatment effect of IVT prior to EVT. Further studies are needed to confirm these results in patients with larger core volumes and more unfavorable baseline perfusion profiles on CTP imaging.

Background: Computed tomography perfusion (CTP)-estimated core volume is associated with functional outcomes in acute ischemic stroke. This relationship might differ among patients, depending on brain volume. Materials and Methods: We retrospectively included patients from the MR CLEAN Registry. Cerebrospinal fluid (CSF) and intracranial volume (ICV) were automatically segmented on NCCT. We defined the proportion of the ICV and total brain volume (TBV) affected by the ischemic core as ICV_core and TBV_core. Associations between the core volume, ICV_core, TBV_core, and functional outcome are reported per interquartile range (IQR). We calculated the area under the curve (AUC) to assess diagnostic accuracy. Results: In 200 patients, the median core volume was 13 (5–41) mL. Median ICV and TBV were 1377 (1283–1456) mL and 1108 (1020–1197) mL. Median ICV_core and TBV_core were 0.9 (0.4–2.8)% and 1.7 (0.5–3.6)%. Core volume (acOR per IQR 0.48 [95%CI 0.33–0.69]), ICV_core (acOR per IQR 0.50 [95%CI 0.35–0.69]), and TBV_core (acOR per IQR 0.41 95%CI 0.33–0.67]) showed a lower likelihood of achieving improved functional outcomes after 90 days. The AUC was 0.80 for the prediction of functional independence at 90 days for the CTP-estimated core volume, the ICV_core, and the TBV_core. Conclusion: Correcting the CTP-estimated core volume for the intracranial or total brain volume did not improve the association with functional outcomes in patients who underwent EVT.