Pre-hospital LVO Screen - American Heart Association

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DISCLOSURES ANDREW HARRELL MD FAEMS UNM DEPARTMENT OF EMERGENCY MEDICINEUNM EMS MEDICALDIRECTION CONSORTIUMMEDICAL DIRECTOR, ALBUQUERQUE FIRE DEPARTMENTMEDICAL DIRECTOR, GRAND CANYON NATIONAL PARKTEMS PHYSICIAN & MEDICAL DIRECTOR, BERNALILLO CO. SHERIFF'SDEPARTMENTSTAKEHOLDER OWNERSHIP SHARE IN CPR/AED/FIRST AID TRAININGCOMPANYHUY TRAN MD UNM DEPARTMENT OF NEUROLOGY AND NEUROSURGERYNO DISCLOSURES

OBJECTIVESREVIEW PRE-HOSPITAL LVO SCREENSRACEC-STATLAMS

2014 – A REVOLUTIONIN STROKE DEC 2014 – MR CLEANFEBRUARY 2015: AT ISC ESCAPESWIFT-PRIME EXTEND-IA REVASCATMECHANICAL THROMBECTOMY PROVEN BENEFICIALFOR STROKES DUE TO ANTERIOR LARGE VESSELOCCLUSION (LVO)

TIME TO TREATMENT STILL IMPORTANT AS W IV TPA EVERY 30 MINUTES DELAY 10%DECREASE IN THE CHANCE OF GOODOUTCOME EARLIER ENDOVASCULAR THERAPY SUBSTANTIALLY BETTER OUTCOMESKhatri P, Abruzzo T, Yeatts SD, et al. Good clinical outcome after ischemicstroke with successful revascularization is time-dependent. Neurology 2009;73:1066–72.Vagal AS, Khatri P, Broderick JP, et al. Time to angiographic reperfusion inacuteischemic stroke: decision analysis. Stroke 2014;45:3625–30.Sheth SA, Jahan R, Gralla J, et al. Time to endovascular reperfusion anddegree 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 thrombectomyand 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 FORENDOVASCULAR 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 ANDIMPROVES 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 TOPREDICT WHOHAS LVO

ASSESSING STROKE SEVERITY SCALES A HIGH NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) SCORE IS STRONGLYASSOCIATED WITH THE PRESENCE OF LVO NIHSS 11 IS PRETTY ACCURATE FOR PREDICTING LVO 42 ITEM SCALEHeldner 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], ANDCINCINNATI PREHOSPITAL STROKE SEVERITY SCALE [CPSSS]) CSTATMARIA PREHOSPITAL STROKE SCALE (MPSS)RECOGNITION OF STROKE IN THE EMERGENCY ROOM (ROSIER)3-ITEM STROKE SCALE (31-SS)VANSHORTENED 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 ISPARAMOUNT

VALIDATEDSCALESRACEC STATformerlyCPSSSLAMS

RACERAPID ARTERIAL OCCLUSION EVALUATION SCALEOssa et al. Stroke. 2014;45:87-91

RACE 5nSensitivitySpecificityAUC35785%68%NDTurc et al. Stroke.2016;47:1466-1472100467%85%0.79Harstrup et al. Stroke.2016;47:00-00312759%86%0.72Lima et al. Stroke. 2016;47:000074155%87%0.77Zhao et al . Stroke.2017;48:568-57356566%90%0.78Carrera et al.J. Strokecerebrovasdis.;2017; 26:74 - 7734184%68%350571%68%Ossa et al. Stroke. 2014;45:8791Shietz et al. Stroke.2017;48:290-297RACE RACE 5 SEN 85%, SPEC 68%CORRECTLY CLASSIFIED71% OF PATIENTS

C-STATCINCINNATI PREHOSPITAL STROKE SEVERITY SCALEKatz et al. Stroke. 2015;46:1508-1512

nC-STAT 2Sensitivity SpecificityAUCC-STATKatz et al. Stroke. 2015;46:1508-151230383%40%0.67Turc et al. Stroke. 6%0.72OBJECTIVE: ABSENT ORPRESENT74156%85%0.75FAST 1 MINUTE5871%70%Zhao et al . Stroke.2017;48:568-57356556%86%Shietz et al. Stroke.2017;48:290-297350571%67%Kummer et al. J Stroke andCerebrovasc Disease. 25:5 (May),2016: 1270-1274Harstrup et al. Stroke. 2016;47:00-00Lima et al. Stroke. 2016;47:00-00McMullen et al. Pre-hospital EmergCare. 2017; 1-8C-STAT 2EMS APPROVED0.71

LAMSThe Los Angeles Motor Scale (LAMS) IS A VALIDATED, 3-ITEM, 0- TO 5-POINT MOTORSTROKE DEFICIT SCALE, DEVELOPED FORPREHOSPITAL AND ED USE, THAT TAKES 20 TO30 SECONDS TO PERFORM. THE LAMS HAS GOOD INTERRATER RELIABILITY,CORRELATES STRONGLY WITH THE FULL NIHSS(CONCURRENT VALIDITY), AND PREDICTS FINALSTROKE FUNCTIONAL OUTCOMES AS WELL ASTHE NIHSS (PREDICTIVE VALIDITY).

LAMS 4nSensitivity SpecificityAUC11981%89%0.854Harstrup et al. Stroke.2016;47:00-00312757%84%0.7Noorian et al. Stroke.2016;47:A8319074%58%0.7Zhao et al . Stroke.2017;48:568-57356566%86%0.78Nazliel et al. Stroke.2008;39:2264-2267LAMS

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 CTAMOST SCORES ARE SUBSETS OF NIHSS SCORES PATIENTS WITH ICH, POST SEIZURE PARALYSIS, HYPERGLYCEMIA IN THE FIELD CAN HAVE HIGHNIHSSMaas MB, Furie KL, Lev MH, Ay H, Singhal AB, Greer DM, et al. National Institutes of Health Stroke Scale score is poorly predictive ofproximal occlusion in acute cerebral ischemia. Stroke. 2009;40:2988– 2993. doi: 10.1161/STROKEAHA.109.555664

TYPICAL VS ATYPICAL PRESENTATIONTYPICAL PRESENTATION PROMINENT ARM WEAKNESS (NIHSSMOTOR ARM 2) PLUS AN ADDITIONAL CORTICAL SIGN: EITHER SEVERE SPEECH DISTURBANCE PROMINENT INATTENTION GAZE DEVIATIONATYPICAL PRESENTATION LVO WHO DID NOT PRESENT WITH THEDEFINED SEVERE MCA SYNDROME PATIENTS WHO PRESENTED WITH THESEVERE MCA SYNDROME DESPITE NOTHAVING AN LVO (NON-LVO)Zhao et al . Stroke. 2017;48:568-573

THE GOOD NEWS AMONG NON-LVO W ATYPICALPRESENTATIONS 64% WERE ICHSPECIFICITY 80%; FPR 20%20% * 36%* 7.2% FUTILE TRANSFERS AMONG LVO 58% WERE M2 OCCLUSIONSENSITIVITY 66%; FNR 33%33%*16% 5.3% MISSEDTHROMBECTOMY CANDIDATE

FINAL THOUGHTS STATE-WIDE PROTOCOL

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. Stro

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