Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Introduction— Endovascular thrombectomy is a highly efficacious treatment for large vessel occlusion (LVO). LVO prediction instruments, based on stroke signs and symptoms, have been proposed to identify stroke patients with LVO for rapid transport to endovascular thrombectomy–capable hospitals. This evidence review committee was commissioned by the American Heart Association/American Stroke Association to systematically review evidence for the accuracy of LVO prediction instruments. Methods— Medline, Embase, and Cochrane databases were searched on October 27, 2016. Study quality was assessed with the Quality Assessment of Diagnostic Accuracy-2 tool. Results— Thirty-six relevant studies were identified. Most studies (21 of 36) recruited patients with ischemic stroke, with few studies in the prehospital setting (4 of 36) and in populations that included hemorrhagic stroke or stroke mimics (12 of 36). The most frequently studied prediction instrument was the National Institutes of Health Stroke Scale. Most studies had either some risk of bias or unclear risk of bias. Reported discrimination of LVO mostly ranged from 0.70 to 0.85, as measured by the C statistic. In meta-analysis, sensitivity was as high as 87% and specificity was as high as 90%, but no threshold on any instruments predicted LVO with both high sensitivity and specificity. With a positive LVO prediction test, the probability of LVO could be 50% to 60% (depending on the LVO prevalence in the population), but the probability of LVO with a negative test could still be ≥10%. Conclusions— No scale predicted LVO with both high sensitivity and high specificity. Systems that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. More prospective studies are needed to assess the accuracy of LVO prediction instruments in the prehospital setting in all patients with suspected stroke, including patients with hemorrhagic stroke and stroke mimics.

[1]  W. Powers,et al.  2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2018, Stroke.

[2]  Mary G. George,et al.  Clinical Performance Measures for Adults Hospitalized With Intracerebral Hemorrhage: Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association , 2014, Stroke.

[3]  Michael D Hill,et al.  Time to Endovascular Thrombectomy for Acute Stroke-Reply. , 2017, JAMA.

[4]  B. Campbell,et al.  Predictive Value of Modifications of the Prehospital Rapid Arterial Occlusion Evaluation Scale for Large Vessel Occlusion in Patients with Acute Stroke. , 2017, Journal of Stroke & Cerebrovascular Diseases.

[5]  Heinz Holling,et al.  Meta-Analysis of Diagnostic Accuracy with mada , 2015 .

[6]  H. Mattle,et al.  Letter by Heldner et al Regarding Article, "Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion: Design and Comparison With Other Scales". , 2016, Stroke.

[7]  Gerta Rücker,et al.  Modelling multiple thresholds in meta-analysis of diagnostic test accuracy studies , 2016, BMC Medical Research Methodology.

[8]  Michael H. Lev,et al.  Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes , 2016, Stroke.

[9]  A. Rai,et al.  A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA , 2016, Journal of NeuroInterventional Surgery.

[10]  G. Andersen,et al.  Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion: Design and Comparison With Other Scales , 2016, Stroke.

[11]  P. Mordasini,et al.  Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible? , 2016, Journal of Neurology.

[12]  P. Cras,et al.  Prediction of Large Vessel Occlusions in Acute Stroke: National Institute of Health Stroke Scale Is Hard to Beat* , 2016, Critical care medicine.

[13]  J. Mocco,et al.  Maximizing efficiency and diagnostic accuracy triage of acute stroke patients: A case-control study , 2016, Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences.

[14]  J. Baron,et al.  Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion , 2016, Stroke.

[15]  Benjamin R. Kummer,et al.  External Validation of the Cincinnati Prehospital Stroke Severity Scale. , 2016, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[16]  A. Demchuk,et al.  Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials , 2016, The Lancet.

[17]  P. Bhattacharya,et al.  Gaze Deviation and Acute Stroke Care Strategies (I6.001) , 2016 .

[18]  S. Levine,et al.  Comparison of Large Vessel Occlusion Prediction Scores (S16.004) , 2016 .

[19]  M. Jayaraman,et al.  Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices , 2016, Journal of NeuroInterventional Surgery.

[20]  R. Conwit,et al.  Abstract 83: Field Validation of Prehospital LAMS Score to Identify Large Vessel Occlusion Ischemic Stroke Patients for Direct Routing to Emergency Neuroendovascular Centers , 2016, Stroke.

[21]  Ryan D. Moore,et al.  Revisiting the NIH Stroke Scale as a screening tool for proximal vessel occlusion: can advanced imaging be targeted in acute stroke? , 2016, Journal of NeuroInterventional Surgery.

[22]  Charith N. Cooray,et al.  Threshold for NIH Stroke Scale in Predicting Vessel Occlusion and Functional Outcome after Stroke Thrombolysis , 2015, International journal of stroke : official journal of the International Stroke Society.

[23]  M. Endres,et al.  National Institutes of Health Stroke Scale for Prediction of Proximal Vessel Occlusion in Anterior Circulation Stroke , 2015, International journal of stroke : official journal of the International Stroke Society.

[24]  J. Broderick,et al.  Design and Validation of a Prehospital Scale to Predict Stroke Severity: Cincinnati Prehospital Stroke Severity Scale , 2015, Stroke.

[25]  C. Hansen,et al.  Stroke Severity and Incidence of Acute Large Vessel Occlusions in Patients with Hyper-Acute Cerebral Ischemia: Results from a Prospective Cohort Study Based on CT-Angiography (CTA) , 2015, International journal of stroke : official journal of the International Stroke Society.

[26]  F. Guyette,et al.  Comparing National Institutes of Health Stroke Scale Among a Stroke Team and Helicopter Emergency Medical Service Providers , 2015, Stroke.

[27]  Eric E. Smith,et al.  Clinical performance measures for adults hospitalized with acute ischemic stroke: performance measures for healthcare professionals from the American Heart Association/American Stroke Association. , 2014, Stroke.

[28]  G. Collins,et al.  Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies: The CHARMS Checklist , 2014, PLoS medicine.

[29]  J. Matías-Guiu,et al.  Oclusión arterial de gran vaso diagnosticada por angiografía por tomografía computarizada en el ictus isquémico agudo: frecuencia, factores predictores y seguridad , 2014 .

[30]  M. Fernández-Matarrubia,et al.  Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety. , 2014, Neurologia.

[31]  V. Janardhan,et al.  Abstract T MP59: Texas Stroke Intervention Pre-Hospital Stroke Severity Scale (aka LEGS score): A Triaging Tool for Interventional Stroke Therapy , 2014 .

[32]  R. Gonzalez,et al.  Good Outcome Rate of 35% in IV-tPA–Treated Patients With Computed Tomography Angiography Confirmed Severe Anterior Circulation Occlusive Stroke , 2013, Stroke.

[33]  Gerhard Schroth,et al.  National Institutes of Health Stroke Scale Score and Vessel Occlusion in 2152 Patients With Acute Ischemic Stroke , 2013, Stroke.

[34]  M. Wintermark,et al.  Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2013, Stroke.

[35]  Deepak L. Bhatt,et al.  ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. , 2013, Journal of the American College of Cardiology.

[36]  Deepak L. Bhatt,et al.  ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. , 2013, Journal of the American College of Cardiology.

[37]  Susan Mallett,et al.  QUADAS-2: A Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies , 2011, Annals of Internal Medicine.

[38]  P. Lavados,et al.  Validity of the NIHSS in predicting arterial occlusion in cerebral infarction is time-dependent , 2011, Neurology.

[39]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. , 2010, International journal of surgery.

[40]  K. Furie,et al.  National Institutes of Health Stroke Scale Score Is Poorly Predictive of Proximal Occlusion in Acute Cerebral Ischemia , 2009, Stroke.

[41]  G. Duckwiler,et al.  A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions , 2008, Stroke.

[42]  A. Pancioli,et al.  Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council. , 2007, Stroke.

[43]  日本脳卒中学会,et al.  Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association , 2007 .

[44]  S. Johnston,et al.  NIH Stroke Scale Reliability in Ratings from a Large Sample of Clinicians , 2006, Cerebrovascular Diseases.

[45]  G. Christoforidis,et al.  Clinical predictors of cerebrovascular occlusion for patients presenting with acute stroke. , 2006, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[46]  Gerhard Schroth,et al.  NIHSS Score and Arteriographic Findings in Acute Ischemic Stroke , 2005, Stroke.

[47]  T. Neumann-Haefelin,et al.  A Simple 3-Item Stroke Scale: Comparison With the National Institutes of Health Stroke Scale and Prediction of Middle Cerebral Artery Occlusion , 2005, Stroke.

[48]  M. Uchino,et al.  Relationships between angiographic findings and National Institutes of Health stroke scale score in cases of hyperacute carotid ischemic stroke. , 2004, AJNR. American journal of neuroradiology.

[49]  P. Adeleine,et al.  Early Detection of Cerebral Arterial Occlusion on Magnetic Resonance Angiography: Predictive Value of the Baseline NIHSS Score and Impact on Neurological Outcome , 2002, Cerebrovascular Diseases.