A Bayesian Framework to Optimize Performance of Pre-Hospital Stroke Triage Scales

Goyal, Mayank; Ospel, Johanna M.; Kim, Beom Joon; Kashani, Nima; Duvekot, Martijne H C; Roozenbeek, Bob; Ganesh, Aravind

doi:10.5853/jos.2021.01312

Cited by 7 publications

(10 citation statements)

References 24 publications

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“…Our results suggest that future studies should focus on improving the ability of prehospital tools to detect aLVO in patients with mild-to-moderate deficit severity. As we previously estimated in a modeling article, 31 most patients with aLVO in the PRESTO study were patients with severities in the mild-moderate range (16.0% had NIHSS 0-4, 21.0% had NIHSS 5-9, and 25.2% had NIHSS 10-15, collectively accounting for 62.2% of patients with aLVO). At present, the overall sensitivity of prehospital scales is especially low for patients with mild strokes, which represents a frequent situation in the field, given that the median NIHSS score in PRESTO was 2; the usefulness of scales in this common situation is debatable.…”

Section: Discussionmentioning

confidence: 75%

Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study

Ganesh

Wijdeven

Ospel

et al. 2022

Stroke

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BACKGROUND: The usefulness of prehospital scales for identifying anterior circulation large vessel occlusion (aLVO) in patients with suspected stroke may vary depending on the severity of their presentation. The performance of these scales across the spectrum of deficit severity is unclear. The aim of this study was to evaluate the diagnostic performance of 8 prehospital scales for identifying aLVO across the spectrum of deficit severity. METHODS: We used data from the PRESTO study (Prehospital Triage of Patients With Suspected Stroke Symptoms), a prospective observational study comparing prehospital stroke scales in detecting aLVO in suspected stroke patients. We used the National Institutes of Health Stroke Scale (NIHSS) score, assessed in-hospital, as a proxy for the Clinical Global Impression of stroke severity during prehospital assessment by paramedics. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and the difference in aLVO probabilities with a positive or negative prehospital scale test (ΔP aLVO ) for each scale for mild (NIHSS 0–4), intermediate (NIHSS 5–9), moderate (NIHSS 10–14), and severe deficits (NIHSS≥15). RESULTS: Among 1033 patients with suspected stroke, 119 (11.5%) had an aLVO, of whom 19 (16.0%) had mild, 25 (21.0%) had intermediate, 30 (25.2%) had moderate, and 45 (37.8%) had severe deficits. The scales had low sensitivity and positive predictive value in patients with mild-intermediate deficits, and poor specificity, negative predictive value, and accuracy with moderate-severe deficits. Positive results achieved the highest ΔP aLVO in patients with mild deficits. Negative results achieved the highest ΔP aLVO with severe deficits, but the probability of aLVO with a negative result in the severe range was higher than with a positive test in the mild range. CONCLUSIONS: Commonly-used prehospital stroke scales show variable performance across the range of deficit severity. Probability of aLVO remains high with a negative test in severely affected patients. Studies reporting prehospital stroke scale performance should be appraised in the context of the NIHSS distribution of their samples.

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Section: Discussionmentioning

confidence: 75%

Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study

Ganesh

Wijdeven

Ospel

et al. 2022

Stroke

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“…They generally perform best at both ends of the severity spectrum, which is of limited value since, in these patients, paramedics may often be able to make the diagnosis purely based on their clinical experience. 7 In patients with intermediate symptom severity, where diagnostic uncertainty is greatest, performance of clinical symptom severity scales is poorest. In some situations, certain pre-hospital triage scales may even be misguiding and, in extreme cases, may sway an EMS team from the correct diagnosis.…”

Section: Clinical Stroke Severity Scalesmentioning

confidence: 99%

“…That being said, the performance of all pre-hospital scales varies substantially across the spectrum of deficit severity. They generally perform best at both ends of the severity spectrum, which is of limited value since, in these patients, paramedics may often be able to make the diagnosis purely based on their clinical experience 7. In patients with intermediate symptom severity, where diagnostic uncertainty is greatest, performance of clinical symptom severity scales is poorest.…”

Section: Pre-hospital Triage: Detecting Evt Candidates In the Fieldmentioning

confidence: 99%

“…While there are excellent policy statements outlining general guiding principles for the establishment of stroke systems of care, 5 6 there is likely no universal 'right way' of triaging patients for EVT, since EVT triage is highly context-specific, and depends on the local infrastructure and geography (eg, widespread rural geography with low hospital density vs urban area with high hospital density). 7 Furthermore, although financial and staff resources should ideally not influence EVT triage, in reality they often do. Regardless of the triage paradigm, optimization of its diagnostic accuracy and speed are central to successful performance.…”

Section: Introductionmentioning

confidence: 99%

“…The goal of EVT triage is to direct AIS patients who can benefit from EVT to an EVT-capable hospital as fast as possible. While there are excellent policy statements outlining general guiding principles for the establishment of stroke systems of care,5 6 there is likely no universal ‘right way’ of triaging patients for EVT, since EVT triage is highly context-specific, and depends on the local infrastructure and geography (eg, widespread rural geography with low hospital density vs urban area with high hospital density) 7. Furthermore, although financial and staff resources should ideally not influence EVT triage, in reality they often do.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment

Ospel

Dmytriw

Regenhardt

et al. 2022

J NeuroIntervent Surg

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Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.

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Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

Radu,

Gascou,

Machi

et al. 2023

European Journal of Radiology Open

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A Bayesian Framework to Optimize Performance of Pre-Hospital Stroke Triage Scales

Cited by 7 publications

References 24 publications

Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study

Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study

Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

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