Leukoaraiosis Attenuates Diagnostic Accuracy of Large-Vessel Occlusion Scales

Abstract

Background and purpose Pre-hospital stroke scales may help identify patients likely to have large vessel occlusion (LVO) to facilitate rapid triage to thrombectomy-capable stroke centers. Scale misclassification may result in inaccurate decisions and possible harm. Pre-existing leukoaraiosis has been shown to attenuate the association between deficit type and stroke severity. We sought to determine whether leukoaraiosis affects the predictive ability of 5 commonly used LVO scales. Materials and Methods We retrospectively analyzed 274 consecutive stroke patients with available brain MRI and vessel imaging. The following LVO scales were used: 3 Item Stroke Scale (3I/SS), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), Rapid Arterial Occlusion Evaluation (RACE), Vision, Aphasia, Neglect (VAN) score, and Cincinnati Pre-hospital Stroke Severity Scale (CPSSS). For diagnostic scale accuracy, we assessed sensitivity, specificity, positive predictive value, negative predictive value, and kappa. Multivariable logistic regression was used to determine the scales' predictive ability after adjustment for leukoaraiosis and potential confounders. Results In unadjusted analyses, all scales predicted the presence of LVO (n=46; P<0.01, each); though diagnostic accuracy was attenuated among patients with moderate-to-severe leukoaraiosis. After adjustment, the FAST-ED (OR 3.2 [1.1-9.5]; P=0.033), and RACE (OR 3.7 [1.3-10.8]; P=0.015) but not 3I/SS (OR 5.4 [0.86-33.9]); P=0.073), VAN (OR 2.5 [0.8-7.2]), and CPSSS (OR 2.8 [1.0-8.0]) predicted LVO. Conclusion The diagnostic accuracy of the tested LVO scales was attenuated in the presence of moderate-to-severe leukoaraiosis. This information that may aid the design of future studies that require LVO scale screening of patients that are likely to have concomitant leukoaraiosis.

Endovascular Treatment of Anterior Circulation Large Vessel Occlusion in the Elderly

“…If such diversion is to occur, is there a differential accuracy of field severity screening tools in younger vs. older patients? One recent study suggests in patients with leukoariosis, severity scores may be less accurate for detection of LVO ( 44 ). In addition, a newer trial (NCT02930018) is examining whether a novel neuroprotective agent can improve outcomes in patients undergoing thrombectomy for ICA or M1 occlusions.…”

Pre-existing White Matter Hyperintensity Lesion Burden and Diagnostic Certainty of Transient Ischemic Attack

“…29,30 Furthermore, WMH has been shown to affect the clinical presentation in the setting of acute cerebral ischemia. 12,[31][32][33][34] Specifically, we previously demonstrated that among stroke patients with similar functional deficit severity at the time of their presentation those with a high WMH lesion burden had significantly smaller infarcts. 32 Accordingly, in the setting of a high WMH lesion burden smaller infarcts under the detection limit of MRI 35 would be expected to produce typical TIA deficits that can be more easily recognized as a probable TIA as determined by existing guidelines or the PREDISC scoring system.…”

Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke

“…In comparison, the Vision, Aphasia, Neglect (VAN) stroke assessment does not require score calculation or motor severity testing. Although initially published as an ELVO nurse triage in the emergency department (ED), 15 VAN has since been validated in multiple external EMS and hospital datasets [16][17][18] but has yet to be studied in a prospective prehospital EMS cohort.…”