Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service

Dickson, Robert; Crowe, Remle P.; Patrick, Casey; Crocker, K.; Aiken, Michaël; Adams, Andrew; Gleisberg, Guy R; Nichols, Tyler; Mason, Christopher; Panchal, Ashish R.

doi:10.1080/10903127.2019.1573281

Cited by 37 publications

(39 citation statements)

References 20 publications

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“…Although the proportion of false-positive results in our study differed from those found in the revalidation study (lower ICH and higher stroke mimics rates), the proportion of RACE ≥5 patients with AIS with LVOs was nearly identical between the studies (37% vs 35%). These results differ from a recent prehospital RACE study in Texas, where the authors report a lower LVO rate of 28.8% in their RACE ≥5 patients 19. The lower rate found by Dickson et al in their population might be attributed to the lack of imaging data to confirm LVO and location status.…”

Section: Discussioncontrasting

confidence: 84%

“…Several stroke LVO scales have been validated1 14–16 20 21; however, few have been prospectively applied by the EMS in a prehospital setting within the USA 18 19. Our 3-year experience demonstrates the long-term feasibility of implementing a countywide EMS-based prehospital AIS triage protocol using the RACE Scale.…”

Section: Discussionmentioning

confidence: 90%

“…The Rapid Arterial oCclusion Evaluation (RACE) Scale is one of the few prehospital scales that have been prospectively validated in the field, and has been recently revalidated in a large cohort in Catalonia 16 17. To date, there have been limited, real-world, prospective US experiences of emergency medical services (EMS) triage of patients with AIS using prehospital LVO scales 18 19…”

Section: Introductionmentioning

confidence: 99%

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Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Jumaa

Castonguay

Salahuddin

et al. 2019

J NeuroIntervent Surg

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BackgroundData on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA.ObjectiveTo report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score.MethodsOur prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated.ResultsBetween July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively.ConclusionsWe have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

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Section: Discussioncontrasting

confidence: 84%

Section: Discussionmentioning

confidence: 90%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Jumaa

Castonguay

Salahuddin

et al. 2019

J NeuroIntervent Surg

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“…Clinical variables: Four clinical variables that have established relationships with stroke severity and are easily measured in the prehospital setting were retrieved from the patient's record: age, sex, time from last known well (LKW) to EEG, and Rapid Arterial Occlusion Evaluation (RACE) 3, 6 score. RACE score was selected to be a clinical variable because, although no single prehospital LVO scale is optimal 7 , RACE performs well in identifying prehospital patients with stroke and LVO 4,8,9 and can be retrospectively calculated from the NIHSS score using specific guidelines 3,6 . Other patient data, including NIHSS scores in the ED, were available from the initial neurological consultation; for patients with intracerebral hemorrhage or TIA, a stroke neurologist (SCC) retrospectively estimated values from chart data 3,6 .…”

Section: Supplemental Materials Supplemental Methodsmentioning

confidence: 99%

Electroencephalography Might Improve Diagnosis of Acute Stroke and Large Vessel Occlusion

Erani

Zolotova

Vanderschelden

et al. 2020

Stroke

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Background and Purpose: Clinical methods have incomplete diagnostic value for early diagnosis of acute stroke and large vessel occlusion (LVO). Electroencephalography is rapidly sensitive to brain ischemia. This study examined the diagnostic utility of electroencephalography for acute stroke/transient ischemic attack (TIA) and for LVO. Methods: Patients (n=100) with suspected acute stroke in an emergency department underwent clinical exam then electroencephalography using a dry-electrode system. Four models classified patients, first as acute stroke/TIA or not, then as acute stroke with LVO or not: (1) clinical data, (2) electroencephalography data, (3) clinical+electroencephalography data using logistic regression, and (4) clinical+electroencephalography data using a deep learning neural network. Each model used a training set of 60 randomly selected patients, then was validated in an independent cohort of 40 new patients. Results: Of 100 patients, 63 had a stroke (43 ischemic/7 hemorrhagic) or TIA (13). For classifying patients as stroke/TIA or not, the clinical data model had area under the curve=62.3, whereas clinical+electroencephalography using deep learning neural network model had area under the curve=87.8. Results were comparable for classifying patients as stroke with LVO or not. Conclusions: Adding electroencephalography data to clinical measures improves diagnosis of acute stroke/TIA and of acute stroke with LVO. Rapid acquisition of dry-lead electroencephalography is feasible in the emergency department and merits prehospital evaluation.

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“…This represents a logistical challenge for virtually all of the qualitative and quantitative large vessel occlusion screens. 7,8,27 In addition to our prospective design, a strength of our study is our measurement of inter-rater reliability, which is lacking from all other studies of qualitative and quantitative screens. The FANG-D screen demonstrated substantial agreement between raters for overall FANG-D score, which further validates its generalizability.…”

Section: Discussionmentioning

confidence: 99%

Test characteristics of a 5‐element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes

et al. 2020

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Objective Stroke severity screens typically include cortical signs, such as field cut, aphasia, neglect, gaze preference, and dense hemiparesis (FANG‐D). The accuracy and reliability of these signs, when assessed by emergency physicians, to identify patients with anterior circulation large vessel occlusion (ACLVO) acute ischemic stroke (AIS) is unknown. We hypothesized that the FANG‐D screen applied by emergency physicians would be sensitive and reliable for identifying ACLVO AIS. Methods We conducted a prospective cohort study enrolling consecutive patients with suspected AIS presenting within 4.5 hours of last known well to the emergency department (ED). Emergency physicians performed the FANG‐D screen prior to, and blinded to the results of, imaging. The imaging standard was defined as a non‐contrast computed tomography (CT) for identifying hemorrhage and CT angiography for identifying large vessel occlusion. ACLVO was defined as an occlusion of the internal carotid artery, the middle cerebral artery, or its first branch. A convenience sample of patients had a duplicate FANG‐D screen performed by a second emergency physician to assess interobserver agreement. Results We performed 608 FANG‐D assessments on 491 patients presenting to the ED, of whom 64 (10%) had an ACLVO. FANG‐D had a sensitivity of 91% (confidence interval [CI] = 81%–96%) and a specificity of 35% (CI = 31%–39%) for identifying ACLVO. Interobserver agreement was tested on 133 patients and was found to be substantial, with a Fleiss’ kappa of 0.77 (CI = 0.64–0.88). Conclusions The FANG‐D screen is a sensitive test for identifying ACLVO when performed by emergency physicians and demonstrates substantial interrater reliability.

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Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service

Cited by 37 publications

References 20 publications

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience

Electroencephalography Might Improve Diagnosis of Acute Stroke and Large Vessel Occlusion

Test characteristics of a 5‐element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes

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