Response by Lima et al to Letter Regarding Article, “Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes”

Abstract

In ResponseWe would like to thank Heldner et al. for taking an interest on our work and applying the FAST-ED scale to their large patient cohort. Triage for stroke centers will undergo major changes given the recently proven benefit of endovascular approaches in the treatment of large vessel occlusion strokes (LVOS). The FAST-ED scale was designed to aid in the decision to triage patients to primary (PSC) versus comprehensive stroke centers (CSC) in the pre-hospital setting. In STOPStroke (n=727; 33% LVOS), FAST-ED had comparable accuracy to predict LVOS to the NIHSS and higher accuracy than RACE and CPSS (AUC: FAST-ED=0.81 as reference; NIHSS=0.80, p=0.28; RACE=0.77, p=0.02; and CPSS=0.75, p=0.002) 1 . Heldner et al. independently corroborated these findings in the Bernese cohort (n=1085; 60.5% LVOS; AUC: FAST-ED=0.847, NIHSS=0.846, RACE=0.831, CPSSS=0.802) 2 . In comparison to RACE, FAST-ED scores only one point for facial weakness and no points for leg weakness. This lowers the chances of a pure motor stroke (~85% lacunar in etiology) being diagnosed as a LVOS 3 . Unlike RACE, FAST-ED scores up to 2 points for gaze deviation, which is one of the most powerful predictors of LVOS 2, 4 . Unlike CPSSS, FAST-ED evaluates for neglect and thus better detects non-dominant hemisphere LVOS. Unlike RACE and CPSSS, FAST ED separately assesses expressive and receptive aphasia, optimizing topographic cortical representation and consequently LVOS detection.We fully agree with Heldner et al. that clinical severity scales cannot identify LVOS with 100% accuracy and as such cannot replace vascular neuroimaging. However, we believe that

Cognitive Rehabilitation for Memory Deficits After Stroke

“…Важно отметить, что многие из этих шкал были разработаны и валидизированы в строго отобранной выборке пациентов, например шкала PASS (Prehospital Acute Stroke Severity Scale) [2], для валидизации которой включали только пациентов с ишемическим инсультом, которым проводили систем-ный тромболизис и которым выполнили визуализацию сосудов, или шкала CPSSS (Cincinnati Prehospital Stroke Severity Scale) [3], которая была разработана с исполь-зованием данных пациентов, включенных в испыта-ния NINDS и IMS-III (National Institute of Neurological Disorders and Stroke and Interventional Management of Stroke-III). Более того, в последующих исследованиях для одновременной ва лидизации этих шкал использо-вали ретроспективные выборки тщательно отобран-ных пациентов с ишемическим инсультом, госпитали-зированных в специализированные отделения [4][5][6]. Следовательно, пациентов с масками инсульта, малыми инсультами, лакунарными инсультами или геморраги-ческими инсультами в большинстве этих исследований, по всей вероятности, пропустили.…”

Large Vessel Occlusion Scales Increase Delivery to Endovascular Centers Without Excessive Harm From Misclassifications

“…There is growing literature around clinical LVO triage scales that aim to allow paramedics to identify LVO in the field and bypass patients to an endovascular center. The Rapid Arterial Occlusion Evaluation (RACE), 3 Los Angeles Motor Scale (LAMS), 4 Cincinnati Prehospital Stroke Severity Scale (CPSSS), 5 Field Assessment Stroke Triage for Emergency Destination (FAST-ED), 6 and Prehospital Acute Stroke Severity scale (PASS) 7 are all recently published scales, using simplifications of items from the National Institutes of Health Stroke Scale 8 (NIHSS) to optimize prediction of LVO. To date, only the RACE and LAMS have undergone paramedic validation studies.…”

Expanding the treatment window for ischemic stroke through the application of novel system-based technology

“…The FAST-ED scale was especially accurate in detecting proximal vessel occlusion, especially those of the internal carotid artery and M 1 segment of the middle cerebral artery, which are the most responsive to ET. 28 …”

“…For example, if a screening test could help EMS personnel determine the presence of a large vessel occlusion stroke, the patient could be directly transported to an endovascular-capable facility rather than a primary stroke center. 28 Emergency responders can use several screening scores as an alternative to the NIHSS (see Table 1) as detailed below.…”