Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study
Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study
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DOI：
10.1016/s1474-4422(20)30439-7
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发表时间：
2021-02-17
期刊：
影响因子：
48
通讯作者：
Roozenbeek, Bob
中科院分区：
文献类型：
--
作者：
Duvekot, Martijne H. C.;Venema, Esmee;Roozenbeek, Bob
背景由于血管内治疗的时间敏感性，院前快速识别疑似卒中患者的大血管闭塞对于优化结局至关重要。院间转运是血管内治疗延迟的重要原因。已经提出了院前卒中量表，以选择大血管闭塞的患者直接运送到具有血管内能力的介入中心。我们的目的是前瞻性地验证8院前中风量表在field.Methods我们做了一个多中心，前瞻性，观察性队列研究的成年人怀疑中风（年龄>= 18岁）谁被救护车运送到荷兰西南部的8家医院之一。疑似中风的定义是正面手臂说话时间（FAST）测试。我们纳入了血糖至少为2.5 mmol/L的个体。在症状发作后超过6小时出现的人被排除在分析之外。经过结构化培训后，护理人员使用移动的应用程序评估8个院前卒中量表中的项目：快速动脉闭塞评估（RACE）、洛杉矶运动量表（LAMS）、辛辛那提卒中分类评估工具（C-STAT）、凝视-面部-手臂-言语时间（G-FAST）、院前急性卒中严重程度（PASS）、辛辛那提院前卒中量表（CPSS）、方便抓握现场评估卒中分类（CG-FAST），和FAST-PLUS（面部-手臂-言语-时间加上严重的手臂或腿部运动缺陷）测试。主要结局是CT血管造影显示缺血性卒中伴前循环（aLVO）近端颅内大血管闭塞的临床诊断。由神经放射科医师集中评估基线神经影像学，以验证真实闭塞状态。院前卒中量表表现表示为受试者工作特征曲线下面积（AUC），并与急诊科临床医生评估的美国国立卫生研究院卒中量表（NIHSS）评分进行比较。该研究在荷兰试验注册中心（NL 7387）注册。结果在2018年8月13日至2019年9月2日期间，护理人员确定了1039例疑似卒中患者（中位年龄72岁[IQR 61-811]），其中120例（12%）被诊断为aLVO。在所有院前卒中量表中，RACE的AUC最高（0.83，95% CI 0.79-0.86），然后是G-FAST的AUC（0- 80，0.76 -0-84），CG-FAST（0.80，0.76-0-84）、LAMS（0.79，0.75-0.83）、CPSS（0.79，0.75-0.83）、PASS（0.76，0.72-0.80）、C-STAT（0.75，0-71-0.80）和FAST-PLUS（0.72，0.67-0.76）。急诊科临床医生评估的NIHSS比院前卒中量表稍好，AUC为0.86（95% CI 0.83-0.89）。院前卒中量表检测aLVO的准确性可接受至良好。RACE、G-FAST和CG-FAST是测试的8个量表中表现最好的院前卒中量表，接近临床医生评估的NIHSS的表现。需要进一步的研究来调查在区域交通策略中使用这些量表是否可以优化缺血性卒中患者的结局。版权所有（C）2021爱思唯尔有限公司保留所有权利。
Background Due to the time-sensitive effect of endovascular treatment, rapid prehospital identification of large-vessel occlusion in individuals with suspected stroke is essential to optimise outcome. Interhospital transfers are an important cause of delay of endovascular treatment. Prehospital stroke scales have been proposed to select patients with large-vessel occlusion for direct transport to an endovascular-capable intervention centre. We aimed to prospectively validate eight prehospital stroke scales in the field.Methods We did a multicentre, prospective, observational cohort study of adults with suspected stroke (aged >= 18 years) who were transported by ambulance to one of eight hospitals in southwest Netherlands. Suspected stroke was defined by a positive Face-Arm-Speech-Time (FAST) test. We included individuals with blood glucose of at least 2.5 mmol/L. People who presented more than 6 h after symptom onset were excluded from the analysis. After structured training, paramedics used a mobile app to assess items from eight prehospital stroke scales: Rapid Arterial oCclusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), Cincinnati Stroke Triage Assessment Tool (C-STAT), GazeFace-Arm-Speech-Time (G-FAST), Prehospital Acute Stroke Severity (PASS), Cincinnati Prehospital Stroke Scale (CPSS), Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST), and the FAST-PLUS (Face-Arm-Speech-Time plus severe arm or leg motor deficit) test. The primary outcome was the clinical diagnosis of ischaemic stroke with a proximal intracranial large-vessel occlusion in the anterior circulation (aLVO) on CT angiography. Baseline neuroimaging was centrally assessed by neuroradiologists to validate the true occlusion status. Prehospital stroke scale performance was expressed as the area under the receiver operating characteristic curve (AUC) and was compared with National Institutes of Health Stroke Scale (NIHSS) scores assessed by clinicians at the emergency department. This study was registered at the Netherlands Trial Register, NL7387.Findings Between Aug 13,2018, and Sept 2,2019,1039 people (median age 72 years [IQR 61-811]) with suspected stroke were identified by paramedics, of whom 120 (12%) were diagnosed with aLVO. Of all prehospital stroke scales, the AUC for RACE was highest (0.83, 95% CI 0.79-0.86), followed by the AUC for G-FAST (0-80,0.76-0-84), CG-FAST (0.80, 0.76-0-84), LAMS (0.79, 0.75-0.83), CPSS (0.79, 0.75-0.83), PASS (0.76, 0.72-0.80), C-STAT (0.75, 0-71-0.80), and FAST-PLUS (0.72, 0.67-0.76). The NIHSS as assessed by a clinician in the emergency department did somewhat better than the prehospital stroke scales with an AUC of 0.86 (95% CI 0.83-0.89).Interpretation Prehospital stroke scales detect aLVO with acceptable-to-good accuracy. RACE, G-FAST, and CG-FAST are the best performing prehospital stroke scales out of the eight scales tested and approach the performance of the clinician-assessed NIHSS. Further studies are needed to investigate whether use of these scales in regional transportation strategies can optimise outcomes of patients with ischaemic stroke. Copyright (C) 2021 Elsevier Ltd. All rights reserved.