DISCLOSURES HUY TRAN MD UNM DEPARTMENT OF NEUROLOGY AND NEUROSURGERY NO DISCLOSURES

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2 DISCLOSURES ANDREW HARRELL MD FAEMS UNM DEPARTMENT OF EMERGENCY MEDICINEUNM EMS MEDICAL DIRECTION CONSORTIUM MEDICAL DIRECTOR, ALBUQUERQUE FIRE DEPARTMENT MEDICAL DIRECTOR, GRAND CANYON NATIONAL PARK TEMS PHYSICIAN & MEDICAL DIRECTOR, BERNALILLO CO. SHERIFF'S DEPARTMENT STAKEHOLDER OWNERSHIP SHARE IN CPR/AED/FIRST AID TRAINING COMPANY HUY TRAN MD UNM DEPARTMENT OF NEUROLOGY AND NEUROSURGERY NO DISCLOSURES

3 OBJECTIVES REVIEW PRE-HOSPITAL LVO SCREENS RACE C-STAT LAMS

4 2014 A REVOLUTION IN STROKE DEC 2014 MR CLEAN FEBRUARY 2015: AT ISC ESCAPE SWIFT-PRIME EXTEND-IA REVASCAT MECHANICAL THROMBECTOMY PROVEN BENEFICIAL FOR STROKES DUE TO ANTERIOR LARGE VESSEL OCCLUSION (LVO)

5 TIME TO TREATMENT STILL IMPORTANT AS W IV TPA EVERY 30 MINUTES DELAY 10% DECREASE IN THE CHANCE OF GOOD OUTCOME EARLIER ENDOVASCULAR THERAPY SUBSTANTIALLY BETTER OUTCOMES Khatri P, Abruzzo T, Yeatts SD, et al. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology 2009;73: Vagal AS, Khatri P, Broderick JP, et al. Time to angiographic reperfusion in acute ischemic stroke: decision analysis. Stroke 2014;45: Sheth SA, Jahan R, Gralla J, et al. Time to endovascular reperfusion and degree of disability in acute stroke. Ann Neurol 2015;78: Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316: doi: /jama

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7 INTERFACILITY TRANSFERS CAUSE DELAY AND RESULT IN WORSE OUTCOMES COMPARED TO DIRECT TRANSPORT TO AND ENDOVASCULAR FACILITY. SUN CH, NOGUEIRA RG, GLENN BA, ET AL. PICTURE TO PUNCTURE : A NOVEL TIME METRIC TO ENHANCE OUTCOMES IN PATIENTS TRANSFERRED FOR ENDOVASCULAR REPERFUSION IN ACUTE ISCHEMIC STROKE. CIRCULATION 2013;127: MOHAMAD NF, HASTRUP S, RASMUSSEN M, ANDERSEN MS, JOHNSEN SP, ANDERSEN G, ET AL. BYPASSING PRIMARY STROKE CENTRE REDUCES DELAY AND IMPROVES OUTCOMES FOR PATIENTS WITH LARGE VESSEL OCCLUSION. EUR STROKE J. 2016;1: DOI: /

8 SYSTEMS OF CARE NEED TO BE RE-ORGANIZED TO PROVIDE OPTIMAL CARE TO ALL STROKE PATIENTS ELVO SHOULD GO TO ENDOVASCULAR TREATMENT FACILITY NO ELVO SHOULD GO TO NEAREST PSC

9 HOW TO PREDICT WHO HAS LVO

10 ASSESSING STROKE SEVERITY SCALES A HIGH NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) SCORE IS STRONGLY ASSOCIATED WITH THE PRESENCE OF LVO NIHSS 11 IS PRETTY ACCURATE FOR PREDICTING LVO 42 ITEM SCALE Heldner MR, Zubler C, Mattle HP, Schroth G, Weck A, Mono ML, et al. National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke. 2013;44: doi: /STROKEAHA Vanacker P, Heldner MR, Amiguet M, Faouzi M, Cras P, Ntaios G, et al. Prediction of large vessel occlusions in acute stroke: National Institute of Health Stroke Scale is hard to beat. Crit Care Med. 2016;44:e336 e343. doi: /CCM

11 STROKE SEVERITY SCALES RAPID ARTERIAL OCCLUSION EVALUATION [RACE] LOS ANGELES MOTOR SCALE [LAMS] FIELD ASSESSMENT STROKE TRIAGE FOR EMERGENCY DESTINATION [FAST-ED] PREHOSPITAL ACUTE STROKE SEVERITY SCALE [PASS], AND CINCINNATI PREHOSPITAL STROKE SEVERITY SCALE [CPSSS]) = CSTAT MARIA PREHOSPITAL STROKE SCALE (MPSS) RECOGNITION OF STROKE IN THE EMERGENCY ROOM (ROSIER) 3-ITEM STROKE SCALE (31-SS) VAN SHORTENED VERSIONS OF THE NIHSS (SNIHSS-1, SNIHSS-5, AND SNIHSS-8) G-FAST MELBOURNE AMBULANCE STROKE SCREEN (MASS) MEDIC PREHOSPITAL ASSESSMENT FOR CODE STROKE (MED PACS) ONTARIO PREHOSPITAL STROKE SCREENING (OPSS)

12 HOW DO YOU CHOOSE A SCALE KEEP IT SIMPLE EXTERNAL VALIDATION VALIDATED IN PRE-HOSPITAL SETTING IS PARAMOUNT

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14 VALIDATED SCALES RACE C STAT LAMS formerly CPSSS

15 RACE RAPID ARTERIAL OCCLUSION EVALUATION SCALE Ossa et al. Stroke. 2014;45:87-91

16 RACE 5 n Sensitivity Specificity AUC RACE Ossa et al. Stroke. 2014;45: % 68% ND Turc et al. Stroke. 2016;47: % 85% 0.79 Harstrup et al. Stroke. 2016;47: % 86% 0.72 Lima et al. Stroke. 2016;47: % 87% 0.77 RACE 5 SEN 85%, SPEC 68% CORRECTLY CLASSIFIED 71% OF PATIENTS Zhao et al. Stroke. 2017;48: % 90% 0.78 Carrera et al.j. Stroke cerebrovasdis.;2017; 26: % 68% Shietz et al. Stroke. 2017;48: % 68%

17 C-STAT CINCINNATI PREHOSPITAL STROKE SEVERITY SCALE Katz et al. Stroke. 2015;46:

18 C-STAT 2 n Sensitivity Specificity AUC C-STAT Katz et al. Stroke. 2015;46: % 40% 0.67 Turc et al. Stroke. 2016;47: % 84% 0.78 Kummer et al. J Stroke and Cerebrovasc Disease. 25:5 (May), 2016: % 87% ND Harstrup et al. Stroke. 2016;47: % 86% 0.72 Lima et al. Stroke. 2016;47: % 85% 0.75 McMullen et al. Pre-hospital Emerg Care. 2017; % 70% C-STAT 2 OBJECTIVE: ABSENT OR PRESENT FAST < 1 MINUTE EMS APPROVED Zhao et al. Stroke. 2017;48: % 86% 0.71 Shietz et al. Stroke. 2017;48: % 67%

19 LAMS The Los Angeles Motor Scale (LAMS) IS A VALIDATED, 3-ITEM, 0- TO 5-POINT MOTOR STROKE DEFICIT SCALE, DEVELOPED FOR PREHOSPITAL AND ED USE, THAT TAKES 20 TO 30 SECONDS TO PERFORM. THE LAMS HAS GOOD INTERRATER RELIABILITY, CORRELATES STRONGLY WITH THE FULL NIHSS (CONCURRENT VALIDITY), AND PREDICTS FINAL STROKE FUNCTIONAL OUTCOMES AS WELL AS THE NIHSS (PREDICTIVE VALIDITY).

20 LAMS 4 n Sensitivity Specificity AUC LAMS Nazliel et al. Stroke. 2008;39: % 89% Harstrup et al. Stroke. 2016;47: % 84% 0.7 Noorian et al. Stroke. 2016;47:A % 58% 0.7 Zhao et al. Stroke. 2017;48: % 86% 0.78

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22 AUC SCALES ARE PRETTY EQUIVALENT MODERATELY GOOD PERFORMANCE MATTER OF CHOOSING WHICH ONE IS EASIEST

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25 WHY YOU CAN T HAVE A PERFECT SCALE UP TO 29% OF PATIENTS W BASELINE NIHSS OF 0 HAD PROXIMAL OCCLUSION ON CTA MOST SCORES ARE SUBSETS OF NIHSS SCORES PATIENTS WITH ICH, POST SEIZURE PARALYSIS, HYPERGLYCEMIA IN THE FIELD CAN HAVE HIGH NIHSS Maas MB, Furie KL, Lev MH, Ay H, Singhal AB, Greer DM, et al. National Institutes of Health Stroke Scale score is poorly predictive of proximal occlusion in acute cerebral ischemia. Stroke. 2009;40: doi: /STROKEAHA

26 TYPICAL VS ATYPICAL PRESENTATION TYPICAL PRESENTATION PROMINENT ARM WEAKNESS (NIHSS MOTOR ARM 2) PLUS AN ADDITIONAL CORTICAL SIGN: EITHER SEVERE SPEECH DISTURBANCE PROMINENT INATTENTION GAZE DEVIATION ATYPICAL PRESENTATION LVO WHO DID NOT PRESENT WITH THE DEFINED SEVERE MCA SYNDROME PATIENTS WHO PRESENTED WITH THE SEVERE MCA SYNDROME DESPITE NOT HAVING AN LVO (NON-LVO) Zhao et al. Stroke. 2017;48:

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28 THE GOOD NEWS AMONG NON-LVO W ATYPICAL PRESENTATIONS 64% WERE ICH SPECIFICITY ~80%; FPR 20% 20% * 36%* = 7.2% FUTILE TRANSFERS AMONG LVO 58% WERE M2 OCCLUSION SENSITIVITY ~66%; FNR 33% 33%*16% = 5.3% MISSED THROMBECTOMY CANDIDATE

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30 FINAL THOUGHTS STATE-WIDE PROTOCOL