title: Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion.
abstract: It remains debated whether clinical scores can help identify acute ischemic stroke patients with large-artery occlusion and hence improve triage in the era of thrombectomy. We aimed to determine the accuracy of published clinical scores to predict large-artery occlusion.
  
  
  
  We assessed the performance of 13 clinical scores to predict large-artery occlusion in consecutive patients with acute ischemic stroke undergoing clinical examination and magnetic resonance or computed tomographic angiography ≤6 hours of symptom onset. When no cutoff was published, we used the cutoff maximizing the sum of sensitivity and specificity in our cohort. We also determined, for each score, the cutoff associated with a false-negative rate ≤10%.
  
  
  
  Of 1004 patients (median National Institute of Health Stroke Scale score, 7; range, 0-40), 328 (32.7%) had an occlusion of the internal carotid artery, M1 segment of the middle cerebral artery, or basilar artery. The highest accuracy (79%; 95% confidence interval, 77-82) was observed for National Institute of Health Stroke Scale score ≥11 and Rapid Arterial Occlusion Evaluation Scale score ≥5. However, these cutoffs were associated with false-negative rates >25%. Cutoffs associated with an false-negative rate ≤10% were 5, 1, and 0 for National Institute of Health Stroke Scale, Rapid Arterial Occlusion Evaluation Scale, and Cincinnati Prehospital Stroke Severity Scale, respectively.
  
  
  
  Using published cutoffs for triage would result in a loss of opportunity for ≥20% of patients with large-artery occlusion who would be inappropriately sent to a center lacking neurointerventional facilities. Conversely, using cutoffs reducing the false-negative rate to 10% would result in sending almost every patient to a comprehensive stroke center. Our findings, therefore, suggest that intracranial arterial imaging should be performed in all patients with acute ischemic stroke presenting within 6 hours of symptom onset.
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.). g.turc@ch-sainte-anne.fr.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Turc
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Benjamin
authors.initials: B
authors.lastname: Maïer
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Olivier
authors.initials: O
authors.lastname: Naggara
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Pierre
authors.initials: P
authors.lastname: Seners
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Clothilde
authors.initials: C
authors.lastname: Isabel
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Marie
authors.initials: M
authors.lastname: Tisserand
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Igor
authors.initials: I
authors.lastname: Raynouard
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Myriam
authors.initials: M
authors.lastname: Edjlali
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: David
authors.initials: D
authors.lastname: Calvet
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Baron
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Mas
authors.affiliation: From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
authors.forename: Catherine
authors.initials: C
authors.lastname: Oppenheim
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy; D002545:Brain Ischemia / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy; D016893:Carotid Stenosis / Q000175:diagnosis / Q000000981:diagnostic imaging; D002536:Cerebral Arteries / Q000000981:diagnostic imaging; D015331:Cohort Studies; D057510:Endovascular Procedures / Q000706:statistics & numerical data; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D020521:Stroke / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D014057:Tomography, X-Ray Computed; D014218:Triage / Q000379:methods
keywords: basilar artery; middle cerebral artery; stroke; thrombectomy; triage