Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?
Simple clinical scores to predict large vessel occlusion (LVO) in acute ischemic stroke would be helpful to triage patients in the prehospital phase. We assessed the ability of various combinations of National Institutes of Health Stroke Scale (NIHSS) subitems and published stroke scales (i.e., RACE scale, 3I-SS, sNIHSS-8, sNIHSS-5, sNIHSS-1, mNIHSS, a-NIHSS items profiles A-E, CPSS1, CPSS2, and CPSSS) to predict LVO on CT or MR arteriography in 1085 consecutive patients (39.4 % women, mean age 67.7 years) with anterior circulation strokes within 6 h of symptom onset. 657 patients (61 %) had an occlusion of the internal carotid artery or the M1/M2 segment of the middle cerebral artery. Best cut-off value of the total NIHSS score to predict LVO was 7 (PPV 84.2 %, sensitivity 81.0 %, specificity 76.6 %, NPV 72.4 %, ACC 79.3 %). Receiver operating characteristic curves of various combinations of NIHSS subitems and published scores were equally or less predictive to show LVO than the total NIHSS score. At intersection of sensitivity and specificity curves in all scores, at least 1/5 of patients with LVO were missed. Best odds ratios for LVO among NIHSS subitems were best gaze (9.6, 95 %-CI 6.765-13.632), visual fields (7.0, 95 %-CI 3.981-12.370), motor arms (7.6, 95 %-CI 5.589-10.204), and aphasia/neglect (7.1, 95 %-CI 5.352-9.492). There is a significant correlation between clinical scores based on the NIHSS score and LVO on arteriography. However, if clinically relevant thresholds are applied to the scores, a sizable number of LVOs are missed. Therefore, clinical scores cannot replace vessel imaging.
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Mirjam R
MR
Heldner
Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Kety
K
Hsieh
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Anne
A
Broeg-Morvay
Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Pasquale
P
Mordasini
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Monika
M
Bühlmann
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.|Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Simon
S
Jung
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Marcel
M
Arnold
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Heinrich P
HP
Mattle
Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Jan
J
Gralla
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland. urs.fischer@insel.ch.
Urs
U
Fischer
D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D002561:Cerebrovascular Disorders / Q000175:diagnosis* / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009316:National Institutes of Health (U.S.) / Q000592:standards; D011237:Predictive Value of Tests; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications* / Q000175:diagnosis; D014481:United States
Acute ischemic stroke; CT; Clinical neurological examination; MRI; Stroke management; Triage