title: Clinical Selection Strategies to Identify Ischemic Stroke Patients With Large Anterior Vessel Occlusion: Results From SITS-ISTR (Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Registry).
abstract: The National Institutes of Health Stroke Scale (NIHSS) correlates with presence of large anterior vessel occlusion (LAVO). However, the application of the full NIHSS in the prehospital setting to select patients eligible for treatment with thrombectomy is limited. Therefore, we aimed to evaluate the prognostic value of simple clinical selection strategies.
  
  
  
  Data from the Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Registry (January 2012-May 2014) were analyzed retrospectively. Patients with complete breakdown of NIHSS scores and documented vessel status were included. We assessed the association of prehospital stroke scales and NIHSS symptom profiles with LAVO (internal carotid artery, carotid-terminus or M1-segment of the middle cerebral artery).
  
  
  
  Among 3505 patients, 23.6% (n=827) had LAVO. Pathological finding on the NIHSS item best gaze was strongly associated with LAVO (adjusted odds ratio 4.5, 95% confidence interval 3.8-5.3). All 3 face-arm-speech-time test (FAST) items identified LAVO with high sensitivity. Addition of the item gaze to the original FAST score (G-FAST) or high scores on other simplified stroke scales increased specificity. The NIHSS symptom profiles representing total anterior syndromes showed a 10-fold increased likelihood for LAVO compared with a nonspecific clinical profile. If compared with an NIHSS threshold of ≥6, the prehospital stroke scales performed similarly or even better without losing sensitivity.
  
  
  
  Simple modification of the face-arm-speech-time score or evaluating the NIHSS symptom profile may help to stratify patients' risk of LAVO and to identify individuals who deserve rapid transfer to comprehensive stroke centers. Prospective validation in the prehospital setting is required.
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.). jan.scheitz@charite.de.
authors.forename: Jan F
authors.initials: JF
authors.lastname: Scheitz
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Azmil H
authors.initials: AH
authors.lastname: Abdul-Rahim
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Rachael L
authors.initials: RL
authors.lastname: MacIsaac
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Charith
authors.initials: C
authors.lastname: Cooray
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Heidi
authors.initials: H
authors.lastname: Sucharew
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Dawn
authors.initials: D
authors.lastname: Kleindorfer
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Pooja
authors.initials: P
authors.lastname: Khatri
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Broderick
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Heinrich J
authors.initials: HJ
authors.lastname: Audebert
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Niaz
authors.initials: N
authors.lastname: Ahmed
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Nils
authors.initials: N
authors.lastname: Wahlgren
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Matthias
authors.initials: M
authors.lastname: Endres
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Christian H
authors.initials: CH
authors.lastname: Nolte
authors.affiliation: From the Center for Stroke Research Berlin (J.F.S., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.J.A., M.E., C.H.N.), Excellence Cluster NeuroCure (M.E.), German Center for Cardiovascular Research (DZHK) (M.E.), and German Center for Neurodegenerative Diseases (DZNE) (M.E.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Stroke Research, Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., R.L.M., K.R.L.); Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Solna, Sweden (C.C., N.A., N.W.); Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.); and Department of Emergency Medicine, University of Cincinnati, College of Medicine, OH (D.K., P.K., J.P.B.).
authors.forename: Kennedy R
authors.initials: KR
authors.lastname: Lees
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D002561:Cerebrovascular Disorders / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D005260:Female; D006801:Humans; D038622:Internationality; D008297:Male; D008875:Middle Aged; D009316:National Institutes of Health (U.S.) / Q000592:standards*; D012042:Registries; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D010959:Tissue Plasminogen Activator
keywords: FAST; stroke management; thrombectomy; thrombolysis; vessel occlusion