3.8 Article

Large vessel occlusion prediction scales provide high negative but low positive predictive values in prehospital suspected stroke patients

Journal

BMJ NEUROLOGY OPEN
Volume 4, Issue 2, Pages -

Publisher

BMJ PUBLISHING GROUP
DOI: 10.1136/bmjno-2022-000272

Keywords

STROKE

Funding

  1. NIH StrokeNet Fellowship [U10NS086494, U24NS107229]
  2. 2019 Clinician Scientist Development Three-Year Award in Interventional Neurology - Society of Vascular and Interventional Neurology
  3. American Brain Foundation
  4. American Academy of Neurology Institute
  5. National Center for Advancing Translational Sciences, National Institutes of Health [UL1TR001860]

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This study evaluates the prevalence of stroke and validates the predictive values of large vessel occlusion (LVO) stroke prediction scales. The findings demonstrate that multiple scales provide high negative predictive values, but are associated with a high rate of false positives.
Introduction We studied a registry of Emergency Medical Systems (EMS) identified prehospital suspected stroke patients brought to an academic endovascular capable hospital over 1 year to assess the prevalence of disease and externally validate large vessel occlusion (LVO) stroke prediction scales with a focus on predictive values. Methods All patients had last known well times within 6 hours and a positive prehospital Cincinnati Prehospital Stroke Scale. LVO prediction scale scores were retrospectively calculated from emergency department arrival National Institutes of Health Stroke Scale scores. Final diagnoses were determined by chart review. Prevalence and diagnostic performance statistics were calculated. We prespecified analyses to identify scale thresholds with positive predictive values (PPVs) >= 80% and negative predictive values (NPVs) >= 95%. A secondary analysis identified thresholds with PPVs >= 50%. Results Of 220 EMS transported patients, 13.6% had LVO stroke, 15.9% had intracranial haemorrhage, 20.5% had non-LVO stroke and 50% had stroke mimic diagnoses. LVO stroke prevalence was 15.8% among the 184 diagnostic performance study eligible patients. Only Field Assessment Stroke Triage for Emergency Destination (FAST-ED) >= 7 had a PPV >= 80%, but this threshold missed 83% of LVO strokes. FAST-ED >= 6, Prehospital Acute Severity Scale =3 and Rapid Arterial oCclusion Evaluation >= 7 had PPVs >= 50% but sensitivities were <50%. Several standard and lower alternative scale thresholds achieved NPVs >= 95%, but false positives were common. Conclusions Diagnostic performance tradeoffs of LVO prediction scales limited their ability to achieve high PPVs without missing most LVO strokes. Multiple scales provided high NPV thresholds, but these were associated with many false positives.

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