[Correspondence] Prehospital scales in acute ischaemic stroke management

We read with much interest the Article by Martijne Duvekot and colleagues.Duvekot MHC Venema E Rozeman AD et al.Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Their goal was to compare and validate eight prehospital stroke scales to distinguish patients with large-vessel occlusion in the anterior circulation (aLVO), who must be directly transferred to a hospital capable of endovascular thrombectomy. Among the scales tested, Rapid Arterial oCclusion Evaluation (RACE) had the highest sensitivity (0·67, 95% CI 0·58–0·75). The most specific scale was Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST; specificity 0·89, 95% CI 0·87–0·91), but this scale had a low sensitivity (0·50, 0·41–0·59). The positive predictive value of RACE was 0·40. Notably, 66 (16%) patients who were considered not affected by aLVO did not undergo CT angiography, which might have led to overestimation of sensitivity. Furthermore, the unusually low percentage of intracranial haemorrhages (72 [7%] patients) could have enhanced the specificity of RACE compared with previous studies.Duvekot and colleagues concluded that three scales (RACE, Gaze-Face-Arm-Speech-Time [G-FAST], and CG-FAST) performed similarly to the in-hospital National Institutes of Health Stroke Scale (NIHSS) and that they should be implemented in clinical practice in most urban and suburban regions. We regret not being able to share this conclusion. We maintain that a positive predictive value of 0·40, although statistically significant, might not be clinically relevant. With such a value, more than half of patients with stroke showing a RACE score equal to or higher than 5 will not have aLVO on CT angiography, and a direct transfer to a hospital capable of endovascular thrombectomy could prolong their time to receipt of intravenous alteplase. Early intravenous alteplase is correlated with less disability at 3 months, including in patients with large-vessel occlusion.Goyal M Almekhlafi M Dippel DW et al.Rapid alteplase administration Improves functional outcomes in patients with stroke due to large vessel occlusions. Meta-analysis of the noninterventional arm from the HERMES Collaboration.Considering that these prehospital stroke scales were well designed, it is unlikely, in our opinion, that one of them (or a new score) will reach a satisfying level of sensitivity and specificity. Further prospective studies must be encouraged, but alternative solutions to the current challenges in the organisation of acute stroke care should be pursued. Among them, increasing the availability of endovascular therapy,Lopez-Rivera V Salazar-Marioni S Abdelkhaleq R et al.Integrated stroke system model expands availability of endovascular therapy while maintaining quality outcomes. improving the efficiency of primary stroke centres,Holodinsky JK Williamson TS Demchuk AM et al.Modeling stroke patient transport for all patients with suspected large-vessel occlusion. implementing mobile interventional stroke teams that can do endovascular thrombectomy at the hospital where the patient is primarily transported,Morey JR Oxley TJ Wei D et al.Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke: The NYC MIST Trial. and applying portable devices (ie, transcranial Doppler) that can identify large-vessel occlusion in a prehospital setting.Siniscalchi A Malferrari G Lochner P Sanguigni S Transcranial Doppler ultrasonography in pre-hospital management of stroke: can make a difference?. Furthermore, the transport models (mothership vs drip-and-ship) are context specific and need to take into account regional population distribution and density. Our aim must be to optimise treatment options for every patient with stroke.

We declare no competing interests.

References1.Duvekot MHC Venema E Rozeman AD et al.

Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study.

Lancet Neurol. 20: 213-2212.Goyal M Almekhlafi M Dippel DW et al.

Rapid alteplase administration Improves functional outcomes in patients with stroke due to large vessel occlusions. Meta-analysis of the noninterventional arm from the HERMES Collaboration.

Stroke. 50: 645-6513.Lopez-Rivera V Salazar-Marioni S Abdelkhaleq R et al.

Integrated stroke system model expands availability of endovascular therapy while maintaining quality outcomes.

Stroke. 52: 1022-10294.Holodinsky JK Williamson TS Demchuk AM et al.

Modeling stroke patient transport for all patients with suspected large-vessel occlusion.

JAMA Neurol. 75: 1477-14865.Morey JR Oxley TJ Wei D et al.

Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke: The NYC MIST Trial.

Stroke. 51: 3495-35036.Siniscalchi A Malferrari G Lochner P Sanguigni S

Transcranial Doppler ultrasonography in pre-hospital management of stroke: can make a difference?.

Curr Med Imaging. ()Article InfoPublication HistoryIdentification

DOI: https://doi.org/10.1016/S1474-4422(21)00167-8

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