BACKGROUND: The Rapid Arterial oCclusion Evaluation (RACE) score can identify patients with anterior circulation large‐vessel occlusion (aLVO) ischemic stroke for transportation to a comprehensive... Show moreBACKGROUND: The Rapid Arterial oCclusion Evaluation (RACE) score can identify patients with anterior circulation large‐vessel occlusion (aLVO) ischemic stroke for transportation to a comprehensive stroke center for endovascular thrombectomy. However, patients with intracranial hemorrhage (ICH) may also benefit from direct transportation to a comprehensive stroke center for neurosurgical treatment. We aimed to assess if the RACE score can distinguish patients with ICH in addition to aLVO stroke from other patients with suspected stroke. METHODS: We analyzed data from the LPSS (Leiden Prehospital Stroke Study), a multicenter, prospective, observational cohort study in 2 Dutch ambulance regions. Ambulance paramedics documented prehospital observations in all patients aged ≥18 years with suspected stroke. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of a positive RACE score (≥5 points) for a diagnosis of ICH or aLVO stroke, compared with patients with non‐aLVO stroke, transient ischemic attack, or stroke mimic. In addition, we performed a multivariable logistic regression analysis and calculated adjusted odds ratios (ORs).RESULTS: We included 2004 patients with a stroke code, of whom 149 had an ICH, 153 had an aLVO stroke, 687 had a non‐aLVO stroke, 262 had a transient ischemic attack, and 753 had a stroke mimic. Patients with ICH and aLVO stroke more often had a positive RACE score than other patients with suspected stroke (46.2% and 58.0%, respectively, versus 6.4%; P<0.01). A positive RACE score had a sensitivity of 52.7%, a specificity of 93.6%, a positive predictive value of 55.4%, and a negative predictive value of 92.9% for a diagnosis of ICH or aLVO stroke. In multivariable analysis, a positive RACE score had the strongest association with ICH or aLVO stroke (adjusted OR, 10.11 [95% CI, 6.84–14.93]). CONCLUSIONS: Our study shows that the RACE score can also identify patients with ICH in addition to aLVO stroke. This emphasizes the potential of the RACE score for improving prehospital triage and allocation of patients with stroke. Show less
IMPORTANCE The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke... Show moreIMPORTANCE The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. OBJECTIVE To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort studywas conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. EXPOSURES Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. MAIN OUTCOMES AND MEASURES Planned primary and secondary outcomeswere sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. RESULTS Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. CONCLUSIONS AND RELEVANCE This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale. Show less
