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Stroke Vasc Neurol. 2018 Sep 3;3(4):215-221. doi: 10.1136/svn-2018-000165. eCollection 2018 Dec.

Are you suffering from a large arterial occlusion? Please raise your arm!

Author information

1
Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden.
2
Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.
3
Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
4
Center for Stroke Research Berlin and Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
5
Stroke Research, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
6
International Clinical Research Center and Neurology Department, St. Anne's University Hospital in Brno and Masaryk University, Brno, Czech Republic.
7
Department of Radiology, University Hospital, Hradec Kralove, Czech Republic.
8
Comprehensive Cerebrovascular Center, Hospital České Budějovice, Ceske Budejovice, Czech Republic.
9
Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Hospital Policlinico Umberto I, 'Sapienza' University, Rome, Italy.

Abstract

Background and purpose:

Triage tools to identify candidates for thrombectomy are of utmost importance in acute stroke. No prognostic tool has yet gained any widespread use. We compared the predictive value of various models based on National Institutes of Health Stroke Scale (NIHSS) subitems, ranging from simple to more complex models, for predicting large artery occlusion (LAO) in anterior circulation stroke.

Methods:

Patients registered in the SITS international Stroke Register with available NIHSS and radiological arterial occlusion data were analysed. We compared 2042 patients harbouring an LAO with 2881 patients having no/distal occlusions. Using binary logistic regression, we developed models ranging from simple 1 NIHSS-subitem to full NIHSS-subitems models. Sensitivities and specificities of the models for predicting LAO were examined.

Results:

The model with highest predictive value included all NIHSS subitems for predicting LAO (area under the curve (AUC) 0.77), yielding a sensitivity and specificity of 69% and 76%, respectively. The second most predictive model (AUC 0.76) included 4-NIHSS-subitems (level of consciousness commands, gaze, facial and arm motor function) yielding a sensitivity and specificity of 67% and 75%, respectively. The simplest model included only deficits in arm motor-function (AUC 0.72) for predicting LAO, yielding a sensitivity and specificity of 67% and 72%, respectively.

Conclusions:

Although increasingly more complex models yield a higher discriminative performance for predicting LAO, differences between models are not large. Assessing grade of arm dysfunction along with an established stroke-diagnosis model may serve as a surrogate measure of arterial occlusion-status, thereby assisting in triage decisions.

KEYWORDS:

stroke; thrombectomy; thrombolysis

Conflict of interest statement

Competing interests: CC was supported by the Stockholm County Council (combined clinical residency and PhD training program). MVM is an employee of SITS International, which receives a grant from Boehringer Ingelheim for the SITS-ISTR. MVM is also supported by the Stockholm County Council (clinical postdoctoral appointment). TPM has received travel and speaker grants from Boehringer Ingelheim for the SITS-ISTR and research grants from Cerevast Inc. NW has received expenses from Boehringer Ingelheim for his role as member of the Steering Committee in relation to the ECASS III trial with alteplase and served as a consultant to Thrombogenics as chairman of the Data and Safety Monitoring Board. SITS International (chaired by NW) receives a grant from Boehringer Ingelheim for the SITS-ISTR. His institution has also received grant support towards administrative expenses for coordination of the ECASS III trial. NW has also received lecture fees from Boehringer Ingelheim and Ferrer. NW is also supported by grants provided by the Stockholm County Council (ALF project). NA is an employee of SITS International, which receives a grant from Boehringer Ingelheim for the SITS-ISTR. NA is also supported by grants provided by the Stockholm County Council (ALF project) and Swedish Heart-lung foundation.

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