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Sonoda T, Hamada M, Yanagawa Y. Cardio-Cerebral Infarction in a Patient with Deep Coma: A Diagnostic Challenge. J Emerg Trauma Shock 2023; 16:22-25. [PMID: 37181740 PMCID: PMC10167818 DOI: 10.4103/jets.jets_23_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/25/2022] [Accepted: 05/26/2022] [Indexed: 03/29/2023] Open
Abstract
The patient was a 69-year-old man who called an ambulance due to dyspnea. When emergency medical technicians found him, he had collapsed into deep coma in front of his house. On arrival, he remained in a deep coma with severe hypoxia. He underwent tracheal intubation. An electrocardiogram showed ST elevation. Chest roentgen showed bilateral butterfly shadow. Cardiac ultrasound revealed diffuse hypokinesis. Head computed tomography (CT) showed early cerebral ischemic signs that had been initially overlooked. Urgent transcutaneous coronary angiography showed obstruction of the right coronary artery that was treated successfully. However, the next day, he was still in coma and demonstrated anisocoria. Repeated head CT showed diffuse cerebral infarction. He died on the 5th day. We herein report a rare case of cardio-cerebral infarction with a fatal outcome. Patients with acute myocardial infarction and a coma state should be evaluated for cerebral perfusion or occlusion of major cerebral vessels by enhanced CT or an aortogram if percutaneous coronary intervention is performed.
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Affiliation(s)
- Taketo Sonoda
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Japan
| | - Michika Hamada
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Japan
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2
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An updated review and meta-analysis of screening tools for stroke in the emergency room and prehospital setting. J Neurol Sci 2022; 442:120423. [PMID: 36201961 DOI: 10.1016/j.jns.2022.120423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Stroke screening tools should have good diagnostic performance for early diagnosis and a proper therapeutic plan. This paper describes and compares various diagnostic tools used to identify stroke in emergency departments and prehospital setting. METHODS The meta-analysis was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. The PubMed and Scopus databases were searched until December 31, 2021, for studies published on stroke screening tools. These tools' diagnostic performance (sensitivity and specificity) was pooled using a bivariate random-effects model whenever appropriate. RESULTS Eleven screening tools for stroke were identified in 29 different studies. The various tools had a wide range of sensitivity and specificity in different studies. In the meta-analysis, the Cincinnati Pre-hospital Stroke Scale, Face Arm Speech Test, and Recognition of Stroke in the Emergency Room (ROSIER) had sensitivity (between 83 and 91%) but poor specificity (all below 64%). When comparing all the tools, ROSIER had the highest sensitivity 90.5%. Los Angeles Pre-hospital Stroke Screen performed best in terms of specificity 88.7% but had low sensitivity (73.9%). Melbourne Ambulance Stroke Screen had a balanced performance in terms of sensitivity (86%) and specificity (76%). Sensitivity analysis consisting of only prospective studies showed a similar range of sensitivity and specificity. CONCLUSION All the stroke screening tools included in the review were comparable, but no clear superior screening tool could be identified. Simple screening tools like Cincinnati prehospital stroke scale (CPSS) have similar performance compared to more complex tools.
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Prehospital Stroke Detection Devices: A Bibliometric Analysis of Current Trends. World Neurosurg 2022; 167:e1360-e1375. [PMID: 36113713 DOI: 10.1016/j.wneu.2022.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Stroke represents the second highest disease burden worldwide. It is well documented that rapid stroke identification and treatment are associated with improved outcomes. In particular, prehospital stroke detection (PSD) devices have emerged as possible tools to facilitate more rapid and accurate stroke triage. Bibliometric analyses offer a powerful tool to characterize the entire field from an interdisciplinary perspective. This bibliometric analysis aims to analyze current themes and identify future trends within the PSD space. METHODS The Web of Science collection database was surveyed for PSD literature. Search terms focused on stroke diagnostic techniques, clinical indicators for ischemia/hemorrhage, and prehospital timing. Subsequently, VOSviewer was used for visual mapping analyses. RESULTS A total of 237 documents were identified between 1995 and 2021 from 1190 different authors. Publication volume has increased greatly in recent years. Publications were spread across 156 journals with the largest journal, Stroke, contributing just 7 studies over 26 years. Keywords analysis showed that stroke, near-infrared spectroscopy, and electroencephalography were the most common keywords. CONCLUSIONS Novel PSD devices are promising tools for the early detection and characterization of stroke. This study identifies recent increased attention to PSD technology, a trend that will likely continue in the coming years. Devices using near-infrared spectroscopy, ultrasonography, microwave, and electroencephalography represent the central areas of future PSD research. The multidisciplinary, and therefore fractured, nature of the PSD space requires those interested in the field to maintain active search habits across multiple journals to remain up to date on PSD innovations.
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Lyng JW, Braithwaite S, Abraham H, Brent CM, Meurer DA, Torres A, Bui PV, Floccare DJ, Hogan AN, Fairless J, Larrimore A. Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA. PREHOSP EMERG CARE 2021; 25:854-873. [PMID: 34388053 DOI: 10.1080/10903127.2021.1967534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Air medical services involves providing medical care in transit while using either fixed wing (airplane) or rotor wing (helicopter) aircraft to move patients between locations. The modern use and availability of air medical services has expanded access to various health system resources, including specialty care. While this is generally beneficial, such expansion has also contributed to the complexity of health care delivery systems.(1, 2) Since the publication of the 2013 joint position statement Appropriate and Safe Utilization of Helicopter Emergency Medical Services,(3) research has shown that patient benefit is gained from the clinical care capabilities of air medical services independent of potential time saved when transporting patients.(4-6) Because the evidence basis for utilization of air medical services continues to evolve, NAEMSP, ACEP, and AMPA believe that an update regarding the appropriate utilization of air medical services is warranted, and that such guidance for utilization can be divided into three major categories: clinical considerations, safety considerations, and system integration and quality assurance considerations.
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Affiliation(s)
- John W Lyng
- University of Minnesota School of Medicine, Department of Emergency Medicine (NAEMSP)
| | - Sabina Braithwaite
- Washington University in Saint Louis School of Medicine, Department of Emergency Medicine (NAEMSP)
| | | | - Christine M Brent
- University of Michigan, Department of Emergency Medicine (NAEMSP, AMPA)
| | - David A Meurer
- University of Florida College of Medicine, Department of Emergency Medicine (NAEMSP)
| | - Alexander Torres
- Cleveland Clinic Florida, Department of Emergency Medicine (NAEMSP)
| | - Peter V Bui
- Augusta University, Department of Emergency Medicine (NAEMSP)
| | - Douglas J Floccare
- Maryland Institute for EMS Systems (MIEMSS), Maryland State Police Aviation Command, University of Maryland, Department of Emergency Medicine (AMPA)
| | - Andrew N Hogan
- UT Southwestern Medical Center, Department of Emergency Medicine (AMPA)
| | - Justin Fairless
- Texas Christian University and University of North Texas Health Science Center School of Medicine, Department of Emergency Medicine (ACEP)
| | - Ashley Larrimore
- The Ohio State University, Department of Emergency Medicine (NAEMSP)
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Mayampurath A, Parnianpour Z, Richards CT, Meurer WJ, Lee J, Ankenman B, Perry O, Mendelson SJ, Holl JL, Prabhakaran S. Improving Prehospital Stroke Diagnosis Using Natural Language Processing of Paramedic Reports. Stroke 2021; 52:2676-2679. [PMID: 34162217 DOI: 10.1161/strokeaha.120.033580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
| | - Zahra Parnianpour
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
| | | | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, IL (W.J.M.)
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (J.L.)
| | - Bruce Ankenman
- Department of Industrial Engineering and Management Studies, Northwestern University (B.A., O.P.)
| | - Ohad Perry
- Department of Industrial Engineering and Management Studies, Northwestern University (B.A., O.P.)
| | - Scott J Mendelson
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
| | - Jane L Holl
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
| | - Shyam Prabhakaran
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
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Alijanpour S, Mostafazdeh-Bora M, Ahmadi Ahangar A. Different Stroke Scales; Which Scale or Scales Should Be Used? CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:1-21. [PMID: 33680393 PMCID: PMC7919174 DOI: 10.22088/cjim.12.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 02/01/2020] [Accepted: 02/12/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There has been a considerable development in the clinometric of stroke. But researchers are concerned that some scales are too generic, inherently and the insight may not be provided. The current study was conducted to determine which scale or scales should be used in stroke survivors. METHODS We selected 67 studies which were published between January 2010 and December 2018 from Up to date, CINAHL, ProQuest, Scopus, PubMed, Embase, Medline, Elsevier and Web of Science with MeSH terms. Inclusion criteria were: clinical trials, prospective studies, retrospective cohort studies, or cross-sectional studies; original research in adult human stroke survivors. We excluded the following articles: non-adult population; highly selected studies or treatment studies without incidence data; commentaries, single case reports, review article, editorials and non-English articles or articles without full text available. RESULTS Face Arm Speech Test and Cincinnati Pre-Hospital Stroke Scale scales because it was easy to learn and rapidly administer the recommended dose to use in pre-hospital, but there are not gold standard in stroke diagnosis in Pre-Hospital. National Institutes of Health Stroke Scale valuable in the acute stage for middle cerebral artery, not chronic or long term post stroke outcome. The Barthel Index scores for approximately three weeks could predict activities of daily living disabilities in 6 months. CONCLUSION Every scale has an advantage and a disadvantage and we were not able to introduce the gold standard for each item, but some special scales were used more in the studies, preferred for comparing with other studies to match the research results.
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Affiliation(s)
- Shayan Alijanpour
- Education, Research and Planning Unit, Pre-Hospital Emergency Organization and Emergency Medical Service Center, Babol University of Medical Sciences, Babol, Iran
- Student Research Committee, Faculty of Nursing and Midwifery, Isfahan University of Medical Science, Isfahan, Iran
| | | | - Alijan Ahmadi Ahangar
- Mobility Impairment Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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Meyran D, Cassan P, Avau B, Singletary E, Zideman DA. Stroke Recognition for First Aid Providers: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e11386. [PMID: 33312787 PMCID: PMC7725197 DOI: 10.7759/cureus.11386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim To perform a systematic review of the literature on the effectiveness of existing stroke recognition scales used in a prehospital setting and suitable for use by first aid providers. The systematic review will be used to inform an update of international first aid guidelines. Methods We followed the Cochrane Handbook for Systematic Reviews of Interventions methodology and report results according to PRISMA guidelines. We searched Medline, Embase and CENTRAL on May 25, 2020 for studies of stroke recognition scales used by first aid providers, paramedics and nurses for adults with suspected acute stroke in a prehospital setting. Outcomes included change in time to treatment, initial recognition of stroke, survival and discharge with favorable neurologic status, and increased layperson recognition of the signs of stroke. Two investigators reviewed abstracts, extracted and assessed the data for risk of bias. The certainty of evidence was evaluated using GRADE methodology. Results We included 24 observational studies with 10,446 patients evaluating 10 stroke scales (SS). All evidence was of moderate to very low certainty. Use of the Kurashiki Prehospital SS (KPSS), Ontario Prehospital SS (OPSS) and Face Arm Speech Time SS (FAST) was associated with an increased number of suspected stroke patients arriving to a hospital within three hours and, for OPSS, a higher rate of thrombolytic therapy. The KPSS was associated with a decreased time from symptom onset to hospital arrival. Use of FAST Emergency Response (FASTER) was associated with decreased time from door to tomography and from symptom onset to treatment. The Los Angeles Prehospital Stroke Scale (LAPSS) was associated with an increased number of correct initial diagnoses. Meta-analysis found the summary estimate sensitivity of four scales ranged from 0.78 to 0.86. The FAST and Cincinnati Prehospital Stroke Scale (CPSS) were found to have a summary estimated sensitivity of 0.86, 95% CI [0.69-0.94] and 0.81, 95% CI [0.70-0.89], respectively. Conclusion Stroke recognition scales used in the prehospital first aid setting improves the recognition and diagnosis of stroke, thereby aiding the emergency services to triage stroke victims directly down an appropriate stroke care pathway. Of those prehospital scales evaluated by more than a single study, FAST and Melbourne Ambulance Stroke Screen (MASS) were found to be the most sensitive for stroke recognition, while the CPSS had higher specificity. When blood glucose cannot be measured, the simplicity of FAST and CPSS makes these particular stroke scales appropriate for non-medical first aid providers.
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Affiliation(s)
- Daniel Meyran
- Healthcare Division, French Red Cross, Paris, FRA.,Prehospital Emergency Care, Bataillon De Marins Pompiers De Marseille, Marseille, FRA
| | - Pascal Cassan
- International Federation of Red Cross and Red Crescent Societies (IFRC) Global First Aid Reference Center, French Red Cross, Paris, FRA
| | - Bert Avau
- Centre for Evidence-Based Practice, Rode Kruis-Vlaanderen, Mechelen, BEL
| | | | - David A Zideman
- Pre-Hospital Emergency Medicine, Thames Valley Air Ambulance, Oxford, GBR
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Singletary EM, Zideman DA, Bendall JC, Berry DA, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djärv T, Douma MJ, Epstein JL, Hood NA, Markenson DS, Meyran D, Orkin A, Sakamoto T, Swain JM, Woodin JA, De Buck E, De Brier N, O D, Picard C, Goolsby C, Oliver E, Klaassen B, Poole K, Aves T, Lin S, Handley AJ, Jensen J, Allan KS, Lee CC. 2020 International Consensus on First Aid Science With Treatment Recommendations. Resuscitation 2020; 156:A240-A282. [PMID: 33098920 DOI: 10.1016/j.resuscitation.2020.09.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life- threatening bleeding through the use of tourniquets, haemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research. The 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) is the fourth in a series of annual summary publications from the International Liaison Committee on Resuscitation (ILCOR). This 2020 CoSTR for first aid includes new topics addressed by systematic reviews performed within the past 12 months. It also includes updates of the first aid treatment recommendations published from 2010 through 2019 that are based on additional evidence evaluations and updates. As a result, this 2020 CoSTR for first aid represents the most comprehensive update since 2010.
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9
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Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djärv T, Douma MJ, Epstein JL, Hood NA, Markenson DS, Meyran D, Orkin AM, Sakamoto T, Swain JM, Woodin JA. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation 2020; 142:S284-S334. [PMID: 33084394 DOI: 10.1161/cir.0000000000000897] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life-threatening bleeding through the use of tourniquets, hemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research.
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10
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De Luca A, Mariani M, Riccardi MT, Damiani G. The role of the Cincinnati Prehospital Stroke Scale in the emergency department: evidence from a systematic review and meta-analysis. Open Access Emerg Med 2019; 11:147-159. [PMID: 31410071 PMCID: PMC6646799 DOI: 10.2147/oaem.s178544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/21/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Stroke is one of the leading causes of morbidity, disability, and mortality in high-income countries. Early prehospital stroke recognition plays a fundamental role, because most clinical decisions should be made within the first hours after onset of symptoms. The Cincinnati Prehospital Stroke Scale (CPSS) is a validated screening tool whose utilization is suggested during triage. The aim of this study is to review the role of the CPSS by assessing its sensitivity and specificity in prehospital and hospital settings. Methods A systematic review and a meta-analysis of the literature reporting the CPSS sensitivity and specificity among patients suspected of stroke were undertaken. Electronic databases were searched up to December 2018, and the quality assessment was carried out by using the Revised Quality Assessment of Diagnostic Accuracy Studies −2 (QUADAS-2). Results Eleven studies were included in the meta-analysis. Results showed an overall sensitivity of 82.46% (95% confidence interval [CI] 74.83–88.09%) and specificity of 56.95% (95% CI 41.78–70.92). No significant differences were found in terms of sensitivity when CPSS was performed by physicians (80.11%, 95% CI 66.14–89.25%) or non-physicians (81.11%, 95% CI 69.78–88.87%). However, administration by physicians resulted in higher specificity (73.57%, 95% CI 65.78–80.12%) when compared to administration by non-physicians (50.07%, 95% CI 31.54–68.58%). Prospective studies showed higher specificity 71.61% (95% CI 61.12–80.18%) and sensitivity 86.82% (95% CI 74.72–93.63) when compared to retrospective studies which showed specificity of 33.37% (95% CI 22.79–45.94%) and sensitivity of 78.52% (95% CI 75.08–81.60). Conclusions The CPSS is a standardized and easy-to-use stroke screening tool whose implementation in emergency systems protocols, along with proper and consistent coordination with local, regional, and state agencies, medical authorities and local experts are suggested.
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Affiliation(s)
- A De Luca
- Istituti Fisioterapici Ospitalieri, Rome, Italy
| | - M Mariani
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - M T Riccardi
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Damiani
- Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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11
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Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Syst Rev 2019; 4:CD011427. [PMID: 30964558 PMCID: PMC6455894 DOI: 10.1002/14651858.cd011427.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Rapid and accurate detection of stroke by paramedics or other emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage. However, their accuracy remains uncertain and there is no agreement which of the scales perform better. OBJECTIVES To systematically identify and review the evidence pertaining to the test accuracy of validated stroke recognition scales, as used in a prehospital or emergency room (ER) setting to screen people suspected of having stroke. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and the Science Citation Index to 30 January 2018. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data. SELECTION CRITERIA We included studies evaluating the accuracy of stroke recognition scales used in a prehospital or ER setting to identify stroke and transient Ischemic attack (TIA) in people suspected of stroke. The scales had to be applied to actual people and the results compared to a final diagnosis of stroke or TIA. We excluded studies that applied scales to patient records; enrolled only screen-positive participants and without complete 2 × 2 data. DATA COLLECTION AND ANALYSIS Two review authors independently conducted a two-stage screening of all publications identified by the searches, extracted data and assessed the methodologic quality of the included studies using a tailored version of QUADAS-2. A third review author acted as an arbiter. We recalculated study-level sensitivity and specificity with 95% confidence intervals (CI), and presented them in forest plots and in the receiver operating characteristics (ROC) space. When a sufficient number of studies reported the accuracy of the test in the same setting (prehospital or ER) and the level of heterogeneity was relatively low, we pooled the results using the bivariate random-effects model. We plotted the results in the summary ROC (SROC) space presenting an estimate point (mean sensitivity and specificity) with 95% CI and prediction regions. Because of the small number of studies, we did not conduct meta-regression to investigate between-study heterogeneity and the relative accuracy of the scales. Instead, we summarized the results in tables and diagrams, and presented our findings narratively. MAIN RESULTS We selected 23 studies for inclusion (22 journal articles and one conference abstract). We evaluated the following scales: Cincinnati Prehospital Stroke Scale (CPSS; 11 studies), Recognition of Stroke in the Emergency Room (ROSIER; eight studies), Face Arm Speech Time (FAST; five studies), Los Angeles Prehospital Stroke Scale (LAPSS; five studies), Melbourne Ambulance Stroke Scale (MASS; three studies), Ontario Prehospital Stroke Screening Tool (OPSST; one study), Medic Prehospital Assessment for Code Stroke (MedPACS; one study) and PreHospital Ambulance Stroke Test (PreHAST; one study). Nine studies compared the accuracy of two or more scales. We considered 12 studies at high risk of bias and one with applicability concerns in the patient selection domain; 14 at unclear risk of bias and one with applicability concerns in the reference standard domain; and the risk of bias in the flow and timing domain was high in one study and unclear in another 16.We pooled the results from five studies evaluating ROSIER in the ER and five studies evaluating LAPSS in a prehospital setting. The studies included in the meta-analysis of ROSIER were of relatively good methodologic quality and produced a summary sensitivity of 0.88 (95% CI 0.84 to 0.91), with the prediction interval ranging from approximately 0.75 to 0.95. This means that the test will miss on average 12% of people with stroke/TIA which, depending on the circumstances, could range from 5% to 25%. We could not obtain a reliable summary estimate of specificity due to extreme heterogeneity in study-level results. The summary sensitivity of LAPSS was 0.83 (95% CI 0.75 to 0.89) and summary specificity 0.93 (95% CI 0.88 to 0.96). However, we were uncertain in the validity of these results as four of the studies were at high and one at uncertain risk of bias. We did not report summary estimates for the rest of the scales, as the number of studies per test per setting was small, the risk of bias was high or uncertain, the results were highly heterogenous, or a combination of these.Studies comparing two or more scales in the same participants reported that ROSIER and FAST had similar accuracy when used in the ER. In the field, CPSS was more sensitive than MedPACS and LAPSS, but had similar sensitivity to that of MASS; and MASS was more sensitive than LAPSS. In contrast, MASS, ROSIER and MedPACS were more specific than CPSS; and the difference in the specificities of MASS and LAPSS was not statistically significant. AUTHORS' CONCLUSIONS In the field, CPSS had consistently the highest sensitivity and, therefore, should be preferred to other scales. Further evidence is needed to determine its absolute accuracy and whether alternatives scales, such as MASS and ROSIER, which might have comparable sensitivity but higher specificity, should be used instead, to achieve better overall accuracy. In the ER, ROSIER should be the test of choice, as it was evaluated in more studies than FAST and showed consistently high sensitivity. In a cohort of 100 people of whom 62 have stroke/TIA, the test will miss on average seven people with stroke/TIA (ranging from three to 16). We were unable to obtain an estimate of its summary specificity. Because of the small number of studies per test per setting, high risk of bias, substantial differences in study characteristics and large between-study heterogeneity, these findings should be treated as provisional hypotheses that need further verification in better-designed studies.
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Affiliation(s)
- Zhivko Zhelev
- University of ExeterNIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical SchoolSt Luke's CampusSouth Cloisters (Room 3.09)ExeterDevonUKEX1 2LU
| | - Greg Walker
- University of British ColumbiaDepartment of NeurologyVancouver General HospitalVancouverBCCanada
| | | | - Jonathan Fridhandler
- University of British ColumbiaDepartment of NeurologyVancouver General HospitalVancouverBCCanada
| | - Samuel Yip
- University of British ColumbiaDepartment of NeurologyVancouver General HospitalVancouverBCCanada
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