Skip to main content

Advertisement

Log in

Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?

  • Original Communication
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Simple clinical scores to predict large vessel occlusion (LVO) in acute ischemic stroke would be helpful to triage patients in the prehospital phase. We assessed the ability of various combinations of National Institutes of Health Stroke Scale (NIHSS) subitems and published stroke scales (i.e., RACE scale, 3I-SS, sNIHSS-8, sNIHSS-5, sNIHSS-1, mNIHSS, a-NIHSS items profiles A–E, CPSS1, CPSS2, and CPSSS) to predict LVO on CT or MR arteriography in 1085 consecutive patients (39.4 % women, mean age 67.7 years) with anterior circulation strokes within 6 h of symptom onset. 657 patients (61 %) had an occlusion of the internal carotid artery or the M1/M2 segment of the middle cerebral artery. Best cut-off value of the total NIHSS score to predict LVO was 7 (PPV 84.2 %, sensitivity 81.0 %, specificity 76.6 %, NPV 72.4 %, ACC 79.3 %). Receiver operating characteristic curves of various combinations of NIHSS subitems and published scores were equally or less predictive to show LVO than the total NIHSS score. At intersection of sensitivity and specificity curves in all scores, at least 1/5 of patients with LVO were missed. Best odds ratios for LVO among NIHSS subitems were best gaze (9.6, 95 %-CI 6.765–13.632), visual fields (7.0, 95 %-CI 3.981–12.370), motor arms (7.6, 95 %-CI 5.589–10.204), and aphasia/neglect (7.1, 95 %-CI 5.352–9.492). There is a significant correlation between clinical scores based on the NIHSS score and LVO on arteriography. However, if clinically relevant thresholds are applied to the scores, a sizable number of LVOs are missed. Therefore, clinical scores cannot replace vessel imaging.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20

    Article  PubMed  Google Scholar 

  2. Campbell BC, Mitchell PJ, Kleinig TJ, EXTEND-IA Investigators et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018

    Article  CAS  PubMed  Google Scholar 

  3. Goyal M, Demchuk AM, Menon BK, ESCAPE Trial Investigators et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030

    Article  CAS  PubMed  Google Scholar 

  4. Saver JL, Goyal M, Bonafe A, SWIFT PRIME Investigators et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295

    Article  CAS  PubMed  Google Scholar 

  5. Jovin TG, Chamorro A, Cobo E, REVASCAT Trial Investigators et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306

    Article  CAS  PubMed  Google Scholar 

  6. Brott T, Adams HP Jr, Olinger CP et al (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20:864–870

    Article  CAS  PubMed  Google Scholar 

  7. Maas MB, Furie KL, Lev MH et al (2009) National Institutes of Health Stroke Scale score is poorly predictive of proximal occlusion in acute cerebral ischemia. Stroke 40:2988–2993

    Article  PubMed  PubMed Central  Google Scholar 

  8. Olavarría VV, Delgado I, Hoppe A et al (2011) Validity of the NIHSS in predicting arterial occlusion in cerebral infarction is time-dependent. Neurology. 76:62–68

    Article  PubMed  Google Scholar 

  9. Fischer U, Arnold M, Nedeltchev K et al (2005) NIHSS score and arteriographic findings in acute ischaemic stroke. Stroke 36:2121–2125

    Article  PubMed  Google Scholar 

  10. Heldner MR, Zubler C, Mattle HP et al (2013) NIHSS score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke 44:1153–1157

    Article  PubMed  Google Scholar 

  11. Cooray C, Fekete K, Mikulik R, Lees KR, Wahlgren N, Ahmed N (2015) Threshold for NIH stroke scale in predicting vessel occlusion and functional outcome after stroke thrombolysis. Int J Stroke. 10:822–829

    Article  PubMed  Google Scholar 

  12. Meyer BC, Hemmen TM, Jackson CM, Lyden PD (2002) Modified National Institutes of Health Stroke Scale for use in stroke clinical trials: prospective reliability and validity. Stroke 33:1261–1266

    Article  PubMed  Google Scholar 

  13. Meyer BC, Lyden PD (2009) The modified National Institutes of Health Stroke Scale: its time has come. Int J Stroke. 4:267–273

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Pérez de la Ossa N, Carrera D, Gorchs M et al (2014) Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke 45:87–91

    Article  PubMed  Google Scholar 

  15. Singer OC, Dvorak F, du Mesnil de Rochemont R, Lanfermann H, Sitzer M, Neumann-Haefelin T (2005) A simple 3-item stroke scale: comparison with the National Institutes of Health Stroke Scale and prediction of middle cerebral artery occlusion. Stroke 36:773–776

    Article  PubMed  Google Scholar 

  16. Abdul-Rahim AH, Fulton RL, Sucharew H, For the VISTA Collaborators et al (2015) National Institutes of Health Stroke Scale Item Profiles as predictor of patient outcome: external validation on independent trial data. Stroke 46:395–400

    Article  PubMed  Google Scholar 

  17. Kesinger MR, Sequeira DJ, Buffalini S, Guyette FX (2015) Comparing National Institutes of Health Stroke Scale among a stroke team and helicopter emergency medical service providers. Stroke 2:575–578

    Article  Google Scholar 

  18. Tirschwell DL, Longstreth WT Jr, Becker KJ et al (2002) Shortening the NIH Stroke scale for use in the prehospital setting. Stroke 33:2801–2806

    Article  PubMed  Google Scholar 

  19. Kothari R, Hall K, Brott T, Broderick J (1997) Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 4:986–990

    Article  CAS  PubMed  Google Scholar 

  20. Katz BS, McMullan JT, Sucharew H, Adeoye O, Broderick JP (2015) Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke 46:1508–1512

    Article  PubMed  PubMed Central  Google Scholar 

  21. Rajajaee V, Kidwell C, Starkman S et al (2006) Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology. 67:980–984

    Article  Google Scholar 

  22. Jauch EC, Saver JL, Adams HP Jr, On behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease and Council on Clinical Cardiology, On behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease and Council on Clinical Cardiology et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44:870–947

    Article  PubMed  Google Scholar 

  23. Heldner MR, Jung S, Zubler C et al (2015) Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients. JNNP. 86:755–760

    Google Scholar 

  24. Arboix A, Bell Y, García-Eroles L et al (2004) Clinical study of 35 patients with dysarthria-clumsy hand syndrome. JNNP. 75:231–234

    CAS  Google Scholar 

Download references

Acknowledgments

We thank Pietro Ballinari, PhD; for statistical advice.

Sources of funding concerning this paper

Swiss Heart Foundation Grant 2013/2014 (main applicant: MR Heldner, 1st joint applicant: U Fischer, 2nd joint applicant: HP Mattle).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Urs Fischer.

Ethics declarations

Ethical standard

The study protocol was approved by our institutional ethics committee in Bern, and the study has, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all patients.

Conflicts of interest

Dr. Heldner reports a grant from the Swiss Heart Foundation. Dr. Hsieh reports no disclosures. Dr. Broeg-Morvay reports no disclosures. PD Dr. Mordasini reports no disclosures. Dr. Bühlmann reports no disclosures. PD Dr. Jung reports no disclosures. Prof. Dr. Arnold received honoraria for lectures and advisory boards from Bayer, Boehringer Ingelheim, Bristol Meyer Squibbs, Pfizer and Covidien. Prof. Dr. Mattle reports a grant from the Swiss Heart Foundation. Prof. Dr. Gralla reports a consultant agreement with Medtronic. Prof. Dr. Fischer reports a grant from the Swiss Heart Foundation and received a speaker’s honorarium from Covidien.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 124 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Heldner, M.R., Hsieh, K., Broeg-Morvay, A. et al. Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?. J Neurol 263, 1633–1640 (2016). https://doi.org/10.1007/s00415-016-8180-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-016-8180-6

Keywords

Navigation