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• W4205358488 abstract "Time-sensitive and effective reperfusion therapies of acute ischemic stroke have evolved during the last two decades. This has urged a need for accurate and time-efficient prehospital diagnostics. Prehospital over and under triage of stroke patients accounts for delays and low treatment rates,1 and interhospital transfers may delay endovascular treatment and worsen outcome for stroke patients.2 In the need of increased accuracy in prehospital identification of stroke symptoms, numerous modified stroke scales have been developed for prehospital stroke screening and identification of large vessel occlusion (LVO) in the field. However, no scale has shown clear superiority. Currently, there is no gold standard prehospital stroke scale and thus clinical assessment varies between countries and health regions. The prehospital scale selected in a specific region seems to be based merely on local preferences. This is in contrary to in-hospital clinical acute stroke evaluations where the National Institute of Health Stroke Scale (NIHSS) has been thoroughly validated and accepted as the preferred scale. In this edition of Acta Neurologica Scandinavica, Puolakka et al. have in a retrospective cohort study compared the performance of 16 prehospital LVO scales by extracting symptoms from prehospital medical records. Only three of the scales achieved acceptable area under the curve (AUC): Field Assessment Stroke Triage for Emergency Destination (FAST-ED), Emergency Medical Stroke Assessment (EMSA), and Gaze-Face-Arm-Speech-Time (G-FAST). These three scales proved to exclude LVO with a high certainty (NPV >0.9), but on the other hand, the highest positive predictive value (PPV) was only 0.4 (FAST-ED). A negative test can therefore with a high degree of certainty exclude LVO. However, a positive test will result in unnecessary transportations of non-LVO patients to EVT capable centers with potential overload and strain of local health resources, and potential delay of acute treatment for non-LVO strokes. FAST-ED had the best overall performance, which the authors rightfully argue may be due to the scale including cortical symptoms such as neglect. Cortical symptoms are previously described to be reliable indicators of LVO and that prehospital identification of such symptoms may justify direct transportation to an EVT capable center.3 In general, scales including more complex symptoms such as neglect have been criticized to be too difficult to be used by ambulance personnel. But this criticism is not based on solid research evidence and should be explored. Prehospital personnel requires solid training programs in recognizing and identifying stroke symptoms including both motor, cortical, and posterior stroke symptoms. The LVO scale scores in the present study were retrospectively derived from prehospital medical records where ambulance personnel report stroke symptoms including neglect, but it is unknown how the prehospital personnel were trained to perform the standard prehospital scale (FAST) and to recognize more complex symptoms. Most prehospital stroke scales are based on elements from NIHSS, however, the NIHSS is rarely used in the prehospital setting under the assumption that this scale is too complicated and time consuming for prehospital use. This is perhaps also why the authors did not include NIHSS in the present analysis. Interestingly, NIHSS was originally adapted to be used by non-neurologists4 and the scale is used successfully in various prehospital settings and has been validated among non-neurologists. 5-8 NIHSS is the in-hospital gold standard and has also previously proven superior to other prehospital stroke scales in identifying LVO.9 NIHSS enables prehospital stroke severity quantification, monitoring of symptom progression, and LVO identification. Moreover, using the same clinical stroke scale in pre- and in-hospital settings may improve communication between ambulance personnel and the stroke physicians. LVO identification through stroke scales has previously been indicated to be a “mission impossible” since the scales only give a gross estimate of the presence or absence of LVO.10 Prehospital stroke scales are created to detect single aspects of acute stroke care like screening for stroke or prediction of LVO, which may be a challenge as the scales, scores and interpretations are not compatible to in-hospital standards. NIHSS holds the potential to streamline acute stroke care from pre- to in-hospital settings, and we want to challenge the assumption that NIHSS is too complex and time consuming to be used by trained ambulance personnel in the field—the mission is possible. The time has come to create a common language along the stroke care chain and a prehospital gold standard stroke scale for all acute strokes, not just LVO stroke. None KL is an investigator of the Treat-NASPP study. ECS and MRH are principal investigators of the ParaNASPP study, investigating the use of NIHSS in the prehospital setting and communication between pre- and in-hospital services using a mobile application. The peer review history for this article is available at https://publons.com/publon/10.1111/ane.13577. The peer review history for this article is available at https://publons.com/publon/10.1111/ane.13577." @default.
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• W4205358488 date "2022-01-08" @default.
• W4205358488 modified "2023-10-14" @default.
• W4205358488 title "Prehospital stroke scales—the need for a gold standard in the field" @default.
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• W4205358488 doi "https://doi.org/10.1111/ane.13577" @default.
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