more mnemonics! race, lams, lapss, cpss – wth!...
TRANSCRIPT
More Mnemonics! RACE, LAMS, LAPSS, CPSS – WTH! OMG!: LVO Stroke Screening
Laura Heitsch, MD
Assistant Professor, EM & Neurology Washington University, St Louis MO
Disclosures • Funding
– NIH/NINDS: POINT (local-PI) – EMF Career Development Grant – AHA/ASA Career Development Grant – Pending K23 Career Development Grant (NINDS)
• Industry Relationship – Genentech Speakers Bureau
• Off-Label Discussion – None
Objectives
• Understand what is meant by a LVO and why it’s important
• Recognize several LVO stroke screening tools
• Understand the limitations of these screening tools
LVO = Large Vessel Occlusion Middle Cerebral Artery (MCA)
Anterior Cerebral Artery (ACA)
http://emedicine.medscape.com/article/1916852-overview#a3
LVO = Large Vessel Occlusion
http://www.svuhradiology.ie/case-study/occluded-middle-cerebral-artery-ct-angiography/
Thrombectomy of LVO
Castano C et al. Stroke 2010; 41:1836-1840. http://img.medscape.com/news/2014/ht_141217_stent_retriever_800x600.jpg
M1
Dispatch EMS team Community
Recognize signs and symptoms of stroke
Recognize signs and symptoms of stroke
Assessment and management
Call 911 & Describe Dispatch EMS team Rapid transport to stroke ready hospital with pre-notification
Dispatch EMS team Community
Recognize signs and symptoms of stroke
Recognize signs and symptoms of stroke
Assessment and management
Call 911 & Describe Dispatch EMS team
PSC
Possible LVO?
CSC
Well, you have (lots of) options… • Cincinnati Prehospital Stroke Scale (CPSS)* • Cincinnati Prehospital Stroke Severity Scale
(CPSSS) • Los Angeles Prehospital Stroke Scale (LAPSS)* • Los Angeles Motor Score (LAMS) • Lots of modifications of the original NIHSS (0-42)
– sNIHSS-1, sNIHSS-5, sNIHSS-8, mNIHSS, aNIHSS, rNIHSS A to F, 3I-SS
• RACE • ROSIER
*Originally designed for stroke recognition (not LVO triage)
Well, you have (lots of) options… • Cincinnati Prehospital Stroke Scale (CPSS)*
• Los Angeles Prehospital Stroke Scale (LAPSS)*
*Originally designed for stroke recognition (not LVO triage)
Well, you have (lots of) options… • Cincinnati Prehospital Stroke Scale (CPSS)* • Cincinnati Prehospital Stroke Severity Scale
(CPSSS) • Los Angeles Prehospital Stroke Scale (LAPSS)* • Los Angeles Motor Score (LAMS) • Lots of modifications of the original NIHSS (0-42)
– sNIHSS-1, sNIHSS-5, sNIHSS-8, mNIHSS, aNIHSS, rNIHSS A to F, 3I-SS
• RACE • ROSIER
*Originally designed for stroke recognition (not LVO triage)
Cincinnati Prehospital Stroke Severity Scale (CPSSS)
• Components (all clinical exam) – Abnormal level of consciousness – Conjugate gaze – Arm weakness
• Scoring (0-4): – 1 point: incorrectly answers ≥ 1 LOC plus ≥ 1
command not followed – 2 points: conjugate gaze deviation – 1 point: cannot hold arm up for 10 seconds
• How does it perform for LVO: (score ≥ 2) – Sensitivity 83% – Specificity 40%
Katz et al. Stroke 2015;46:1508-1512.
Recognition of Stroke in the Emergency Room (ROSIER)
• Components – Interview Questions – Clinical examination
• Scoring (0-9): – Associated LOC (yes = -1; no = 0) – Associated Seizure (yes = -1; no = 0) – Asymmetrical face weakness (yes = +1; no = 0) – Asymmetrical arm weakness (yes = +1; no = 0) – Asymmetrical leg weakness (yes = +1; no = 0) – Speech disturbance (yes = +1; no = 0) – Visual field defect (yes = +1; no = 0)
• How does it perform for LVO: – Was not originally designed for this purpose
Nor et al. Lancet Neurol 2005;4:727-34.
What do we really care about?
• Easy to Use – Performing the entire NIH stroke scale?
• Overwhelming the Comprehensive Stroke Center – Not sending ALL stroke patients to the CSC – False Positive Rate = 1 - specificity
• Identify patients who likely have an LVO – Not missing any potential candidates for
thrombectomy – False Negative Rate = 1 - sensitivity
Field Assessment Stroke Triage for Emergency Destination (FAST-ED)
• Components (all clinical exam) • Scoring (0-9):
– Facial Palsy = 0-1 point – Arm weakness = 0-2 points – Speech changes = 0-2 points – Eye deviation = 0-2 points – Denial/neglect = 0-2 points
• How does it perform for LVO (score ≥ 4): – Sensitivity 0.60 (False Negative 40%) – Specificity 0.89 (False Positive 11%)
Lima et al. 2016;47:1997-2002
So where does that leave us??
“The specific scale chosen may be less important than the paradigm that some field severity score assessment should be done to screen for possible (E)LVO.” - Jayaraman et al. J NeuroIntervent Surg. 2016
Endovascular Intervention Process Flow
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