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

A New Era in Acute Stroke Treatment

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

http://worldartsme.com/images/emoticon-question-mark-clipart-1.jpg

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

Turc G, et al. Stroke. 2016;47:1466-1472.

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

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