Abstract
BackgroundRouting of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services particularly when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult. We aimed to develop a prehospital score – called prehospital-intracerebral hemorrhage score (ph-ICH score) – to assist in discriminating between both conditions.MethodsThe ph-ICH score was developed with data from patients treated aboard a mobile stroke unit in Berlin, Germany, between 2011 and 2013 (derivation cohort) and in 2018 (validation cohort). Diagnosis of ICH or AIS was established using clinical data and neuroradiological cerebral imaging. Diagnostic accuracy was measured with significance testing, Cohen’s d and receiver-operating-characteristics.ResultsWe analyzed 416 patients (32 ICH, 224 AIS, 41 transient ischemic attack, 119 stroke mimic) in the derivation cohort and 285 patients (33 ICH and 252 AIS) in the validation cohort. Systolic blood pressure, level of consciousness and severity of neurological deficits (i. e. certain items of the National Institutes of Health Stroke Scale) were used to calculate the ph-ICH score that showed higher values in the ICH compared to the AIS group (derivation cohort: 1.8 ± 1.2 vs. 1.0 ± 0.9 points; validation cohort: 1.8 ± 0.9 vs. 0.8 ± 0.7 points; d = 0.9 and 1.4, both p < 0.01). Receiver-operating-characteristics showed fair and good accuracy with an area under the curve of 0.71 for the derivation and 0.81 for the validation cohort.ConclusionsThe ph-ICH score can assist medical personnel in the field to assess the likelihood of ICH and AIS in emergency patients.
Highlights
Routing of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult
In the validation cohort we evaluated patients treated aboard one of three Stroke Emergency Mobile (STEMO) in Berlin, Germany who were registered in the SPecific Acute Treatment in Ischemic or hAemorrhagic Stroke With Long Term Follow-up (B-SPATIAL) database (ClinicalTrials.gov Identifier: NCT03027453) as part of the Berlin PRe-hospital Or Usual Delivery of Acute Stroke Care (B_PROUD) project (ClinicalTrials.gov Identifier: NCT02869386)
A total of 1400 STEMO alarms were evaluated, and 416 patients were identified with complete documentation in the derivation cohort, as shown in the Flow Chart (Fig. 1)
Summary
Routing of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult. The term stroke derives from the sudden onset of neurological deficits but includes heterogeneous subtypes of acute ischemic stroke (AIS), intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) [1, 2]. Some therapeutic approaches, such as antithrombotic/thrombolytic treatment, are indicated in AIS. Because some time-sensitive interventions like systemic thrombolysis alone or in combination with mechanical thrombectomy [11,12,13] or neurosurgical operations are only available in specialized hospitals, the differentiation between ICH and AIS patients is clinically relevant to make the correct transport decision to the nearest and most appropriate hospital. Secondary transfers from non-specialized hospitals are required, thereby delaying treatment and possibly worsening prognosis
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