Prehospital Stroke Scale Research Articles

Prediction of Thrombolytic Therapy after Stroke-Bypass Transportation: The Maria Prehospital Stroke Scale Score

There is no prehospital stratification tool specifically for predicting thrombolytic therapy after transportation. We developed a new prehospital scale named the Maria Prehospital Stroke Scale (MPSS) by modifying the Cincinnati Prehospital Stroke Scale. Our objective is to evaluate its utility in a citywide bypass transportation protocol for intravenous (IV) tissue plasminogen activator (tPA). In the MPSS, facial droop, arm drift, and speech disturbance are tested by emergency medical technicians (EMTs). Facial droop is graded as normal (0) or abnormal (1), and the other 2 items are graded in 3 levels as normal (0), not severe (1), and severe (2). Thus, the total MPSS score ranges from 0 to 5. The predictive value of MPSS for thrombolytic therapy after bypass transportation was evaluated in 1057 patients. The MPSS scored by EMTs was significantly correlated with the National Institutes of Health Stroke Scale score in the emergency room (Spearman rho = .67, P = .000). The onset-to-door time was significantly longer with a low MPSS score (analysis of variance, F5,4.21 = .001). The rate of thrombolytic therapy was increased when the MPSS score increased from 0 to 5: 0%, 4.1%, 8.8%, 13.0%, 20.3%, and 31.5%, respectively. The areas under the receiver operating characteristic curve for the correct diagnosis of stroke and prediction of IV tPA therapy were calculated as .737 (95% confidence interval [CI]: .688-.786) and .689 (95% CI: .645-.732), respectively. Multivariate logistic regression analysis showed that the MPSS score and the detection-to-door time were independent predictors of tPA use after transportation. The MPSS is a novel prehospital stratification tool for the prediction of thrombolytic therapy after transportation.

Abstract WP253: Effect Of A Feedback System Of The Formal Diagnosis After Admission On The Emergency Medical Service

Background and Purpose: Accurate identification of patients with stroke by emergency medical service (EMS) staffs may shorten prehospital delay. We produced an original stroke check sheet with a total 24 items, including vital signs, past history, Cincinnati prehospital stroke scale (PSS), Kurashiki PSS, and provisional diagnosis of stroke subtypes by EMS staffs. We started to feedback the final diagnosis of each patient 2 to 3 weeks after admission to our institute from June, 2011. The aim of this study was to verify effects of this feedback system on the EMS. Methods: We retrospectively enrolled 4,013 patients who were admitted to our hospital by using EMS from January, 2010 to March, 2012. We started the diagnosis feedback system to EMS from June, 2011. We divided the patients into 2 groups; those being admitted from January, 2010 to May, 2011 (group A) and those from June, 2011 to March, 2012 (group B). We compared positive predictive value (PPV) of provisional stroke diagnosis and the proportion of patients conveyed within 3 hours after the symptom onset between the 2 groups. Results: We collected a total of 2,130 stroke check sheets from conveyed patients; 1,280 in the group A and 850 in the group B. The number of patients with a final diagnosis of stroke was 904 in the group A and 621 in the group B. The number of patients with a provisional diagnosis of stroke at the time of conveyance was 629 in the group A and 406 in the group B. The PPV of a provisional diagnosis of stroke by EMS staff was not different between the 2 groups; 70% in the group A vs. 65% in the group B. Proportion of conveyance within 3 hours after the symptom onset in the group B was as the same level as that in the group A (57% vs. 57%, p=0.964). Conclusion: We started to feedback the final diagnosis of each patient 2 to 3 weeks after admission. The improvement was not accepted by the PPV of stroke and the proportion of conveyance within 3 hours after the symptom onset. Our feedback system of the final diagnosis to the EMS has to be improved.

Abstract WP330: Hospital and EMS Collaborate to Improve Field Stroke Recognition

Background: Comprehensive Stroke Center (CSC) measure DSPR.2 recommends that hospitals collaborate with EMS providers regarding routing and transport plans and educational initiatives. Paramedics have a 61 -66% accuracy in identifying stroke cases with standard training, but this is reported to improve to 86-97% when training includes stroke-specific tools such as the Cincinnati Pre-hospital Stroke Scale (CPSS) or Los Angeles Pre-hospital Stroke Screen. 1 A CPSS-trained EMS team that transports cases to the neuroscience institute requested an assessment of their accuracy in diagnosing stroke in the field as compared to the actual discharge diagnosis. Method: Retrospective review of the EMS data for neurological transports and the hospital database between January 2010 and June 2012 to compare hospital discharge diagnosis to EMS field diagnosis using the CPSS. Result: Of the 74 cases transported for neurological evaluation, 57(77%) were thought to be strokes using the CPSS. At hospital discharge, 28/57(49%) had a confirmed diagnosis of stroke. Overall, 59/74(80%)were discharged with a neurological diagnosis. Conclusions: The accuracy of EMS diagnosis of stroke in the field fell far below their expectations based on the literature. This result led to an action plan for our hospital to partner with the EMS team to increase their accuracy by providing a higher level of education for stroke assessment. This presentation will discuss the performance improvement initiative undertaken by the hospital outreach team with the EMS providers. Based on quarterly case review results, this process may be expanded to include other local and regional EMS systems.

Abstract WP243: Identification of Common Confounders in the Prehospital Identification of Stroke in Urban, Underserved Minorities

Background: Pre-hospital providers report positive predictive values (PPV) of 40-85% for the diagnosis of stroke, typically using the Cincinnati Pre-hospital Stroke Scale. In New York City 911, both emergency medical technicians [Basic Life Support (BLS)] and paramedics [Advanced Life Support (ALS)] care for/transport stroke patients. Hypotheses: (1) In an urban, underserved, minority population, ALS would have greater PPV than BLS for the confirmed diagnosis of stroke, and (2) Hypoglycemia and seizures would be frequent confounders, particularly for BLS providers. Methods: After IRB approval, medical records were reviewed of patients (85% Carribean Blacks) transported by EMS to participating Brooklyn facilities from 1/1/10-12/31/11. We compared EMS impressions of the presenting problem with AHA/ASA “Get with the Guidelines” (GWTG) databases - serving as the gold standard for diagnosis of stroke/TIA. Medical records of patients thought to have stroke by EMS but without a GWTG stroke diagnosis were queried for confounders (e.g. hypoglycemia, seizures). Patients who were not transported by EMS were excluded. Differences in confounders between ALS and BLS were analyzed using chi squared and Fisher’s exact test. Results: Of 671 patients suspected of having stroke by EMS, 628 patients (94%) had complete records (n=445 BLS, 183 ALS) available for review; 392 were confirmed strokes (275 ischemic, 46 TIA, 66 ICH, 5 SAH). There was no difference in PPV between ALS 59% (95% CI, 52% to 66%) and BLS 64% (95% CI, 59% to 68%) (P=0.277). Of the remaining 236 who did not have confirmed strokes, seizure was the greatest single confounder (n=72, 31%) followed in frequency by syncope (n=24, 10%), infections (n=23, 10%) and hypoglycemia (n=18, 8%). ALS more frequency diagnosed confounders than BLS (chi squared 8.64, df=3, p = 0.034), driven by seizure (2 tailed p < 0.0001). Conclusions: Our data suggest EMS called seizures a stroke more commonly than the other 3 leading confounders (hypoglycemia, syncope, and infection) combined and this was true more frequent for ALS than BLS, suggesting an area for focused EMS education. There was no difference between ALS and BLS in PPV. Further study is planned to determine the accuracy of ALS vs. BLS providers for the diagnosis of stroke.

Maria Prehospital Stroke Scale を用いた脳卒中患者搬送プロトコールの検証：川崎市救急隊員アンケート調査から

Maria Prehospital Stroke Scale を用いた脳卒中患者搬送プロトコールの検証：川崎市救急隊員アンケート調査から

Derivation of a Novel Pre-Hospital Stroke Scale (S39.005)

Derivation of a Novel Pre-Hospital Stroke Scale (S39.005)

Abstract 3468: Correlation of the Miami Emergency Neurologic Deficit (MEND) Exam Performed in the Field by Paramedics with an Abnormal NIHSS and Final Diagnosis of Stroke for Patients Airlifted from the Scene.

Introduction Early recognition and rapid transport to a stroke center by prehospital providers is essential in the care of stroke patients. In this study, prehospital providers were trained to perform the Miami Emergency Neurologic Deficit (MEND) exam as part of an 8-hour comprehensive course, Advanced Stroke Life Support (ASLS ® ). The MEND exam was devised to facilitate communication between healthcare providers throughout the continuum of care for stroke patients. It can provide a baseline exam in the prehospital setting, and then be used by nurses for initial evaluation and subsequent exams in the ED, ICU or hospital floor. The MEND exam incorporates all three components of the Cincinnati Prehospital Stroke Scale (CPSS) and six additional components from the NIHSS (level of consciousness, orientation, commands, visual fields, gaze, leg motor, limb ataxia, sensation). The exam takes less than 2 minutes and requires no tools, making it ideal for the Prehospital environment. Purpose Determine the correlation of the MEND exam completed by a prehospital provider on scene to the initial NIHSS performed by the neurologist at the receiving facility, and the final diagnosis. Methods All prehospital providers from three Fire Rescue agencies participated in the training (96 EMT-P, 68 EMT, 5 RN). The Prehospital providers conducted the CPSS, and if abnormal, placed the helicopter team on standby. They then completed the MEND exam and communicated their findings to a receiving hospital stroke neurologist. We retrospectively reviewed the MEND exam performed by the prehospital providers to determine the correlation with the same components of the initial NIHSS at the hospital. While the NIHSS assigned a numerical value to those specific components, the MEND exam did not. Additionally, we examined the final discharge diagnosis to determine how many patients had a stroke or transient ischemic attack (TIA). Results From Sept. 2008 to June 2011, 51 patients met the criteria of having both a MEND exam and NIHSS completed. There were 32 males (63%) and 19 females (37%) with a median age of 67 years (44-98 years). The average NIHSS score was 9 (range 0-30). 90.2% (46 of 51) of patients had an NIHSS that correlated to the findings on the MEND (95% C.I. 90.1-90.3). Of the 5 remaining patients, 1 completely recovered on the flight (diagnosed with a TIA), and 3 had a NIHSS score of 0 and were diagnosed with other conditions. Stroke or TIA was diagnosed in 40 patients (78.4%). Of 37 strokes, 32 were ischemic (86.5%) and 5 hemorrhagic (13.5%). The 11 patients not diagnosed with a stroke had several other pathologies (e.g. seizure, hypertensive crisis, viral encephalitis, complex migraine). Conclusion The MEND exam completed in the Prehospital setting correlated well with the initial NIHSS performed at the receiving facility. The MEND exam is a valuable tool when assessing stroke patients and determining need for air transport.

Acute Cerebrovascular Accident in Korea

The aim of this study is to reveal the right approach and prognosis of cerebrovascular accident (CVA) by reviewing the various researches on CVAs. The reviews were done by BNBI PubMed, KMBase, RISS, and KoreaMed. Based on the articles, prevalence rate of CVA, prehospital CVA patients assessment and emergency care, and in-hospital care were analyzed. The most important scales are Cincinnati prehospital stroke scale(CPSS) and Los Angeles prehospital stroke screen(LAPSS). These two scales are the basic assessment tools for CVAs and it is necessary to perform the emergency care by way of these scales.

Validation of the use of the ROSIER scale in prehospital assessment of stroke.

Aim:To determine the utility of the Recognition of Stroke in the Emergency Room (ROSIER) scale as a stroke recognition tool among Chinese patients in the prehospital setting.Materials and Methods:Compared with the Cincinnati Prehospital Stroke Scale (CPSS), emergency physicians prospectively used the ROSIER as a stroke recognition tool on suspected patients in the prehospital setting. And, the final discharge diagnosis of stroke or transient ischemic attack made by neurologists, after assessment and review of clinical symptomatology and brain imaging findings, was used as the reference standard for diagnosis in the study. Then, the ROSIER and the CPSS like sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), related coefficient (r) and Kappa value were calculated.Results:In this study, 540 of 582 suspected stroke patients met the study criteria. The CPSS showed a diagnostic Se of 88.77% (95% confidence intervals [CI] 86.11–91.43%), Sp of 68.79% (95% CI 64.88–72.70%), PPV of 87.40% (95% CI 85.97–88.83%), NPV of 71.52% (95% CI 67.71–75.33%) and r of 0.503. Relatively, the ROSIER showed a diagnostic Se of 89.97% (95% CI 87.44–92.64%), Sp of 83.23% (95% CI 80.08–86.38%), PPV of 92.66% (95% CI 90.46–94.86%), NPV of 77.91% (95% CI 74.41–81.41%) and r of 0.584. According to the final discharge diagnosis, both the ROSIER and the CPSS were associated with the final discharge diagnosis (P < 0.05).The Kappa statistic value of the ROSIER and the CPSS were 0.718 and 0.582, respectively. However, there was no statistical significance of the positive rate between the ROSIER and the CPSS in this study (P > 0.05).Conclusions:The ROSIER is a sensitive and specific stroke recognition tool for health providers’ use among Chinese patients in the prehospital setting. However, it cannot be used to confidently rule out or identify stroke as a diagnosis. Comprehensive clinical assessment and further examination on potential stroke patients are still important and cannot be replaced. When it is difficult to objectively complete the ROSIER for patients, the CPSS could replace it in the prehospital setting.

The Kurashiki Prehospital Stroke Scale Is a Prehospital Scale That Can Predict Long-Term Outcome of Patients with Acute Cerebral Ischemia

Background and Purpose: Our aim was to confirm the clinical relationship between the Kurashiki Prehospital Stroke Scale (KPSS) scored by paramedics and favorable outcomes in patients with modified Rankin scale (mRS) scores of 0–1 assessed 3 months after symptom onset. Methods: We enrolled patients with acute stroke and transient ischemic attack showing symptoms on admission. Paramedics transferred patients to our hospital after estimating stroke severity using the KPSS. After categorizing patients into either the mRS 0–1 group (favorable outcome) or the mRS 2–6 group (no favorable outcome), we compared the background data between the two groups. We assessed KPSS scores predictive of a favorable outcome. Multivariate regression modeling was conducted to identify factors independently associated with a favorable outcome. Results: The study cohort comprised 147 patients with a premorbid status of mRS 0–1: 69 patients (47%) of them were in the mRS 0–1 group and 78 (53%) in the mRS 2–6 group at the follow-up 3 months after symptom onset. The median KPSS score was lower in the mRS 0–1 group than in the mRS 2–6 group (1 vs. 4, p < 0.001). After classifying the 147 patients into KPSS tertiles with thresholds of 2 and 4, the frequency of mRS 0–1 gradually decreased with increasing KPSS score (lower KPSS, 67.2%; middle KPSS, 47.6%, and higher KPSS, 21.3%; p < 0.001). KPSS score <3 was able to predict a favorable outcome with 67% sensitivity and 71% specificity, and independently associated with mRS 0–1 (odds ratio, 3.0; 95% confidence interval, 1.2–7.3; p = 0.015). Conclusion: KPSS score <3 apparently presents a reasonable cutoff for predicting a favorable outcome in patients with acute cerebral ischemia.

Utility of the Kurashiki Prehospital Stroke Scale for Hyperacute Stroke

Backgrounds: Our aim was to confirm the utility of paramedics using the Kurashiki Prehospital Stroke Scale (KPSS), with a maximum score of 13, for patients who may be eligible for administration of intravenous tissue plasminogen activator (IV t-PA). Methods: The subjects comprised acute stroke and transient ischemic attack (TIA) patients transferred to our hospital by paramedics. We analyzed correlations between KPSS and the National Institutes of Health Stroke Scale (NIHSS). Patients admitted within 3 h of onset were categorized into 2 groups: KPSS ≧4 and KPSS <4. We compared the proportion of patients receiving IV t-PA between the groups. Results: Among 430 consecutive patients (mean age = 73 years; 266 men), paramedics recorded KPSS for 256 patients (59.5%). Excellent correlation was observed between KPSS and NIHSS in all 256 patients (R = 0.766; p < 0.001) and in 94 patients (ischemic stroke and TIA with symptoms on admission) admitted within 3 h of onset (R = 0.706; p < 0.001). Among these 94 patients, IV t-PA was more frequently given in the KPSS ≧4 group (30 of 58 patients, 51.7%) than in the KPSS <4 group (5 of 36 patients, 13.9%; p < 0.001). Arterial occlusion was more frequently observed in the KPSS ≧4 group (57.9 vs. 31.4%, p = 0.018). KPSS ≧4 was independently associated with administration of IV t-PA (odds ratio = 4.7; 95% confidence interval = 1.5–14.6, p = 0.008). Conclusion: Reliable concordance between KPSS and NIHSS was found in acute stroke and TIA patients. KPSS ≧4 represents a good score to indicate prospective t-PA patients among those admitted within 3 h of stroke onset.

Part 11: Adult Stroke

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

Paramedic Diagnosis of Stroke

Recent evidence suggests the Cincinnati Prehospital Stroke Scale is ineffectively used and lacks sensitivity and specificity. Melbourne (Australia) paramedics have been using the Melbourne Ambulance Stroke Screen (MASS) since 2005. The aim of this study was to review the real-world use of MASS 3 years after city wide implementation. Two groups of consecutively admitted patients to an Australian hospital between January and May 2008 were used: (1) patients for whom paramedics performed MASS; and (2) patients with a discharge diagnosis of stroke or transient ischemic attack. Use of MASS was examined for all transports and for patients diagnosed with stroke or transient ischemic attack. The sensitivity and specificity of paramedic diagnosis, MASS, and Cincinnati Prehospital Stroke Scale were calculated. Paramedic diagnosis of stroke among patients with stroke was statistically compared with those obtained immediately post-MASS implementation in 2002. For the study period, MASS was performed for 850 (16%) of 5286 emergency transports, including 199 of 207 (96%) patients with confirmed stroke and transient ischemic attack. In patients in whom MASS was performed (n=850), the sensitivity of paramedic diagnosis of stroke (93%, 95% CI: 88% to 96%) was higher than the MASS (83%, 95% CI: 77% to 88%, P=0.003) and equivalent to Cincinnati Prehospital Stroke Scale (88%, 95% CI: 83% to 92%, P=0.120), whereas the specificity of the paramedic diagnosis of stroke (87%, 95% CI: 84% to 89%) was equivalent to MASS (86%, 95% CI: 83% to 88%, P=0.687) and higher than Cincinnati Prehospital Stroke Scale (79%, 95% CI: 75% to 82%, P<0.001). The initial improvement in stroke paramedic diagnosis seen in 2002 (94%, 95% CI: 86% to 98%) was sustained in 2008 (89%, 95% CI: 84% to 94%, P=0.19). In our experience, paramedics have successfully incorporated MASS into the assessment of neurologically compromised patients. The initial improvement to the paramedics' diagnosis of stroke with MASS was sustained 3 years after city wide implementation.

Prehospital stroke scales in a Belgian prehospital setting: a pilot study

To compare the diagnostic value of the Cincinnati Prehospital Stroke Scale, the Face Arm Speech Test, the Los Angeles Prehospital Stroke Screen and the Melbourne Ambulance Stroke Screen for identifying patients with an acute stroke in a prehospital setting in Belgium. A prospective study was performed, using a questionnaire for every primarily transported patient within emergency medial service with relevant neurological complaints. Exclusion criteria were: patients below 18 years, trauma victims, Glasgow Coma Scale of less than 8 or transported to another hospital. The questionnaire is a comprehension of different stroke scales. The Face Arm Speech Test and Cincinnati Prehospital Stroke Scale demonstrate a high sensitivity (95%) but a lower specificity (33%). The sensitivity of the Los Angeles Prehospital Stroke Screen and Melbourne Ambulance Stroke Screen was lower (74%), but the specificity increased (83 and 67%). Items investigating unilateral facial paralysis and unilateral loss/absence of motor response in upper extremities seemed to be most discriminating between the stroke group (68-78%) and the nonstroke group (17%), suggesting that items related to clinical assessment are more important in stroke recognition than history items. Combination of all clinical parameters of the different scores resulted in a sensitivity and specificity of 95 and 83%, respectively. The results obtained in this study are comparable with earlier investigations. Given the limitations of the study, we could not identify the most adequate stroke scale. History items seem to be less relevant compared with clinical assessment. Further research is needed to determine the most adequate stroke scale.

3TOP system : Fast-track Medical Care System with Electronic Path for t-PA Therapy in Hyperacute Stage Ischemic Stroke Using Prehospital Stroke Scale TOPSPIN

3TOP system : Fast-track Medical Care System with Electronic Path for t-PA Therapy in Hyperacute Stage Ischemic Stroke Using Prehospital Stroke Scale TOPSPIN

Compliance With and Use of Up-to-Date National Academies of Medical Dispatch Medical Priority Dispatch System Protocols in Dispatch Practice and Research Studies Must Be a Requirement

To the Editor: We observed significant omissions and errors in the study’s methods/design, findings, and conclusions in the recent paper by Buck et al,1 which we respectfully want to point out. First, the National Academies of Emergency Dispatch Medical Priority Dispatch System (MPDS) protocol version (Version 11.1, valid from 2001 to 2004) used in this study1 is significantly outdated. Three subsequent versions (Version 11.2, valid from 2004 to 2006; Version 11.3, valid from 2006 to 2008; and Version 12.0, valid from 2008 to date) have been issued, each containing significant clinically predictive modifications in the stroke protocol (Protocol 28). Using an outdated protocol is unsafe in a communication center, not the standard of dispatch practice, and misleads readers about the “current” effectiveness of the state of the art of an evolving protocol system. In the MPDS Version 11.1 protocol’s rules at that time, a …

Response to Letter by Bray and Bladin

HomeStrokeVol. 40, No. 5Response to Letter by Bray and Bladin Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter by Bray and Bladin Larry B. Goldstein Larry B. GoldsteinLarry B. Goldstein Duke University Medical Center, Durham, NC Search for more papers by this author Originally published26 Mar 2009https://doi.org/10.1161/STROKEAHA.109.550772Stroke. 2009;40:e399Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 26, 2009: Previous Version 1 Response:We thank Ms Bray and Dr Bladin for their comments and agree with their general points. Audit and feedback can improve performance, but the effect is usually modest.1 Although we did not provide the specific type of feedback they describe, regular performance evaluations are part of the standard educational and quality improvement programs provided to the Emergency Medical Services personnel included in our study. The patients were taken to a medical center with a rapid response stroke team that continuously monitors performance, so in our case, the issue of transporting patients expeditiously only to have treatment delayed or deferred does not apply.We also found that the sensitivity of the Cincinnati Prehospital Stroke Scale, the subject of our study, could be improved by the addition of several items at a cost of reduced specificity. Specificity is particularly important if the results are used to aid in ambulance routing or diversion. Given the importance of rapid stroke patient identification and transport,2 additional studies carried out in the field similar to those described in our report and by Ms Bray and Dr Bladin are needed.DisclosuresNone.1 Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006 (2): CD000259; PMID:16625533.Google Scholar2 Acker JE III, Pancioli AM, Crocco TJ, Eckstein MK, Jauch EC, Larrabee H, Meltzer NM, Mergendahl WC, Munn JW, Prentiss SM, Sand C, Saver JL, Eigel B, Gilpin BR, Schoeberl M, Solis P, Bailey JR, Horton KB, Stranne SK; American Heart Association; American Stroke Association Expert Panel on Emergency Medical Services Systems, Stroke Council. Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke. 2007; 38: 3097–3115.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2009Vol 40, Issue 5 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.109.550772 Originally publishedMarch 26, 2009 PDF download Advertisement

Success With Paramedic Diagnosis of Stroke

To the Editor: We read with interest the recent article by Frendle et al,1 the first study to demonstrate a lack of improvement in paramedic stroke diagnosis after training and implementation of a prehospital stroke scale. Having implemented a similar program to Australian paramedics with success (stroke detection …

A mobile telemedicine system for remote consultation in cases of acute stroke

A mobile telemedicine system, capable of transmitting video and audio simultaneously, was designed for consulting acute stroke patients remotely. It could use a wireless local area network (e.g. inside the hospital) or a mobile phone network (e.g. outside the hospital). When initiating a call, the sending unit chose a suitable encoding profile based on the measured data throughput, in order to allocate appropriate bit rates for video and audio transmission. The system was tested using a portable digital assistant (PDA) type phone and smart phone as receiving units. Video and audio recordings were made from five patients (two normal and three stroke patients) and then transmitted at different rates. Subjectively, both video and audio qualities improved as the data throughput increased. The physical findings, including facial droop, arm drift and abnormal speech, were observed remotely by four specialists according to the Cincinnati Pre-hospital Stroke Scale guideline. A comparison between the face-to-face method and the mobile telemedicine method showed that there were no discrepancies at bit rates of more than 400 kbit/s. We conclude that specialists could generally conduct remote consultations for stroke patients either using a public mobile network or a wireless LAN.

Use of Biomarkers in Triage of Patients with Suspected Stroke

The absence of a rapidly available and sensitive diagnostic test represents an important limitation in the triage of patients with suspected stroke. The aim of the present study was to investigate the triage accuracy of a novel test that measures blood-borne biomarkers (triage stroke panel, TSP) and to compare its accuracy with that of the Cincinnati Prehospital Stroke Scale (CPSS). Consecutive patients with suspected stroke presenting to the Emergency Departments of three Italian hospitals underwent triage by a trained nurse according to the CPSS and had blood drawn for TSP testing. The TSP simultaneously measures four markers (B-type natriuretic peptide, D-dimer, matrix metalloproteinase-9, and S100β) presenting a single composite result, the Multimarker Index (MMX). Stroke diagnosis was established by an expert committee blinded to MMX and CPSS results. There were 155 patients enrolled, 87 (56%) of whom had a final diagnosis of stroke. The area under the receiver operating characteristic (ROC) curve for CPSS was 0.77 (95% confidence interval [CI] 0.70-0.84) and that of MMX was 0.74 (95% CI 0.66-0.82) (p = 0.285). Thus, both tests, when used alone, failed to recognize approximately 25% of strokes. The area under the ROC curve of the combination of the two tests (0.86, 95% CI 0.79-0.91) was significantly greater than that of either single test (p = 0.01 vs. CPSS and p < 0.001 vs. TSP). In an emergency care setting, a panel test using multiple biochemical markers showed triage accuracy similar to that of CPSS. Further studies are needed before biomarkers can be introduced in the clinical work-up of patients with suspected stroke.