Recognition Of Stroke In The Emergency Room Research Articles

A nomogram-based clinical tool for acute ischemic stroke screening in prehospital setting.

Background: We believe that designing a new tool which is comparable in terms of both sensitivity and specificity may play an important role in rapid and more accurate diagnosis of acute ischemic stroke (AIS) in prehospital stage. Therefore, we intended to develop a new clinical tool for the diagnosis of AIS in the prehospital stage. Methods: This was a cross-sectional diagnostic accuracy study. All patients transferred to the emergency department (ED) who underwent brain magnetic resonance imaging (MRI) with impression of AIS were evaluated by 9 clinical tools for stroke diagnosis in the pre-hospital phase including Rapid Arterial Occlusion Evaluation (RACE), Cincinnati Prehospital Stroke Scale (CPSS), Los Angeles Prehospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS), Ontario Prehospital Stroke Screening Tool (OPSS), PreHospital Ambulance Stroke Test (PreHAST), Recognition of Stroke in the Emergency Room (ROSIER), and Face Arm Speech Test (FAST), and totally 19 items were reviewed and recorded. The new clinical tool was developed based on backward method of multivariable logistic regression analysis. The discrimination power of the new clinical tool for diagnosis of AIS was assessed with the area under the receiver operating characteristic curve (AUC-ROC). Results: Data from 806 patients were analyzed; of them, 57.4% were men. The mean age of the study patients was 66.9 years [standard deviation (SD) = 13.9]. In the multivariable model, 8 items remained. The AUC-ROC of the new clinical tool was 0.893 [95% confidence interval (CI): 0.869-0.917], and its best cut-off point was score ≥ 3 for positive AIS. At this cut-off point, sensitivity and specificity were 84.42% and 79.72%, respectively. Conclusion: We introduced a new nomogram-based clinical tool for the diagnosis of AIS in the prehospital stage, which has acceptable specificity and sensitivity; moreover, it is comparable with previous tools.

Recognition of Stroke in the Emergency Room (ROSIER) Scale in Identifying Strokes and Transient Ischemic Attacks (TIAs); a Systematic Review and Meta-Analysis.

A range of screening tools has been developed to assist emergency healthcare providers in rapidly and accurately diagnosing strokes. In this study, we investigated the diagnostic value of the Recognition of Stroke in the Emergency Room (ROSIER) scale in identifying individuals with stroke and transient ischemic attack (TIA). We conducted a systematic search across online databases of PubMed, Embase, Scopus, and Web of Science until June 12th, 2023, aiming to identify studies that assessed the diagnostic performance of the ROSIER scale in detecting strokes and TIAs among individuals with suspected stroke symptoms. Data extracted from 34 studies were analyzed, demonstrating that the ROSIER score, with a cut-off value of ≥ 1, has sensitivity of 0.89 (95% confidence interval (CI): 0.86-0.92), specificity of 0.76 (95% CI: 0.69-0.81), diagnostic odds ratio (DOR) of 25.41 (95% CI: 17.2-37.54), and area under the curve (AUC) of 0.91 (95% CI: 0.85-0.90) in detection of strokes and TIAs. Meta-regression subgroup analysis revealed variations in sensitivity and specificity based on different settings and assessors. Sensitivity was higher in pre-hospital settings when the test was administered by emergency medical services (EMS) and emergency department (ED) paramedic staff, whereas specificity was higher in emergency department settings and when physicians and neurologists conducted the test. A moderate level of evidence shows that the ROSIER scale is considered an excellent tool for identifying strokes and TIAs. As a valid method for identifying strokes, it holds applicability across diverse settings and can be effectively used by assessors with different specialties.

Validation of Recognition of Stroke in the Emergency Room scale in Turkish population and comparison of its efficiency with Face-Arm-Speech Test

INTRODUCTION: Various risk scores were developed to recognize acute stroke easily and to start treatment right away in the emergency departments. Although the Recognition of Stroke in the Emergency Room (ROSIER) score used for this purpose is indicated better than the other scoring systems, it is expressed that it will be able to have social differentiations. In this study, we targeted to research validation of the ROSIER scale and to compare its efficiency with Face-Arm-Speech Test (FAST), another stroke diagnosis method, for the patients who applied to the emergency department with the stroke or transient ischemic attack symptoms. MATERIAL AND METHODS: The patients who reported to the emergency department with the suggestive symptoms or findings of stroke and were above 18 years of age were included in the study. The study forms were filled out by the emergency medicine specialist or the senior emergency medical assistant after the patients were evaluated, and then they were consulted by the neurology specialist. The final diagnosis, which was established after the clinical evaluation and necessary imaging done by the neurology specialists, was accepted as a standard reference. RESULTS: A total of 335 patients, including 168 (50.1%) females, were included in the study. The sensitivity was 68.5%, specificity was 79.0%, Positive Predictive Value (PPV) was 78.7%, NPV (Negative Predictive Value) was 68.9%, and test validity was 73.4% for the ROSIER scale. For the FAST scale the sensitivity was 63.5%, specificity was 88.5%, PPV was 86.3%, NPV was 68.1%, and test validity was 75.2%. CONCLUSION: In the present study, it was seen that the ROSIER scale could be used in separating the patients with CVO (cerebrovascular accident) from the patients who applied with the similar clinical findings. However, FAST was superior because its specificity and PPV were higher and its practicability was easier than the ROSIER.

Comparison of two screening scales used by 120 dispatchers for early identification of pre-hospital stroke patients and telephone guidance for treatment

To observe the effect of two different screening scales used by 120 dispatchers to early identify stroke patients and give telephone guidance for treatment. From October 2018 to August 2019, 2 027 stroke and suspect stroke patients who called the Kaifeng 120 Emergency Center were enrolled. The differences in the final positive rate of stroke diagnosis and the incidence of adverse events were compared and analyzed in 1 020 cases using recognition of stroke in the emergency room (ROSIER) and 1 007 cases using facial drooping, arm weakness, speech difficulties and time (FAST) scale scores for telephone guidance. The positive rate of stroke identification in ROSIER score group was higher than that in FAST score group [31.4% (320/1 020) vs. 29.3% (295/1 007)], the false report rate was significantly lower than that in FAST score group [14.9% (152/1 020) vs. 18.8% (189/1 007), P < 0.05], the incidence of adverse events caused by vomiting, falling from bed and convulsions in ROSIER score group were lower than those in FAST score group [0.5% (1/208) vs. 2.2% (4/185), 0% (0/26) vs. 20.0% (2/10), 2.1% (1/48) vs. 10.3% (3/29)], however, the incidence of adverse events caused by falling out of bed was significantly lower (P < 0.05). The incidence of total adverse events in ROSIER score group was significantly lower than that in FAST score group [0.7% (2/305) vs. 3.8% (9/235), P < 0.05]. The time of FAST score group was shorter than that of ROSIER score group (minutes: 1.2±0.2 vs. 2.5±0.3), but the difference was not statistically significant (P > 0.05). Two different scales can be used to early identify stroke patients and provide timely pre-hospital guidance, thus reduce the incidence of adverse events. Although the ROSIER score takes longer time, the dispatchers guide the patients by phone which does not affect the dispatch time.

Abstract P281: Acute Stroke Mimics: Etiological Spectrum and Efficacy of Stroke Assessing Scores

Introduction: Stroke mimics constitute a good number of patients referred as acute strokes within the window period for acute therapies. Proper triaging can avoid unnecessary imaging and even thrombolytic therapies in these patients. This study looked at etiological spectrum of acute stroke mimics presenting within the 4.5 hours therapeutic window. We also evaluated the FAST (Face-Arm-Speech-Time), BEFAST (Balance -Eyes-Face-Arm-Speech-Time) and the ROSIER (Recognition of Stroke in the Emergency Room) tools in picking true strokes. Methods: A prospective observational cohort study over a 2- year period; A descriptive analysis of various etiologies presenting as acute stroke was done. The presenting symptoms, signs and the diagnostic value of the FAST, BEFAST, and the ROSIER Scores in both the stroke mimics and true strokes were noted and the sensitivity and specificity for picking up the stroke mimics were calculated. Student’s t test, univariate analysis and multivariate logistic regression analysis were done. Diagnosis of stroke was confirmed by MRI. Results: After initial screening by Neurologists, stroke mimics constituted 328/1635 (20%) of referrals for acute stroke. Focal and generalized seizures with transient weakness and peripheral vertigo were the most common acute stroke mimics; followed by metabolic causes and psychiatric disorders. Females were more in the stroke mimic group (p = 0.02). Ischemic heart disease and atherosclerotic risk factors (except diabetes mellitus) were significantly higher among true strokes. 4 (1.2%) of the stroke mimics were treated with IV thrombolysis. Diagnostic accuracy for different stroke differentiating tools were: FAST (Sensitivity 85,9% specificity 52.8% Odds 6.8), BEFAST (Sensitivity 97.0% specificity 31.4% Odds 14.9) And ROSIER Scale (Sensitivity 85.7% specificity 59.4% Odds 8.7%). In Conclusion, Stroke mimics can constitute up to 20% of cases evaluated as strokes. None of the triaging tools appear to have enough accuracy. A proper history and clinical examination should be given priority over fixed protocols whenever acute stroke mimic are suspected, especially before administering acute costly interventions. Auditing stroke mimics is important to improve acute stroke pathways.

The validity of recognition of stroke in the emergency room (ROSIER) scale in the diagnosis of Iranian patients with acute ischemic stroke in the emergency department.

OBJECTIVES:In this study, we aimed to investigate the accuracy of recognition of stroke in the Emergency Room (ROSIER) Scale in the diagnosis of patients with acute ischemic stroke (AIS) transferred to the emergency department (ED).METHODS:The present study was a multicenter study. Records from patients suspected of stroke, who referred to the ED were reviewed. Demographic, clinical, and diagnostic data were extracted and then entered in checklists. ROSIER Scale was used to evaluate the possible diagnosis in this study. The definitive diagnosis of a stroke was made based on neurologist's assessment and clinical and neuroimaging findings, mainly brain magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was conducted for assessing the accuracy of ROSIER in discrimination of stroke.RESULTS:The data of 356 suspected stroke patients were analyzed. Of all, 186 patients (52.2%) were male, and the mean age was 65.2 (standard deviation = 14.0) years ranging from 26 to 95 years. One hundred and fifty-one patients (42.4%) had AIS based on the final diagnosis. The area under the ROC curve was 0.85. The best cutoff point for ROSIER scale was ≥1 with a sensitivity of 85.4% (95% confidence interval [CI]: 78.8, 90.6%) and specificity of 65.8% (95% CI: 58.9, 72.3%).CONCLUSION:Based on the findings, although the best cutoff point was the same as the original (derivation) study, its sensitivity (85.4% vs. 92%) and specificity (65.8% vs. 86%) were considerably lower.

Diagnostic accuracy of recognition of stroke in the emergency room scale: a Meta-analysis

To systematically evaluate the diagnostic accuracy and clinical applicability of recognition of stroke in the emergency room (ROSIER) scale by systematic review and Meta-analysis. The Chinese and English literatures concerning the diagnostic accuracy of ROSIER published from January 1st 2005 to December 31st 2018 by PubMed, Embase, Wanfang, VIP and CNKI databases were searched comprehensively and systematically. The sensitivity, specificity, and diagnostic odds ratio (DOR) of ROSIER in total population and subgroup analysis were pooled by using bivariate mixed effects model. Sensitivity analysis was used to evaluate the stability of the results. Deek funnel plot was utilized to evaluate publication bias. The clinical applicability of ROSIER was evaluated by Fagan Nomogram. A total of 28 studies incorporating 7 579 subjects were enrolled in this Meta-analysis. Meta-analysis in total population showed that the pooled sensitivity, specificity and DOR of ROSIER was 0.89 [95% confidence interval (95%CI) = 0.86-0.91, P = 0.00], 0.74 (95%CI = 0.67-0.80, P = 0.00) and 22.09 (95%CI = 14.86-32.82, P = 0.00), respectively. Subgroup analysis of pooled sensitivity of ROSIER showed that Asian patients was significantly higher than European patients [0.89 (95%CI = 0.86-0.92) vs. 0.74 (95%CI = 0.66-0.82), P < 0.01], prospective study was significantly higher than retrospective study [0.89 (95%CI = 0.87-0.92) vs. 0.74 (95%CI = 0.61-0.88), P < 0.05], pre-hospital emergency was significantly higher than emergency department [0.87 (95%CI = 0.80-0.94) vs. 0.85 (95%CI = 0.81-0.90), P < 0.01], study with sample size ≤ 200 was significantly higher than study with sample size > 200 [0.88 (95%CI = 0.83-0.93) vs. 0.82 (95%CI = 0.76-0.88), P < 0.05], but there was no significant difference between different evaluators or different male to female ratio subgroups. Subgroup analysis of pooled specificity of ROSIER showed that European patients was significantly higher than Asian patients [0.81 (95%CI = 0.73-0.89) vs. 0.79 (95%CI = 0.73-0.85), P < 0.05], retrospective study was significantly higher than prospective study [0.88 (95%CI = 0.78-0.97) vs. 0.79 (95%CI = 0.73-0.84), P < 0.05], pre-hospital emergency was significantly higher than emergency department [0.82 (95%CI = 0.73-0.91) vs. 0.79 (95%CI = 0.73-0.85), P < 0.01], emergency physicians was significantly higher than other medical workers [0.80 (95%CI = 0.74-0.86) vs. 0.79 (95%CI = 0.69-0.90), P < 0.05], study with sample size ≤ 200 was significantly higher than study with sample size > 200 [0.82 (95%CI = 0.76-0.89) vs. 0.78 (95%CI = 0.71-0.85), P < 0.05], but there was no significant difference between different male or female ratio subgroups. Sensitivity analysis showed that there was no significant change in pooled DOR before and after excluding each study, indicating that the results were stable. Funnel plot showed that there was a significant publication bias in the total population (P = 0.04), but there was no publication bias in the European population (P = 0.57) or the Asian population (P = 0.08). According to the results of the Fagan Nomogram, with the pretest probability of 50%, when ROSIER was positive, the probability of being diagnosed with stroke increased to 77%, and when ROSIER was negative, the probability of being diagnosed with non-stroke decreased to 13%. It was suggested that ROSIER had good applicability and high clinical diagnostic value. ROSIER has high diagnostic sensitivity and specificity, and has high clinical diagnostic value. It is a valid stroke identification tool which can be widely used in Asian population, pre-hospital emergency and be utilized by trained medical worker.

Performance of bedside stroke recognition tools in discriminating childhood stroke from mimics.

To assess the utility of the Cincinnati Prehospital Stroke Scale (CPSS) and Recognition of Stroke in the Emergency Room (ROSIER) tools in children presenting to the emergency department (ED) with brain attack symptoms. The ROSIER and CPSS tools were retrospectively applied to 101 children with stroke, presenting from 2003 to 2010, and prospectively to 279 children with mimics, presenting from 2009 to 2010. Positive CPSS was defined as ≥1 positive sign (face/asymmetrical arm weakness, speech disturbance). Positive ROSIER was defined as a score of ≥1. Accuracy and interrater agreement between the tools and patients' true status were assessed for combined stroke types and arterial stroke (AIS) and hemorrhagic stroke (HS) subtypes vs mimics. Stroke subtypes included AIS (55), HS (34), TIA (10), and sinovenous thrombosis (2). Mimic diagnoses included migraine (84), first seizure (45), Bell palsy (29), and conversion disorders (18). Both tools had poor reliability and accuracy for combined strokes vs mimics (CPSS κ 0.36, receiver operator characteristic curve [ROC] 0.66; ROSIER κ 0.32, ROC 0.60) and for AIS vs mimics (CPSS κ 0.37, ROC 0.79; ROSIER κ 0.30, ROC 0.77). Both tools performed inadequately for HS vs mimics (CPSS κ -0.03, ROC 0.51; ROSIER κ -0.02, ROC 0.52). Adult stroke recognition tools perform poorly in children and require modification to be useful for pediatric stroke identification. This study provides Class II evidence that, for children presenting to the ED with brain attack symptoms, the CPSS and ROSIER tools do not accurately distinguish strokes from mimics.

STROKE MIMICS IN THE PRE-HOSPITAL SETTING

Accurate identification of stroke patients is essential to ensure appropriate and timely treatment. Stroke mimics—patients initially suspected to have suffered a stroke who are subsequently diagnosed with a condition other...

Abstract T MP61: Diagnostic Accuracy of Adult Bedside Stroke Recognition Tools in Childhood Stroke

Objective: Bedside stroke recognition tools improve diagnostic accuracy in adult stroke. Our aim was to assess the diagnostic utility of the CPSS and ROSIER tools in children presenting to the emergency department (ED) with brain attack symptoms. Methods: The Cincinnati Prehospital Stroke Scale (CPSS ) and the Recognition of Stroke in the Emergency Room (ROSIER) tool were retrospectively applied to 101 consecutive children with stroke, presenting from 2003-2010, and 279 children with mimics, presenting to the ED from 2009-2010. A positive CPSS was defined as ≥1 positive sign (face or arm weakness, speech disturbance). A positive ROSIER was defined as a score of ≥1. Diagnostic accuracy of the tools in determining the patients’ true status were estimated for arterial (AIS), hemorrhagic (HS) and combined stroke subtypes versus mimics. Results: The CPSS and ROSIER tools correctly discriminated combined stroke subtypes from mimics (diagnostic odds ratio (DOR) 5.6 and 4.7 respectively) and AIS from mimics (DOR 15.1 and 13.4 respectively) but not HS from mimics (DOR 1.2 for both tools). CPSS and ROSIER accuracy were fair for AIS versus mimics (ROC 0.79 and 0.77 respectively), fair to poor for combined stroke subtypes versus mimics (ROC 0.70 and 0.68 respectively) and failed for HS versus mimics (ROC 0.51 and 0.52 respectively). Reasons for limited accuracy include different spectrum of mimics, lower overall prevalence, higher proportion of HS subtype and common seizure occurrence in childhood stroke. Conclusions: Adult stroke recognition tools correctly discriminate combined stroke types and AIS subtype from mimics but their limited accuracy suggest further modifications are required to improve diagnostic utility for identification of childhood stroke in the ED.

Evaluation of the Recognition of Stroke in the Emergency Room (ROSIER) Scale in Chinese Patients in Hong Kong

Background and PurposeThe objective of this study was to determine the performance of the Recognition Of Stroke In the Emergency Room (ROSIER) scale in risk-stratifying Chinese patients with suspected stroke in Hong Kong.MethodsThis was a prospective cohort study in an urban academic emergency department (ED) over a 7-month period. Patients over 18 years of age with suspected stroke were recruited between June 2011 and December 2011. ROSIER scale assessment was performed in the ED triage area. Logistic regression analysis was used to estimate the impacts of diagnostic variables, including ROSIER scale, past history and ED characteristics.Findings715 suspected stroke patients were recruited for assessment, of whom 371 (52%) had acute cerebrovascular disease (302 ischaemic strokes, 24 transient ischaemic attacks (TIA), 45 intracerebral haemorrhages), and 344 (48%) had other illnesses i.e. stroke mimics. Common stroke mimics were spinal neuropathy, dementia, labyrinthitis and sepsis. The suggested cut-off score of>0 for the ROSIER scale for stroke diagnosis gave a sensitivity of 87% (95%CI 83–90), a specificity of 41% (95%CI 36–47), a positive predictive value of 62% (95%CI 57–66), and a negative predictive value of 75% (95%CI 68–81), and the AUC was 0.723. The overall accuracy at cut off>0 was 65% i.e. (323+141)/715.InterpretationThe ROSIER scale was not as effective at differentiating acute stroke from stroke mimics in Chinese patients in Hong Kong as it was in the original studies, primarily due to a much lower specificity. If the ROSIER scale is to be clinically useful in Chinese suspected stroke patients, it requires further refinement.

Prehospital stroke scales in urban environments: a systematic review.

To identify and compare the operating characteristics of existing prehospital stroke scales to predict true strokes in the hospital. We searched MEDLINE, EMBASE, and CINAHL databases for articles that evaluated the performance of prehospital stroke scales. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We abstracted the operating characteristics of published prehospital stroke scales and compared them statistically and graphically. We retrieved 254 articles from MEDLINE, 66 articles from EMBASE, and 32 articles from CINAHL Plus database. Of these, 8 studies met all our inclusion criteria, and they studied Cincinnati Pre-Hospital Stroke Scale (CPSS), Los Angeles Pre-Hospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS), Ontario Prehospital Stroke Screening Tool (OPSS), Recognition of Stroke in the Emergency Room (ROSIER), and Face Arm Speech Test (FAST). Although the point estimates for LAPSS accuracy were better than CPSS, they had overlapping confidence intervals on the symmetric summary receiver operating characteristic curve. OPSS performed similar to LAPSS whereas MASS, Med PACS, ROSIER, and FAST had less favorable overall operating characteristics. Prehospital stroke scales varied in their accuracy and missed up to 30% of acute strokes in the field. Inconsistencies in performance may be due to sample size disparity, variability in stroke scale training, and divergent provider educational standards. Although LAPSS performed more consistently, visual comparison of graphical analysis revealed that LAPSS and CPSS had similar diagnostic capabilities.

Letter by Price et al Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We welcome the comments made by Price et al1 and Brandler and Sharma2 and are grateful for the opportunity to respond to their observations. In our study,3 ambulance clinicians had to suspect a stroke before they used the Recognition of Stroke in the Emergency Room (ROSIER). Our clinicians use a range of factors to suspect that a patient is having a stroke including clinical assessments and observations taken on scene, medical history, history of the current event, medications, and the call determinant allocated during triage of the emergency call for help. Our clinicians practice in line with the Joint Royal Colleges Ambulance Liaison Committee’s UK Ambulance Service Clinical Practice Guidelines.4 The average age of patients in our study was indeed relatively young at 65 years; however, this is representative of suspected stroke patients in the area of London where our study was conducted. Our stroke audit figures from last year (2012/13) show that the average age of suspected stroke patients conveyed by our clinicians to the hospital involved in our study was 67 years, which is consistent with the age reported in our article. Information from the 2011 National Census5 confirms that the …

Letter by Brandler and Sharma Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We read with great interest the article by Fothergill et al1 that address the concern about prehospital identification of stroke. American Heart Association/American Stroke Association guidelines on the early management of adults with ischemic stroke highlight the role of emergency medical services (EMS) and find EMS use to be strongly associated with decreased time to initial physician examination, initial computed tomography imaging, and neurological evaluation.2 Therefore, the stroke chain of survival relies heavily on the accuracy with which EMS providers can identify strokes. The study by Fothergill et al is the first one to validate the use of Recognition of Stroke in the Emergency Room (ROSIER) scale for EMS providers. They compared ROSIER with Face Arm Speech Test (FAST), an another widely used prehospital stroke scale. Even though ROSIER has …

Response to Letter Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We welcome the comments made by Price et al1 and Brandler and Sharma2 and are grateful for the opportunity to respond to their observations. In our study,3 ambulance clinicians had to suspect a stroke before they used the Recognition of Stroke in the Emergency Room (ROSIER). Our clinicians use a range of factors to suspect that a patient is having a stroke including clinical assessments and observations taken on scene, medical history, history of the current event, medications, and the call determinant allocated during triage of the emergency call for help. Our clinicians practice in line with the Joint Royal Colleges Ambulance Liaison Committee’s UK Ambulance Service Clinical Practice Guidelines.4 The average age of patients in our study was indeed relatively young at 65 years; however, this is representative of suspected stroke patients in the area of London where our study was conducted. Our stroke audit figures from last year (2012/13) show that the average age of suspected stroke patients conveyed by our clinicians to the hospital involved in our study was 67 years, which is consistent with the age reported in our article. Information from the 2011 National Census5 confirms that the …

Does Use of the Recognition Of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?

U.K ambulance services assess patients with suspected stroke using the Face Arm Speech Test (FAST). The Recognition Of Stroke In the Emergency Room (ROSIER) tool has been shown superior to the FAST in identifying strokes in emergency departments but has not previously been tested in the ambulance setting. We investigated whether ROSIER use by ambulance clinicians can improve stroke recognition. Ambulance clinicians used the ROSIER in place of the FAST to assess patients with suspected stroke. As the ROSIER includes all FAST elements, we calculated a FAST score from the ROSIER to enable comparisons between the two tools. Ambulance clinicians' provisional stroke diagnoses using the ROSIER and calculated FAST were compared with stroke consultants' diagnosis. We used stepwise logistic regression to compare the contribution of individual ROSIER and FAST items and patient demographics to the prediction of consultants' diagnoses. Sixty-four percent of strokes and 78% of nonstrokes identified by ambulance clinicians using the ROSIER were subsequently confirmed by a stroke consultant. There was no difference in the proportion of strokes correctly detected by the ROSIER or FAST with both displaying excellent levels of sensitivity. The ROSIER detected marginally more nonstroke cases than the FAST, but both demonstrated poor specificity. Facial weakness, arm weakness, seizure activity, age, and sex predicted consultants' diagnosis of stroke. The ROSIER was not better than the FAST for prehospital recognition of stroke. A revised version of the FAST incorporating assessment of seizure activity may improve stroke identification and decision making by ambulance clinicians.

Opinions about the use of the recognition of stroke in the emergency room scale

Sir, We have recently published an article about the use of the recognition of stroke in the emergency room (ROSIER) scale in pre-hospital assessment of stroke in Annals of Indian Academy of Neurology.[1] And it was cited in the Canadian Best Practice Recommendations for Stroke Care 2013 (Fourth Edition) at last week.[2] Please allow us to share a few opinions about the use of the ROSIER scale. In the new Canadian stroke care recommendations guidelines, the ROSIER scale was introduced in detail. And the related published studies about the use of the ROSIER scale were reported. Especially, the new Canadian stroke care guidelines mentioned our study like this: The ROSIER scale was not developed for pre-hospital assessment, but rather was designed for use in the identification for probable stroke by emergency room (ER) physicians. It has been evaluated for use in a pre-hospital setting only once in a limited setting in China where sensitivity was reported to be 90% and specificity 83%.[2] Who can use the ROSIER scale accurately? In previous study, we validated the ROSIER scale could be used by ER physicians in the pre-hospital setting. And in another study, we also recommended ER physicians to use the ROSIER scale both in the pre-hospital setting and in the ER.[3] However, the small size and single center setting limited the study. In my opinion, the ER physicians must get a series of stroke recognition and treatment training and master the initial stroke assessment and stabilization in the ER. Until now, there is not a recognized “paramedics” profession in China. Hence, we are not sure whether the ROSIER scale could be used by paramedics. As we know, Byrne B and O’Halloran P reported that registered nurses working on a stroke unit using the ROSIER assessment tool are able to diagnose stroke with a degree of accuracy comparable to doctors using clinical neurological assessment. And they achieved a diagnostic sensitivity for stroke of 98% (95% confidence interval 88-99), positive predictive value 83% (95% confidence interval 73-90).[4] However, some nursing experts didn't support them.[5] Whether the ROSIER scale could be used by ER physicians in the pre-hospital setting or by registered nurses in the ER is still a problem. Because we lack of convincing evidence and need large size and multi-center validation. Whoever using the ROSIER scale, the common target is to reduce the delay of early assessment and ineffective triage on suspected stroke patients and increase the chance of administration of thrombolytic therapy. The search for an ideal stroke recognition tool must continue. There is still a long way to go.

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.

Can the FAST and ROSIER adult stroke recognition tools be applied to confirmed childhood arterial ischemic stroke?

BackgroundStroke recognition tools have been shown to improve diagnostic accuracy in adults. Development of a similar tool in children is needed to reduce lag time to diagnosis. A critical first step is to determine whether adult stoke scales can be applied in childhood stroke.Our objective was to assess the applicability of adult stroke scales in childhood arterial ischemic stroke (AIS)MethodsChildren aged 1 month to < 18 years with radiologically confirmed acute AIS who presented to a tertiary emergency department (ED) (2003 to 2008) were identified retrospectively. Signs, symptoms, risk factors and initial management were extracted. Two adult stroke recognition tools; ROSIER (Recognition of Stroke in the Emergency Room) and FAST (Face Arm Speech Test) scales were applied retrospectively to all patients to determine test sensitivity.Results47 children with AIS were identified. 34 had anterior, 12 had posterior and 1 child had anterior and posterior circulation infarcts. Median age was 9 years and 51% were male. Median time from symptom onset to ED presentation was 21 hours but one third of children presented within 6 hours. The most common presenting stroke symptoms were arm (63%), face (62%), leg weakness (57%), speech disturbance (46%) and headache (46%). The most common signs were arm (61%), face (70%) or leg weakness (57%) and dysarthria (34%). 36 (78%) of children had at least one positive variable on FAST and 38 (81%) had a positive score of ≥1 on the ROSIER scale. Positive scores were less likely in children with posterior circulation stroke.ConclusionThe presenting features of pediatric stroke appear similar to adult strokes. Two adult stroke recognition tools have fair to good sensitivity in radiologically confirmed childhood AIS but require further development and modification. Specificity of the tools also needs to be determined in a prospective cohort of children with stroke and non-stroke brain attacks.

Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study

ObjectiveTo compare the sensitivity and specificity of bedside diagnostic stroke scales in patients with suspected stroke.DesignA cross-sectional observational study of patients with suspected acute stroke in an emergency department in...