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AHA/ASA ReportAccuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Persons with Suspected StrokeA Systematic Review for the 2018 AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic StrokeEric E. Smith MD, MPH, FAHA Chair1; David M. Kent MD, MS, Vice Chair2, Ketan R. Bulsara MD3; Lester Y. Leung MD, MS2; Judith H. Lichtman PhD, MPH, FAHA4; Mathew J. Reeves PhD, DVM5; Amytis Towfighi MD6; William N. Whiteley BM, BCh, MSc, PhD7; Darin Zahuranec MD, FAHA81University of Calgary, Alberta, Canada; 2Tufts Medical Center/Tufts University School of Medicine; 3University of Connecticut; 4Yale School of Public Heath; 5Michigan State University; 6University of Southern California; 7University of Edinburgh; 8University of MichiganDISCLAIMER: This Word document does not reflect changes to the scientific content made during the proofing process. The final version of the publication is available online, free of cost, at (DOI 10.1161/STR.0000000000000160).Corresponding author:Eric E. Smith, MD, MPH, FAHARoom 2941, Health Sciences Building3330 Hospital Drive NWCalgary, Alberta, CanadaT3C 2G7ABSTRACTIntroduction: Endovascular thrombectomy (EVT) is a highly efficacious treatment for large vessel occlusion (LVO). LVO prediction instruments, based on stroke signs and symptoms, have been proposed to identify stroke patients with LVO for rapid transport to EVT-capable hospitals. This Evidence Review Committee was commissioned by the AHA/ASA to systematically review evidence for the accuracy of LVO prediction instruments.Methods: Medline, Embase, and Cochrane databases were searched on October 27, 2016. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy (QUADAS)-2 tool.Results: Thirty-six relevant studies were identified. Most studies (21/36) recruited patients with ischemic stroke, with few studies in the pre-hospital setting (4/36) and in populations that included hemorrhagic stroke or stroke mimics (12/36). The most frequently studied prediction instrument was the NIH Stroke Scale. Most studies had either some risk of bias or unclear risk of bias. Reported discrimination of LVO mostly ranged from 0.70-0.85, as measured by the c-statistic. In meta-analysis, sensitivity was as high as 87% and specificity was as high as 90%, but no threshold on any instruments predicted LVO with both high sensitivity and specificity. With a positive LVO prediction test, the probability of LVO could be 50%-60% (depending on the LVO prevalence in the population), but the probability of LVO with a negative test could still be 10% or more.Conclusions: No scale predicted LVO with both high sensitivity and specificity. Systems that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. More prospective studies are needed to assess the accuracy of LVO prediction instruments in the pre-hospital setting in all patients with suspected stroke, including patients with hemorrhagic stroke and stroke mimics.Keywords: ischemic stroke, endovascular thrombectomyBACKGROUNDEndovascular thrombectomy (EVT) for large vessel occlusion (LVO) is a highly effective therapy for acute ischemic stroke,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb3lhbDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 1 but only a minority of hospitals treating stroke patients are EVT-capable. As the effect of EVT diminishes over time, ADDIN EN.CITE <EndNote><Cite><Author>Saver</Author><Year>2017</Year><RecNum>28602</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>28602</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1496663168">28602</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Saver, J. L.</author><author>Goyal, M.</author><author>Hill, M. D.</author><author>Hermes Collaborators</author></authors></contributors><auth-address>David Geffen School of Medicine, University of California-Los Angeles2Associate Editor, JAMA.
Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.</auth-address><titles><title>Time to Endovascular Thrombectomy for Acute Stroke-Reply</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title><abbr-1>JAMA : the journal of the American Medical Association</abbr-1></periodical><pages>1175-1176</pages><volume>317</volume><number>11</number><keywords><keyword>Brain Ischemia</keyword><keyword>Endovascular Procedures</keyword><keyword>Humans</keyword><keyword>*Stroke</keyword><keyword>*Thrombectomy</keyword></keywords><dates><year>2017</year><pub-dates><date>Mar 21</date></pub-dates></dates><isbn>1538-3598 (Electronic)
0098-7484 (Linking)</isbn><accession-num>28324086</accession-num><urls><related-urls><url> stroke systems of care need to rapidly identify patients with LVO and transport them to EVT-capable hospitals as quickly as possible. LVO can be reliably diagnosed by CT-angiography (CTA), MR-angiography (MRA), or conventional angiography, but this requires evaluation at a hospital with angiographic imaging capabilities. If a prediction instrument could reliably identify LVO in the field, patients with LVO could be transported directly to EVT-capable hospitals, bypassing PSCs.Investigators have proposed several stroke diagnostic instruments and severity scales to predict the presence or absence of LVO. Accurate prediction of LVO prior to angiography could help with triage and referral of acute stroke patients in at least 2 scenarios: 1) where emergency medical services (EMS) assess patients with suspected acute stroke to identify patients with LVO for triage to the nearest EVT-capable hospital, bypassing PSCs that do not provide EVT; and 2) where emergency room physicians diagnose patients with acute ischemic stroke in hospitals that can perform CT but not angiography to identify patients with LVO for transfer to the nearest EVT-capable hospital.It is not clear which LVO prediction instrument for suspected acute stroke or confirmed acute ischemic stroke is most accurate. Therefore, the Writing Committee for the 2017 AHA Guidelines for the Early Management of Acute Ischemic Stroke commissioned an independent Evidence Review Committee (ERC) to review evidence for the accuracy of LVO prediction instruments. The ERC addressed this question: what is the diagnostic accuracy of LVO prediction instruments for identifying LVO in persons with suspected stroke or confirmed to have acute ischemic stroke in the pre-hospital or hospital emergency room settings?METHODSThe ERC systematically reviewed cohort studies that described the diagnostic accuracy of LVO prediction instruments. Analyses were stratified by the population: suspected stroke (i.e., patients with stroke symptoms, including patients ultimately diagnosed with hemorrhagic stroke or stroke mimics), and ischemic stroke based on diagnosis in the ED after initial brain imaging. Review methods adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards ADDIN EN.CITE <EndNote><Cite><Author>Moher</Author><Year>2009</Year><RecNum>18758</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>18758</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1464368766">18758</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moher, D.</author><author>Liberati, A.</author><author>Tetzlaff, J.</author><author>Altman, D. G.</author><author>Prisma Group</author></authors></contributors><auth-address>Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada. dmoher@ohri.ca</auth-address><titles><title>Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>264-9, W64</pages><volume>151</volume><number>4</number><keywords><keyword>Evidence-Based Practice/standards</keyword><keyword>Humans</keyword><keyword>*Meta-Analysis as Topic</keyword><keyword>Periodicals as Topic/standards</keyword><keyword>Publication Bias</keyword><keyword>Publishing/*standards</keyword><keyword>Quality Control</keyword><keyword>*Review Literature as Topic</keyword><keyword>*Terminology as Topic</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug 18</date></pub-dates></dates><isbn>1539-3704 (Electronic)
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ADDIN EN.CITE.DATA 4 Search strategyMedline (via PubMed/OVID), Embase (via OVID), and the Cochrane Central Database of Controlled Trials (via CENTRAL) were searched on October 27, 2016 using free text, medical subject headings, and synonyms for stroke screening and severity scales and large vessel occlusion. The fully specified search strategy is provided in Table I of the online only data supplement. References of individual studies were also back-checked for relevant studies. The search strategy was developed by the ERC in consultation with Doctor Evidence (Santa Monica, CA) and carried out by Doctor Evidence medical librarians. For publications that had appeared as meeting abstracts only, we subsequently performed a targeted search on April 1, 2017 (based on first and last author) to determine if they had later been published as peer-reviewed research articles.Eligibility criteria and review for eligibilityScreening was performed against the predefined selection criteria (Table 1) developed by the ERC. Conference abstracts and peer-reviewed articles were considered eligible to capture recent publication activity in this rapidly expanding area of research.Doctor Evidence imported the search results into the DOC Library (DOC Library, Santa Monica, CA, Doctor Evidence, LLC), a fully indexed central repository, using the Doctor Evidence Library Management System (Doctor Evidence: Library Management System. Santa Monica, CA: Doctor Evidence, LLC). Library Management System (LMS) is a web-based software platform featuring keyword emphasis (coloring or bolding of keywords), search, and ranking functionalities as well as the ability to assign and manage reasons for rejecting references at all stages of screening.Title and abstract eligibility was performed by a Doctor Evidence medical librarian, with subsequent re-assessment by a second independent reviewer. Additional quality control was performed by an independent Doctor Evidence methodologist who validated all included abstracts and a random sample of excluded abstracts.Full text eligibility was performed by dual independent review by members of the ERC. Disagreements were resolved by the ERC Chair.Quality AssessmentTwo ERC members independently assessed the risk of bias and applicability of each study using the Quality Assessment of Diagnostic Accuracy (QUADAS)-2 tool ADDIN EN.CITE <EndNote><Cite><Author>Whiting</Author><Year>2011</Year><RecNum>26218</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>26218</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1484931589">26218</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Whiting, P. F.</author><author>Rutjes, A. W.</author><author>Westwood, M. E.</author><author>Mallett, S.</author><author>Deeks, J. J.</author><author>Reitsma, J. B.</author><author>Leeflang, M. M.</author><author>Sterne, J. A.</author><author>Bossuyt, P. M.</author><author>Quadas- Group</author></authors></contributors><auth-address>University of Bristol, United Kingdom. penny.whiting@bristol.ac.uk</auth-address><titles><title>QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>529-36</pages><volume>155</volume><number>8</number><keywords><keyword>Bias (Epidemiology)</keyword><keyword>*Diagnosis</keyword><keyword>Evidence-Based Medicine</keyword><keyword>Humans</keyword><keyword>Patient Selection</keyword><keyword>Quality Control</keyword><keyword>Reference Standards</keyword><keyword>*Review Literature as Topic</keyword><keyword>*Surveys and Questionnaires</keyword><keyword>Time Factors</keyword></keywords><dates><year>2011</year><pub-dates><date>Oct 18</date></pub-dates></dates><isbn>1539-3704 (Electronic)
0003-4819 (Linking)</isbn><accession-num>22007046</accession-num><urls><related-urls><url> for studies of diagnostic accuracy, complemented by an additional assessment using the CHARMS checklist ADDIN EN.CITE <EndNote><Cite><Author>Moons</Author><Year>2014</Year><RecNum>23821</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>23821</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1476729672">23821</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moons, K. G.</author><author>de Groot, J. A.</author><author>Bouwmeester, W.</author><author>Vergouwe, Y.</author><author>Mallett, S.</author><author>Altman, D. G.</author><author>Reitsma, J. B.</author><author>Collins, G. S.</author></authors></contributors><auth-address>Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands.
Department of Primary Care Health Sciences, New Radcliffe House, University of Oxford, Oxford, United Kingdom.
Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, United Kingdom.</auth-address><titles><title>Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist</title><secondary-title>PLoS Med</secondary-title></titles><periodical><full-title>PLoS Med</full-title></periodical><pages>e1001744</pages><volume>11</volume><number>10</number><keywords><keyword>Decision Support Techniques</keyword><keyword>Humans</keyword><keyword>*Models, Theoretical</keyword></keywords><dates><year>2014</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1549-1676 (Electronic)
1549-1277 (Linking)</isbn><accession-num>25314315</accession-num><urls><related-urls><url> if the study used prediction modeling techniques. Discrepancies were resolved by a third reviewer (the ERC Chair).Data AbstractionData points and meta-data were extracted by Doctor Evidence analysts from the articles and entered manually into the DOC Data 2.0 software platform (Doctor Evidence: DOC Data, Version 2.0, Santa Monica, CA: Doctor Evidence, LLC) using an electronic extraction form and guided by a data configuration protocol with automated quality control features to prevent incorrect data-type entry. Each abstracted data point was verified manually against the source article by an independent reviewer (i.e., single extraction with sequential quality control). Ontology management was undertaken to ensure consistency in the naming of characteristics and outcomes across all studies in a dataset.Abstracted study characteristics included study design, publication type, publication year, sample size, setting, and population. The study setting was defined based on the location where the LVO prediction instrument was applied, categorized as “emergency room”, “pre-hospital/field” (if applied prior to arrival at the hospital where diagnostic angiography was performed), “mixed” (if applied in either or both settings), and “unclear/not specified”. The study population was categorized as “suspected stroke” if it included patients with hemorrhagic stroke and stroke mimics in addition to ischemic stroke, and “ischemic stroke” if it included only patients diagnosed with ischemic stroke, with non-contrast CT to rule out hemorrhagic stroke.Where sufficient data were available the number of true positives, false positives, true negatives, and false negatives were abstracted or calculated from the study data. Authors were contacted as needed to clarify study details required to determine study eligibility, but were not requested to provide additional data. Meta-analysisWhere results from more than 1 study were available, forest plots were produced stratified by LVO prediction instrument and population (suspected stroke or ischemic stroke). There were too few studies in the pre-hospital setting for meta-analysis. Because prediction instruments are based on an ordinal score, the choice of the specific threshold used to define positive or negative results is under the control of the study authors. For studies that presented data based on a single threshold, bivariate diagnostic random effects meta-analysis was used to produce pooled estimates of sensitivity and specificity at the single threshold. ADDIN EN.CITE <EndNote><Cite><Author>Doebler</Author><Year>2015</Year><RecNum>28096</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>28096</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1490108292">28096</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Doebler, P.</author><author>Holling, H</author></authors></contributors><titles><title>Meta-analysis of diagnostic accuracy with mada</title></titles><volume>2017</volume><number>March 21</number><dates><year>2015</year></dates><urls><related-urls><url> sufficient data were available for a given LVO prediction instrument, summary ROC curves were calculated using the R-package developed by Steinhauser et al. ADDIN EN.CITE <EndNote><Cite><Author>Steinhauser</Author><Year>2016</Year><RecNum>28098</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>28098</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1490643425">28098</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Steinhauser, S.</author><author>Schumacher, M.</author><author>Rucker, G.</author></authors></contributors><auth-address>Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Stefan-Meier-Strasse 2679104, Germany.
Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Kerpener Str. 6250937, Germany.
Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Stefan-Meier-Strasse 2679104, Germany. ruecker@imbi.uni-freiburg.de.</auth-address><titles><title>Modelling multiple thresholds in meta-analysis of diagnostic test accuracy studies</title><secondary-title>BMC Med Res Methodol</secondary-title></titles><periodical><full-title>BMC Med Res Methodol</full-title><abbr-1>BMC medical research methodology</abbr-1></periodical><pages>97</pages><volume>16</volume><number>1</number><keywords><keyword>Biomarker</keyword><keyword>Diagnostic accuracy study</keyword><keyword>Meta-analysis</keyword><keyword>ROC curve</keyword><keyword>Threshold</keyword></keywords><dates><year>2016</year><pub-dates><date>Aug 12</date></pub-dates></dates><isbn>1471-2288 (Electronic)
1471-2288 (Linking)</isbn><accession-num>27520527</accession-num><urls><related-urls><url> We compared the restricted maximum likelihood (REML) criterion between a series of models with different specifications (i.e., common random vs. different random intercepts, common vs. different random slopes) and picked the 1 with the smallest REML criterion, indicating the best model fit, employing the same strategy as presented by Steinhauser. For the summary ROC curves, sensitivities and specificities were reported at thresholds based on clinical appropriateness and the availability of data. The post-test probability of LVO in the presence of a positive and negative result on LVO screening was graphed across a range of LVO prevalences using pooled sensitivity and specificity values from the meta-analysis. We found few published data on the population-representative prevalence of LVO ADDIN EN.CITE <EndNote><Cite><Author>Rai</Author><Year>2016</Year><RecNum>29529</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>29529</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1497472513">29529</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rai, A. T.</author><author>Seldon, A. E.</author><author>Boo, S.</author><author>Link, P. S.</author><author>Domico, J. R.</author><author>Tarabishy, A. R.</author><author>Lucke-Wold, N.</author><author>Carpenter, J. S.</author></authors></contributors><auth-address>Department of Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
Stryker Neurovascular, Fremont, California, USA.
Department of Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.</auth-address><titles><title>A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA</title><secondary-title>J Neurointerv Surg</secondary-title></titles><periodical><full-title>J Neurointerv Surg</full-title></periodical><keywords><keyword>Economics</keyword><keyword>Standards</keyword><keyword>Statistics</keyword><keyword>Stroke</keyword><keyword>Thrombectomy</keyword></keywords><dates><year>2016</year><pub-dates><date>Jul 15</date></pub-dates></dates><isbn>1759-8486 (Electronic)
1759-8478 (Linking)</isbn><accession-num>27422968</accession-num><urls><related-urls><url> and substantial variation in the prevalence of LVO in the studies that we reviewed (Table II in the online data supplement). Furthermore, the prevalence of LVO in suspected stroke patients is influenced by the size of the denominator, which in turn is influenced by local dispatch and stroke activation protocols. Therefore, the positive predictive value (PPV) and negative predictive value (NPV) were graphed over a range of LVO prevalences that by consensus reflected realistic ranges.RESULTSThe review returned 2,719 articles, of which 135 received full-text review to identify 36 eligible studies (Figure 1). In total, the 36 studies presented information on 34 different LVO prediction instruments. Most prediction instruments were derived from elements of the National Institutes of Health Stroke Scale (NIHSS). The evidence table with accompanying references is provided in Table II of the online data supplement. A glossary of acronym definitions for the LVO prediction instruments is provided in Table III and full descriptions of commonly used scales are provided in Table IV of the online data supplement. Characteristics of the included studies are shown in Table 2. There were 25 journal articles and 11 conference abstracts. Most studies (25/36) were performed in ischemic stroke populations; only 12/36 were performed in suspected stroke populations (1 study included both). The LVO prediction instrument was employed in a pre-hospital setting in 4/36 studies, in a hospital emergency room in 28/36, and in a mixed setting including pre-hospital and hospital-based assessments in 4/36. In most studies the administrator of the LVO prediction instrument was either a neurologist (11/36) or not specified (17/36). Only four studies specified that the LVO instrument was applied by EMS,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJyZXJhPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48
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PgB=
ADDIN EN.CITE.DATA 11, 13 Study sample sizes are summarized in Table 2; participant numbers were skewed by 1 very large study from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Registry with 11,632 participants.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db29yYXk8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 14 Study quality is shown in Table 3. Many studies had a high risk for bias or unclear risk for bias. Common reasons included: risk for patient selection bias due to lack of consecutive enrollment or potential selection bias (e.g. where patients were deemed ineligible for EVT for unclear reasons and not included), risk for index test bias because thresholds to predict LVO were derived in the same population in which they were tested, risk for index test bias due to lack of pre-specified thresholds for LVO, risk for reference standard bias because interpretation of CTA or MRA was not blinded to stroke severity, and risk for flow and timing bias because the timing between application of the LVO prediction instrument and radiological imaging was either long or not specified (this is important because longer times may bias toward more false positive LVO predictions due to spontaneous recanalization). However, most studies were rated to be applicable to the study question. Additional explanation of the methods for determining bias are given in Table V of the online supplement.Study authors suggested preferred thresholds to identify patients with LVO for 19 different LVO prediction instruments. Thresholds were most commonly provided for the NIHSS (21 studies).cmlhPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVjTnVtPjI2MjcyPC9SZWNOdW0+PHJlY29y
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ADDIN EN.CITE.DATA 11, 14-33 Other LVO prediction instrument thresholds for which multiple studies provided thresholds were the Cincinnati Prehospital Stroke Severity Scale (CPSSS; 6 studies),PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXN0aWxsbzwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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ADDIN EN.CITE.DATA 10, 16, 17, 22, 23, 31, 33, 34, 36, 39-46 (Some studies provided preferred thresholds for more than 1 scale).Area under the ROC curve (where reported) and sensitivity and specificity for author recommended thresholds for scales tested in more than 1 study are listed in Table 4, stratified by population (ischemic stroke vs. suspected stroke). The proportion of suspected strokes that did not have ischemic stroke ranged from 5% to 69% (Table 4 and online Table II, Evidence Table). One study using an NIH Stroke Scale score threshold did not have sufficient information to determine sensitivity and specificity.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZWxkbmVyPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA 47Meta-analysis was possible for the NIHSS, CPSSS, LAMS, RACE, and 3-Item SS. Analyses were stratified by patient population, and performed separately for: a) patients with suspected stroke and b) patients with ischemic stroke. Summary ROC curves could be modeled for NIHSS (in both confirmed and suspected stroke) and for CPSSS (in ischemic stroke only) (Figure 2). Otherwise, we pooled data to calculate sensitivity and specificity for these cut-points: CPSSS ≥2, LAMS ≥4, RACE ≥5, 3-item SS ≥4 (Figure 3).Figure 4 shows the post-test probability of LVO in patients with a positive test (i.e., the positive predictive value) and a negative test for different commonly reported scales and thresholds for both suspected stroke and ischemic stroke. We display results for CPSSS ≥2, LAMS ≥4, RACE ≥5, 3-item SS ≥4, and NIHSS > 6 for suspected stroke, and for NIHSS thresholds > 6, > 8, and > 10 for ischemic stroke. The post-test probability of a LVO given a positive screen ranges from about 35-50% over the range of expected frequency of LVO in suspected stroke patients (Figure 4A), meaning that the false positive rate is expected to be in the range of 50-65%.CONCLUSIONSThis systematic review found that the most frequently validated LVO prediction instruments were the NIHSS, CPSSS, LAMS, and RACE scales. Area under the ROC curve was mostly 0.70-0.85 (Table 4), indicating moderate to good discrimination of the presence vs. absence of LVO in individual patients. No scale, however, determined the presence vs. absence of LVO with both high sensitivity and specificity. Some studies evaluated more than 1 scale in the same population, but without formal statistical comparison of the performance of any of the tested scales with each other. Therefore, we failed to find convincing evidence for the superiority of any 1 prediction instrument.These findings have important implications for the design of hospital bypass and referral policies within stroke systems of care. Choice of an LVO prediction instrument and threshold should depend on the harms of failing to identify LVO (i.e., false negatives) and the cost of transfer for EVT in patients where an LVO is absent (i.e., false positives). The false positive rates for LVO prediction are relatively high (50% to 65%; Figure 4). By comparison, they exceed the goal of 30% over-triage for EMS identification of stroke (all stroke, not just LVO) recommended by AHA/ASA policy for implementing stroke systems of care.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BY2tlcjwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 48 Choosing a more sensitive threshold will avoid missing potentially treatable patients but will lead to more transfers of patients without LVO, increasing the burden on emergency departments and stroke services at EVT-capable hospitals and depriving EVT-incapable hospitals of patients they are otherwise equipped to care for. Depending on the inter-play between the added transport time and the typical door-to-needle time at the destination hospital, bypassing PSCs could either delay or, if the PSCs have longer door-to-needle times than the EVT-capable hospitals, speed up the delivery of alteplase. On the contrary, choosing a more specific threshold will avoid unnecessary transfers of patients without LVO, but will result in more missed opportunities for treatment with EVT.The optimal LVO prediction instrument may also depend on the setting and administrator. We considered 2 main scenarios in which we foresaw LVO prediction instruments being applied. First, we considered the scenario where patients with suspected stroke would be assessed in the field by EMS to aid the decision of whether to transport the patient directly to an EVT-capable hospital. The optimal scale is less clear in this circumstance. We did not consider the NIHSS to be feasible for this purpose because it requires a greater degree of training, may be too time-consuming to perform, and has not been as well validated in the pre-hospital setting. Currently, the CPSSS, LAMS, and RACE scales have been studied the most in pre-hospital settings (but only in four studiesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJyZXJhPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48
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ADDIN EN.CITE.DATA 49 is already a performance measure for quality stroke care in the U.S., ADDIN EN.CITE <EndNote><Cite><Author>Smith</Author><Year>2014</Year><RecNum>849</RecNum><DisplayText><style face="superscript">50</style></DisplayText><record><rec-number>849</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1450577125">849</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smith, E. E.</author><author>Saver, J. L.</author><author>Alexander, D. N.</author><author>Furie, K. L.</author><author>Hopkins, L. N.</author><author>Katzan, I. L.</author><author>Mackey, J. S.</author><author>Miller, E. L.</author><author>Schwamm, L. H.</author><author>Williams, L. S.</author></authors></contributors><titles><title>Clinical performance measures for adults hospitalized with acute ischemic stroke: performance measures for healthcare professionals from the American Heart Association/American Stroke Association</title><secondary-title>Stroke</secondary-title></titles><periodical><full-title>Stroke</full-title></periodical><pages>3472-98</pages><volume>45</volume><number>11</number><edition>2014/09/27</edition><dates><year>2014</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1524-4628 (Electronic)
0039-2499 (Linking)</isbn><accession-num>25256184</accession-num><urls><related-urls><url> [pii]
10.1161/STR.0000000000000045</electronic-resource-num><language>eng</language></record></Cite></EndNote>50 and has acceptable reliability when administered by physicians or nurses. ADDIN EN.CITE <EndNote><Cite><Author>Josephson</Author><Year>2006</Year><RecNum>28600</RecNum><DisplayText><style face="superscript">51</style></DisplayText><record><rec-number>28600</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1496663075">28600</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Josephson, S. A.</author><author>Hills, N. K.</author><author>Johnston, S. C.</author></authors></contributors><auth-address>Stroke Sciences Group, Department of Neurology, University of California, San Francisco, CA 94143-0114, USA.</auth-address><titles><title>NIH Stroke Scale reliability in ratings from a large sample of clinicians</title><secondary-title>Cerebrovasc Dis</secondary-title></titles><periodical><full-title>Cerebrovasc Dis</full-title></periodical><pages>389-95</pages><volume>22</volume><number>5-6</number><keywords><keyword>*Certification</keyword><keyword>Clinical Trials as Topic/methods</keyword><keyword>*Health Personnel</keyword><keyword>Humans</keyword><keyword>Medical Laboratory Personnel</keyword><keyword>*National Institutes of Health (U.S.)</keyword><keyword>Neuropsychological Tests/*standards</keyword><keyword>Nurses</keyword><keyword>Observer Variation</keyword><keyword>Physicians</keyword><keyword>Reproducibility of Results</keyword><keyword>*Severity of Illness Index</keyword><keyword>Social Work</keyword><keyword>Societies, Medical</keyword><keyword>Stroke/*diagnosis/therapy</keyword><keyword>Treatment Outcome</keyword><keyword>United States</keyword><keyword>Videotape Recording</keyword></keywords><dates><year>2006</year></dates><isbn>1015-9770 (Print)
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ADDIN EN.CITE.DATA 10-13, even though this is the setting where LVO prediction instruments would have the greatest impact on referral patterns. For studies of suspected stroke, the denominator population was often not defined precisely, raising questions about the applicability of the results to other stroke systems. Given the importance of the underlying prevalence of LVO on the end results of using these instruments, the lack of high quality studies on the population-representative prevalence of LVO is a major limitation. In conclusion, our findings suggest that the NIHSS is the optimal LVO prediction instrument in the hospital emergency department, while in the pre-hospital setting a variety of scales could be used, including the CPSSS, LAMS, or RACE, without clear evidence for superiority of 1 over the others. It is unlikely that a clinical stroke severity scale predicts LVO with both high sensitivity and specificity. Because of this, systems that use LVO prediction instruments must accept that some patients with LVO and fewer or milder stroke signs will be missed, and false positive results will be common. Nevertheless, based on the predictive performance reported here and depending on the setting, use of a predictive instrument may be preferable to an unselected population-wide strategy (e.g., bypassing the nearest hospital to transport all suspected stroke patients to the nearest EVT-capable hospital). The most important clinical question is how well LVO prediction instruments perform when administered by EMS in the prehospital setting, but this has been the least well studied. There is a need for more prospectively designed studies to compare the accuracy of different LVO prediction instruments administered by EMS in the prehospital setting in precisely defined populations with suspected stroke. Additionally, decision analysis studies are needed to estimate the costs and benefits of different screening, re-routing, and transfer policies in different scenarios depending on the geographical distribution of EVT and non-EVT capable hospitals and their ability to handle changes in stroke case volumes. Given the limited number of studies specific to the pre-hospital setting, we suggest that such modelling studies examine how their conclusions are affected when using a broad range of test performance characteristics and thresholds.ACKNOWLEDGMENTAuthors acknowledge the statistical support of Robin Ruthazer, Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center. DISCLOSURESEvidence Review Committee DisclosuresCommittee MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/ Advisory BoardOtherEric E. Smith (Chair)University of Calgary Clinical Neurosciences, Foothills Medical Centre CANADA NoneNoneNoneNoneNoneNoneNoneDavid M. Kent (Vice Chair)Tufts Medical Center/Tufts University School of Medicine, PACE Center, Institute of Clinical Research and Health Policy StudiesNoneNoneNoneNoneNoneNoneNoneKetan R. BulsaraUniversity of ConnecticutNoneNoneNoneNoneNoneNoneNoneLester Y. LeungTufts Medical CenterNoneNoneNoneNoneNoneNoneNoneJudith H. Lichtman Yale School of Public HealthNoneNoneNoneNoneNoneNoneNoneMathew J. ReevesMichigan State UniversityNoneNoneNoneNoneNoneNoneNoneAmytis TowfighiUniversity of Southern CaliforniaNoneNoneNoneNoneNoneNoneNoneWilliam N. WhiteleyUniversity of Edinburgh UNITED KINGDOMMRC?; Stroke Association?NoneNoneIndependent witness to the court*NoneNoneUniversity of Edinburgh?Darin ZahuranecUniversity of Michigan Cardiovascular CenterNIH?NoneNoneNoneNoneNoneNoneThis table represents the relationships?of writing group members that may be perceived as?actual or reasonably perceived conflicts?of interest?as reported?on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit.?A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. 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Stroke. 2016;47:no pagination.Table 1: Selection CriteriaSelection Criteria:Prospective or retrospective cohort studies, cross-sectional studies, clinical trials, or systematic reviews; excluding case reports and case series.Either suspected stroke (which could include hemorrhagic stroke and stroke mimics in addition to ischemic stroke) or presumed ischemic stroke with brain imaging.Includes adults (≥18 years).Performed in setting of pre-hospital care or emergency room.LVO presence or absence diagnosed by CT-angiography, MR-angiography, or conventional (invasive) angiography.Studies where LVO assessment was based on TCD only were excluded.An LVO prediction instrument was applied and was associated with the presence or absence of LVO using 1 or more of the following metrics: sensitivity, specificity, negative predictive value, positive predictive value, diagnostic odds ratio, likelihood ratio, area under the curve, receiver operator characteristic curve.Table 2. Characteristics of included studiesCharacteristicSuspected StrokeIschemic StrokeNumber12*24DesignAmbispective Observational10Case Control10Prospective Observational58Retrospective Observational516TypeJournal Article916Letter to the Editor01Meeting Abstract37Year of Publication2002-2007232008-2012042013-2014132015-2016914Median Size459.5269SettingEmergency Room914Mixed13Pre-hospital/field20Unclear/Not Specified07AdministratorNeurologist38Other physician01EMS12Mixed (EMS and neurologist)10ED nurse01Research staff11Not specified611Table 2 Legend: Setting refers to the site where the LVO prediction instrument was applied. *One study of suspected stroke also provided diagnostic accuracy for the subset with ischemic stroke; in this table it is included in the “suspected stroke” column.Table 3. Risk for bias and applicability as determined using the QUADAS-2 ADDIN EN.CITE <EndNote><Cite><Author>Whiting</Author><Year>2011</Year><RecNum>26218</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>26218</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1484931589">26218</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Whiting, P. F.</author><author>Rutjes, A. W.</author><author>Westwood, M. E.</author><author>Mallett, S.</author><author>Deeks, J. J.</author><author>Reitsma, J. B.</author><author>Leeflang, M. M.</author><author>Sterne, J. A.</author><author>Bossuyt, P. M.</author><author>Quadas- Group</author></authors></contributors><auth-address>University of Bristol, United Kingdom. penny.whiting@bristol.ac.uk</auth-address><titles><title>QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>529-36</pages><volume>155</volume><number>8</number><keywords><keyword>Bias (Epidemiology)</keyword><keyword>*Diagnosis</keyword><keyword>Evidence-Based Medicine</keyword><keyword>Humans</keyword><keyword>Patient Selection</keyword><keyword>Quality Control</keyword><keyword>Reference Standards</keyword><keyword>*Review Literature as Topic</keyword><keyword>*Surveys and Questionnaires</keyword><keyword>Time Factors</keyword></keywords><dates><year>2011</year><pub-dates><date>Oct 18</date></pub-dates></dates><isbn>1539-3704 (Electronic)
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ADDIN EN.CITE.DATA 212015Journal ArticleLowHighLowLowLowLowLowHastrup ADDIN EN.CITE <EndNote><Cite><Author>Hastrup</Author><Year>2016</Year><RecNum>26260</RecNum><DisplayText><style face="superscript">40</style></DisplayText><record><rec-number>26260</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26260</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hastrup, S.</author><author>Damgaard, D.</author><author>Johnsen, S. P.</author><author>Andersen, G.</author></authors></contributors><auth-address>From the Department of Neurology, Aarhus University Hospital, Aarhus, Denmark (S.H., D.D., G.A.); and Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark (S.H., S.P.J.). sidshast@rm.dk.
From the Department of Neurology, Aarhus University Hospital, Aarhus, Denmark (S.H., D.D., G.A.); and Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark (S.H., S.P.J.).</auth-address><titles><title>Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion: Design and Comparison With Other Scales</title><secondary-title>Stroke</secondary-title></titles><periodical><full-title>Stroke</full-title></periodical><pages>1772-6</pages><volume>47</volume><number>7</number><keywords><keyword>Emergency Medical Services</keyword><keyword>cerebrovascular occlusion</keyword><keyword>scales</keyword><keyword>stroke</keyword><keyword>thrombectomy</keyword><keyword>triage</keyword></keywords><dates><year>2016</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1524-4628 (Electronic)
0039-2499 (Linking)</isbn><accession-num>27272487</accession-num><urls><related-urls><url> ArticleHighHighHighHighHighLowLowHeldner ADDIN EN.CITE <EndNote><Cite><Author>Heldner</Author><Year>2016</Year><RecNum>26261</RecNum><DisplayText><style face="superscript">22</style></DisplayText><record><rec-number>26261</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26261</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Heldner, M. R.</author><author>Hsieh, K.</author><author>Broeg-Morvay, A.</author><author>Mordasini, P.</author><author>Buhlmann, M.</author><author>Jung, S.</author><author>Arnold, M.</author><author>Mattle, H. P.</author><author>Gralla, J.</author><author>Fischer, U.</author></authors></contributors><auth-address>Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland. urs.fischer@insel.ch.</auth-address><titles><title>Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?</title><secondary-title>J Neurol</secondary-title></titles><periodical><full-title>J Neurol</full-title></periodical><pages>1633-40</pages><volume>263</volume><number>8</number><keywords><keyword>Acute ischemic stroke</keyword><keyword>Ct</keyword><keyword>Clinical neurological examination</keyword><keyword>Mri</keyword><keyword>Stroke management</keyword><keyword>Triage</keyword></keywords><dates><year>2016</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1432-1459 (Electronic)
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ADDIN EN.CITE.DATA 352015Journal ArticleHighLowLowHighHighLowLowKesinger ADDIN EN.CITE <EndNote><Cite><Author>Kesinger</Author><Year>2015</Year><RecNum>26264</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>26264</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26264</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kesinger, M. R.</author><author>Sequeira, D. J.</author><author>Buffalini, S.</author><author>Guyette, F. X.</author></authors></contributors><auth-address>From the University of Pittsburgh, PA (M.R.K., D.J.S., F.X.G.); and Duquesne University, Pittsburgh, PA (S.B.). kesingermr2@upmc.edu.
From the University of Pittsburgh, PA (M.R.K., D.J.S., F.X.G.); and Duquesne University, Pittsburgh, PA (S.B.).</auth-address><titles><title>Comparing National Institutes of Health Stroke Scale among a stroke team and helicopter emergency medical service providers</title><secondary-title>Stroke</secondary-title></titles><periodical><full-title>Stroke</full-title></periodical><pages>575-8</pages><volume>46</volume><number>2</number><keywords><keyword>Air Ambulances/*standards</keyword><keyword>Emergency Medical Services/*standards</keyword><keyword>Emergency Medical Technicians/*standards</keyword><keyword>Emergency Service, Hospital/standards</keyword><keyword>Humans</keyword><keyword>National Institutes of Health (U.S.)/*standards</keyword><keyword>Prospective Studies</keyword><keyword>Stroke/*diagnosis/*therapy</keyword><keyword>Time Factors</keyword><keyword>United States/epidemiology</keyword><keyword>aircraft</keyword><keyword>communication system, EMS</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1524-4628 (Electronic)
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ADDIN EN.CITE.DATA 412016Journal ArticleLowHighHigh?LowLowLowMaas ADDIN EN.CITE <EndNote><Cite><Author>Maas</Author><Year>2009</Year><RecNum>21</RecNum><DisplayText><style face="superscript">24</style></DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maas, M. B.</author><author>Furie, K. L.</author><author>Lev, M. H.</author><author>Ay, H.</author><author>Singhal, A. B.</author><author>Greer, D. M.</author><author>Harris, G. J.</author><author>Halpern, E.</author><author>Koroshetz, W. J.</author><author>Smith, W. S.</author></authors></contributors><auth-address>Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass, USA. mmaas@</auth-address><titles><title>National Institutes of Health Stroke Scale score is poorly predictive of proximal occlusion in acute cerebral ischemia</title><secondary-title>Stroke</secondary-title></titles><pages>2988-93</pages><volume>40</volume><number>9</number><keywords><keyword>Acute Disease</keyword><keyword>Aged</keyword><keyword>*Cerebral Angiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infarction, Middle Cerebral Artery/*diagnostic imaging</keyword><keyword>Intracranial Arterial Diseases/*diagnostic imaging</keyword><keyword>Male</keyword><keyword>National Institutes of Health (U.S.)</keyword><keyword>Prospective Studies</keyword><keyword>Stroke/*diagnostic imaging</keyword><keyword>*Tomography, X-Ray Computed</keyword><keyword>United States</keyword></keywords><dates><year>2009</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1524-4628 (Electronic)
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ADDIN EN.CITE.DATA 252014Journal ArticleHighHigh??HighLowLowMoore ADDIN EN.CITE <EndNote><Cite><Author>Moore</Author><Year>2016</Year><RecNum>26269</RecNum><DisplayText><style face="superscript">43</style></DisplayText><record><rec-number>26269</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26269</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moore, R. D.</author><author>Jackson, J. C.</author><author>Venkatesh, S. L.</author><author>Quarfordt, S. D.</author><author>Baxter, B. W.</author></authors></contributors><auth-address>Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA.</auth-address><titles><title>Revisiting the NIH Stroke Scale as a screening tool for proximal vessel occlusion: can advanced imaging be targeted in acute stroke?</title><secondary-title>J Neurointerv Surg</secondary-title></titles><periodical><full-title>J Neurointerv Surg</full-title></periodical><keywords><keyword>CT Angiography</keyword><keyword>History</keyword><keyword>Stroke</keyword><keyword>Thrombectomy</keyword></keywords><dates><year>2016</year><pub-dates><date>Jan 14</date></pub-dates></dates><isbn>1759-8486 (Electronic)
1759-8478 (Linking)</isbn><accession-num>26769727</accession-num><urls><related-urls><url> ArticleHighLowLow?HighLowHighNakajima ADDIN EN.CITE <EndNote><Cite><Author>Nakajima</Author><Year>2004</Year><RecNum>26270</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>26270</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26270</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nakajima, M.</author><author>Kimura, K.</author><author>Ogata, T.</author><author>Takada, T.</author><author>Uchino, M.</author><author>Minematsu, K.</author></authors></contributors><auth-address>Cerebrovascular Division, Department of Medicine, National Cardiovascular Center, Kumamoto, Japan.</auth-address><titles><title>Relationships between angiographic findings and National Institutes of Health stroke scale score in cases of hyperacute carotid ischemic stroke</title><secondary-title>AJNR Am J Neuroradiol</secondary-title></titles><periodical><full-title>AJNR Am J Neuroradiol</full-title></periodical><pages>238-41</pages><volume>25</volume><number>2</number><keywords><keyword>Aged</keyword><keyword>*Angiography, Digital Subtraction</keyword><keyword>Carotid Artery, Internal/*diagnostic imaging</keyword><keyword>Carotid Stenosis/classification/*diagnostic imaging</keyword><keyword>*Cerebral Angiography</keyword><keyword>Dominance, Cerebral/physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infarction, Anterior Cerebral Artery/classification/*diagnostic imaging</keyword><keyword>Infarction, Middle Cerebral Artery/classification/*diagnostic imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Neurologic Examination</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2004</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0195-6108 (Print)
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0039-2499 (Linking)</isbn><accession-num>15731478</accession-num><urls><related-urls><url> ArticleLowHighLow?LowLowLowSlivka ADDIN EN.CITE <EndNote><Cite><Author>Slivka</Author><Year>2006</Year><RecNum>26276</RecNum><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>26276</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26276</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Slivka, A. P.</author><author>Notestine, M. A.</author><author>Li, J.</author><author>Christoforidis, G. A.</author></authors></contributors><auth-address>Department of Neurology, Ohio State University Medical Center, Columbus, Ohio, USA.</auth-address><titles><title>Clinical predictors of cerebrovascular occlusion for patients presenting with acute stroke</title><secondary-title>J Stroke Cerebrovasc Dis</secondary-title></titles><periodical><full-title>J Stroke Cerebrovasc Dis</full-title><abbr-1>Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association</abbr-1></periodical><pages>30-3</pages><volume>15</volume><number>1</number><dates><year>2006</year><pub-dates><date>Jan-Feb</date></pub-dates></dates><isbn>1532-8511 (Electronic)
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Department of Diagnostic Imaging Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.</auth-address><titles><title>Stroke vision, aphasia, neglect (VAN) assessment-a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices</title><secondary-title>J Neurointerv Surg</secondary-title></titles><periodical><full-title>J Neurointerv Surg</full-title></periodical><pages>122-126</pages><volume>9</volume><number>2</number><keywords><keyword>Economics</keyword><keyword>Stroke</keyword><keyword>Thrombectomy</keyword></keywords><dates><year>2017</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1759-8486 (Electronic)
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0090-3493 (Linking)</isbn><accession-num>26958750</accession-num><urls><related-urls><url> ArticleHighHighLow?HighLowLowZuckerman ADDIN EN.CITE <EndNote><Cite><Author>Zuckerman</Author><Year>2016</Year><RecNum>26280</RecNum><DisplayText><style face="superscript">46</style></DisplayText><record><rec-number>26280</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26280</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zuckerman, S. L.</author><author>Sivaganesan, A.</author><author>Zhang, C.</author><author>Dewan, M. C.</author><author>Morone, P. J.</author><author>Ganesh Kumar, N.</author><author>Mocco, J.</author></authors></contributors><auth-address>Department of Neurological Surgery, Vanderbilt University School of Medicine, USA.
Vanderbilt University School of Medicine, USA.
Mt. Sinai Health System, Department of Neurological Surgery, USA j.mocco@.</auth-address><titles><title>Maximizing efficiency and diagnostic accuracy triage of acute stroke patients: A case-control study</title><secondary-title>Interv Neuroradiol</secondary-title></titles><periodical><full-title>Interv Neuroradiol</full-title></periodical><pages>304-9</pages><volume>22</volume><number>3</number><keywords><keyword>NIH Stroke Scale</keyword><keyword>Stroke</keyword><keyword>endovascular</keyword><keyword>mechanical thrombectomy</keyword><keyword>tPA</keyword></keywords><dates><year>2016</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2385-2011 (Electronic)
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ADDIN EN.CITE.DATA 302015Letter to the EditorHighHigh??HighLowLowCastillo ADDIN EN.CITE <EndNote><Cite><Author>Castillo</Author><Year>2016</Year><RecNum>33</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castillo, N.K.</author><author>Angulo, M.</author><author>Hillmann, M. </author><author>Testai, F.D.</author></authors></contributors><auth-address>N.K. Castillo, ChicagoILUnited States</auth-address><titles><title>Large vessel occlusion predicted by stroke screening scales</title><secondary-title>Annals of Neurology</secondary-title><alt-title>Ann. Neurol.</alt-title></titles><pages>S40-S41</pages><volume>80</volume><keywords><keyword>aged</keyword><keyword>blood vessel occlusion</keyword><keyword>California</keyword><keyword>controlled study</keyword><keyword>diagnosis</keyword><keyword>diagnostic test accuracy study</keyword><keyword>emergency medicine</keyword><keyword>human</keyword><keyword>imaging</keyword><keyword>major clinical study</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>neurologist</keyword><keyword>neurology</keyword><keyword>recanalization</keyword><keyword>screening</keyword><keyword>sensitivity and specificity</keyword><keyword>stroke patient</keyword><keyword>symptom</keyword><keyword>telemedicine</keyword><keyword>tertiary care center</keyword></keywords><dates><year>2016</year><pub-dates><date>October</date></pub-dates></dates><isbn>1531-8249</isbn><accession-num>612892228 Status CONFERENCE ABSTRACT Author Castillo N.K.; Angulo M.; Hillmann M.; Testai F.D.</accession-num><work-type>Conference Abstract</work-type><urls></urls><electronic-resource-num> ADDIN EN.CITE <EndNote><Cite><Author>Christensen</Author><Year>2012</Year><RecNum>30</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Christensen, H.</author><author>Hansen, C.K.</author><author>Havsteen, I.</author><author>Christensen, A.F.</author></authors></contributors><auth-address>H. Christensen, Bispebjerg University Hospital, Copenhagen, Denmark</auth-address><titles><title>Does clinical severity in acute stroke reliably predict large vessel occlusion? Results from a prospective cohort study of CT-angiography (CTA) in hyper-acute stroke</title><secondary-title>Cerebrovascular Diseases</secondary-title><alt-title>Cerebrovasc. Dis.</alt-title></titles><pages>52</pages><volume>33</volume><keywords><keyword>cerebrovascular accident</keyword><keyword>cohort analysis</keyword><keyword>computed tomographic angiography</keyword><keyword>occlusion</keyword><keyword>predictive value</keyword><keyword>patient</keyword><keyword>human</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>risk</keyword><keyword>register</keyword><keyword>brain ischemia</keyword><keyword>computed tomography scanner</keyword><keyword>computer assisted tomography</keyword><keyword>catchment</keyword><keyword>university hospital</keyword><keyword>hospital</keyword><keyword>health care</keyword><keyword>aorta arch</keyword><keyword>multidetector computed tomography</keyword></keywords><dates><year>2012</year><pub-dates><date>May</date></pub-dates></dates><isbn>1015-9770</isbn><accession-num>71636788 Author Christensen H.; Hansen C.K.; Havsteen I.; Christensen A.F.</accession-num><work-type>Conference Abstract</work-type><urls></urls><electronic-resource-num> ADDIN EN.CITE <EndNote><Cite><Author>Garcia-Cabo Fernandez</Author><Year>2015</Year><RecNum>35</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Garcia-Cabo Fernandez, C.</author><author>Martinez Camblor, P.</author><author>Perez Alvarez, A.I.</author><author>Martinez Ramos, J.C.</author><author>Benavente Fernandez, L.</author><author>Pascual Gomez, J.</author><author>Calleja Puerta, S.</author></authors></contributors><auth-address>C. Garcia-Cabo Fernandez, Neurology, Hospital Universitario Central De Asturias, Oviedo, Spain</auth-address><titles><title>New prehospital stroke scale: The NIHSS-AS</title><secondary-title>International Journal of Stroke</secondary-title><alt-title>Int. J. Stroke</alt-title></titles><pages>115-116</pages><volume>10</volume><keywords><keyword>cerebrovascular accident</keyword><keyword>European</keyword><keyword>organization</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>human</keyword><keyword>patient</keyword><keyword>neurologist</keyword><keyword>brain ischemia</keyword><keyword>physician</keyword><keyword>area under the curve</keyword><keyword>arm weakness</keyword><keyword>gaze</keyword><keyword>speech</keyword><keyword>emergency health service</keyword><keyword>model</keyword><keyword>occlusion</keyword><keyword>emergency</keyword></keywords><dates><year>2015</year><pub-dates><date>April</date></pub-dates></dates><isbn>1747-4930</isbn><accession-num>72033999 Author Garcia-Cabo Fernandez C.; Martinez Camblor P.; Perez Alvarez A.I.; Martinez Ramos J.C.; Benavente Fernandez L.; Pascual Gomez J.; Calleja Puerta S.</accession-num><work-type>Conference Abstract</work-type><urls></urls><electronic-resource-num>
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ADDIN EN.CITE.DATA 292016AbstractLowLow??LowLow?Sequiera ADDIN EN.CITE <EndNote><Cite><Author>Sequeira</Author><Year>2015</Year><RecNum>29</RecNum><DisplayText><style face="superscript">31</style></DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sequeira, D.</author><author>Martin-Gill, C.</author><author>Guyette, F.X.</author><author>Jadhav, A.P.</author></authors></contributors><auth-address>D. Sequeira, Dept of Emergency Medicine, Univ of Pittsburgh, Pittsburgh, PA, United States</auth-address><titles><title>Comparison of prehospital stroke scales</title><secondary-title>Circulation</secondary-title><alt-title>Circulation</alt-title></titles><pages>no pagination</pages><volume>132</volume><keywords><keyword>cerebrovascular accident</keyword><keyword>resuscitation</keyword><keyword>medical society</keyword><keyword>emergency health service</keyword><keyword>human</keyword><keyword>patient</keyword><keyword>diagnosis</keyword><keyword>sensitivity and specificity</keyword><keyword>therapy</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>gold standard</keyword><keyword>brain ischemia</keyword><keyword>receiver operating characteristic</keyword><keyword>medical record</keyword><keyword>disability</keyword><keyword>hospital</keyword><keyword>cohort analysis</keyword><keyword>occlusion</keyword><keyword>cause of death</keyword></keywords><dates><year>2015</year><pub-dates><date>10 Nov</date></pub-dates></dates><isbn>0009-7322</isbn><accession-num>72181882 Status CONFERENCE ABSTRACT Author Sequeira D.; Martin-Gill C.; Guyette F.X.; Jadhav A.P.</accession-num><work-type>Conference Abstract</work-type><urls></urls><language>English</language></record></Cite></EndNote>312016Abstract?Low??LowLow?Venizelos ADDIN EN.CITE <EndNote><Cite><Author>Venizelos</Author><Year>2014</Year><RecNum>37</RecNum><DisplayText><style face="superscript">45</style></DisplayText><record><rec-number>37</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">37</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Venizelos, A.</author><author>Chen, S.</author><author>Gianatasio, R.</author><author>Coffman, S.</author><author>Gamber, M.</author><author>Myers, J.H.</author><author>Janardhan, V.</author></authors></contributors><auth-address>A. Venizelos, Texas Stroke Institute, Plano, TX, United States</auth-address><titles><title>Texas stroke intervention pre-hospital stroke severity scale (aka LEGS score): A triaging tool for interventional stroke therapy</title><secondary-title>Stroke</secondary-title><alt-title>Stroke</alt-title></titles><pages>no pagination</pages><volume>45</volume><keywords><keyword>cerebrovascular accident</keyword><keyword>emergency care</keyword><keyword>heart</keyword><keyword>United States</keyword><keyword>leg</keyword><keyword>hospital</keyword><keyword>therapy</keyword><keyword>nursing</keyword><keyword>human</keyword><keyword>occlusion</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>predictive value</keyword><keyword>brain ischemia</keyword><keyword>magnetic resonance angiography</keyword><keyword>hypothesis</keyword><keyword>patient</keyword><keyword>speech</keyword><keyword>emergency ward</keyword><keyword>gaze</keyword><keyword>emergency health service</keyword><keyword>scoring system</keyword><keyword>imaging</keyword><keyword>stroke patient</keyword></keywords><dates><year>2014</year><pub-dates><date>February</date></pub-dates></dates><isbn>0039-2499</isbn><accession-num>71465435 Author Venizelos A.; Chen S.; Gianatasio R.; Coffman S.; Gamber M.; Myers J.H.; Janardhan V.</accession-num><work-type>Conference Abstract</work-type><urls></urls><language>English</language></record></Cite></EndNote>452014Abstract????LowLowLowTable 3 Legend: Low, low risk of bias; High, high risk of bias; ?, unclear risk of bias. For details on definitions of high or low risk, please see reference 5 and Table V of the online supplement.Table 4. Sensitivity and specificity of scales reported on by 2 or more studiesLVO prediction instrumentThresholdLead AuthorYearStudy Sample Size% Non-ischemic strokeSettingAUCSensitivitySpecificityNIHSS Ischemic Stroke≥6Teleb ADDIN EN.CITE <EndNote><Cite><Author>Teleb</Author><Year>2017</Year><RecNum>26277</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>26277</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26277</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Teleb, M. S.</author><author>Ver Hage, A.</author><author>Carter, J.</author><author>Jayaraman, M. V.</author><author>McTaggart, R. A.</author></authors></contributors><auth-address>Neurosciences Department, Banner Health, Mesa, Arizona, USA.
Department of Diagnostic Imaging Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.</auth-address><titles><title>Stroke vision, aphasia, neglect (VAN) assessment-a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices</title><secondary-title>J Neurointerv Surg</secondary-title></titles><periodical><full-title>J Neurointerv Surg</full-title></periodical><pages>122-126</pages><volume>9</volume><number>2</number><keywords><keyword>Economics</keyword><keyword>Stroke</keyword><keyword>Thrombectomy</keyword></keywords><dates><year>2017</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1759-8486 (Electronic)
1759-8478 (Linking)</isbn><accession-num>26891627</accession-num><urls><related-urls><url>≥10Christensen ADDIN EN.CITE <EndNote><Cite><Author>Christensen</Author><Year>2012</Year><RecNum>30</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Christensen, H.</author><author>Hansen, C.K.</author><author>Havsteen, I.</author><author>Christensen, A.F.</author></authors></contributors><auth-address>H. Christensen, Bispebjerg University Hospital, Copenhagen, Denmark</auth-address><titles><title>Does clinical severity in acute stroke reliably predict large vessel occlusion? Results from a prospective cohort study of CT-angiography (CTA) in hyper-acute stroke</title><secondary-title>Cerebrovascular Diseases</secondary-title><alt-title>Cerebrovasc. Dis.</alt-title></titles><pages>52</pages><volume>33</volume><keywords><keyword>cerebrovascular accident</keyword><keyword>cohort analysis</keyword><keyword>computed tomographic angiography</keyword><keyword>occlusion</keyword><keyword>predictive value</keyword><keyword>patient</keyword><keyword>human</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>risk</keyword><keyword>register</keyword><keyword>brain ischemia</keyword><keyword>computed tomography scanner</keyword><keyword>computer assisted tomography</keyword><keyword>catchment</keyword><keyword>university hospital</keyword><keyword>hospital</keyword><keyword>health care</keyword><keyword>aorta arch</keyword><keyword>multidetector computed tomography</keyword></keywords><dates><year>2012</year><pub-dates><date>May</date></pub-dates></dates><isbn>1015-9770</isbn><accession-num>71636788 Author Christensen H.; Hansen C.K.; Havsteen I.; Christensen A.F.</accession-num><work-type>Conference Abstract</work-type><urls></urls><electronic-resource-num>≥10Maas ADDIN EN.CITE <EndNote><Cite><Author>Maas</Author><Year>2009</Year><RecNum>21</RecNum><DisplayText><style face="superscript">24</style></DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maas, M. B.</author><author>Furie, K. L.</author><author>Lev, M. H.</author><author>Ay, H.</author><author>Singhal, A. B.</author><author>Greer, D. M.</author><author>Harris, G. J.</author><author>Halpern, E.</author><author>Koroshetz, W. J.</author><author>Smith, W. S.</author></authors></contributors><auth-address>Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass, USA. mmaas@</auth-address><titles><title>National Institutes of Health Stroke Scale score is poorly predictive of proximal occlusion in acute cerebral ischemia</title><secondary-title>Stroke</secondary-title></titles><pages>2988-93</pages><volume>40</volume><number>9</number><keywords><keyword>Acute Disease</keyword><keyword>Aged</keyword><keyword>*Cerebral Angiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infarction, Middle Cerebral Artery/*diagnostic imaging</keyword><keyword>Intracranial Arterial Diseases/*diagnostic imaging</keyword><keyword>Male</keyword><keyword>National Institutes of Health (U.S.)</keyword><keyword>Prospective Studies</keyword><keyword>Stroke/*diagnostic imaging</keyword><keyword>*Tomography, X-Ray Computed</keyword><keyword>United States</keyword></keywords><dates><year>2009</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1524-4628 (Electronic)
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ADDIN EN.CITE.DATA 25 201471N/AED0.797373≥10Nakajima ADDIN EN.CITE <EndNote><Cite><Author>Nakajima</Author><Year>2004</Year><RecNum>26270</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>26270</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26270</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nakajima, M.</author><author>Kimura, K.</author><author>Ogata, T.</author><author>Takada, T.</author><author>Uchino, M.</author><author>Minematsu, K.</author></authors></contributors><auth-address>Cerebrovascular Division, Department of Medicine, National Cardiovascular Center, Kumamoto, Japan.</auth-address><titles><title>Relationships between angiographic findings and National Institutes of Health stroke scale score in cases of hyperacute carotid ischemic stroke</title><secondary-title>AJNR Am J Neuroradiol</secondary-title></titles><periodical><full-title>AJNR Am J Neuroradiol</full-title></periodical><pages>238-41</pages><volume>25</volume><number>2</number><keywords><keyword>Aged</keyword><keyword>*Angiography, Digital Subtraction</keyword><keyword>Carotid Artery, Internal/*diagnostic imaging</keyword><keyword>Carotid Stenosis/classification/*diagnostic imaging</keyword><keyword>*Cerebral Angiography</keyword><keyword>Dominance, Cerebral/physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infarction, Anterior Cerebral Artery/classification/*diagnostic imaging</keyword><keyword>Infarction, Middle Cerebral Artery/classification/*diagnostic imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Neurologic Examination</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2004</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0195-6108 (Print)
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ADDIN EN.CITE.DATA 192005226N/AED8175≥12Kesinger ADDIN EN.CITE <EndNote><Cite><Author>Kesinger</Author><Year>2015</Year><RecNum>26264</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>26264</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26264</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kesinger, M. R.</author><author>Sequeira, D. J.</author><author>Buffalini, S.</author><author>Guyette, F. X.</author></authors></contributors><auth-address>From the University of Pittsburgh, PA (M.R.K., D.J.S., F.X.G.); and Duquesne University, Pittsburgh, PA (S.B.). kesingermr2@upmc.edu.
From the University of Pittsburgh, PA (M.R.K., D.J.S., F.X.G.); and Duquesne University, Pittsburgh, PA (S.B.).</auth-address><titles><title>Comparing National Institutes of Health Stroke Scale among a stroke team and helicopter emergency medical service providers</title><secondary-title>Stroke</secondary-title></titles><periodical><full-title>Stroke</full-title></periodical><pages>575-8</pages><volume>46</volume><number>2</number><keywords><keyword>Air Ambulances/*standards</keyword><keyword>Emergency Medical Services/*standards</keyword><keyword>Emergency Medical Technicians/*standards</keyword><keyword>Emergency Service, Hospital/standards</keyword><keyword>Humans</keyword><keyword>National Institutes of Health (U.S.)/*standards</keyword><keyword>Prospective Studies</keyword><keyword>Stroke/*diagnosis/*therapy</keyword><keyword>Time Factors</keyword><keyword>United States/epidemiology</keyword><keyword>aircraft</keyword><keyword>communication system, EMS</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1524-4628 (Electronic)
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Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland. urs.fischer@insel.ch.</auth-address><titles><title>Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?</title><secondary-title>J Neurol</secondary-title></titles><periodical><full-title>J Neurol</full-title></periodical><pages>1633-40</pages><volume>263</volume><number>8</number><keywords><keyword>Acute ischemic stroke</keyword><keyword>Ct</keyword><keyword>Clinical neurological examination</keyword><keyword>Mri</keyword><keyword>Stroke management</keyword><keyword>Triage</keyword></keywords><dates><year>2016</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1432-1459 (Electronic)
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ADDIN EN.CITE.DATA 29201642N/APre-hospital5887Suspected Stroke≥1Heldner ADDIN EN.CITE <EndNote><Cite><Author>Heldner</Author><Year>2016</Year><RecNum>26261</RecNum><DisplayText><style face="superscript">22</style></DisplayText><record><rec-number>26261</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485966951">26261</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Heldner, M. R.</author><author>Hsieh, K.</author><author>Broeg-Morvay, A.</author><author>Mordasini, P.</author><author>Buhlmann, M.</author><author>Jung, S.</author><author>Arnold, M.</author><author>Mattle, H. P.</author><author>Gralla, J.</author><author>Fischer, U.</author></authors></contributors><auth-address>Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
Department of Neurology, Inselspital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland. urs.fischer@insel.ch.</auth-address><titles><title>Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?</title><secondary-title>J Neurol</secondary-title></titles><periodical><full-title>J Neurol</full-title></periodical><pages>1633-40</pages><volume>263</volume><number>8</number><keywords><keyword>Acute ischemic stroke</keyword><keyword>Ct</keyword><keyword>Clinical neurological examination</keyword><keyword>Mri</keyword><keyword>Stroke management</keyword><keyword>Triage</keyword></keywords><dates><year>2016</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1432-1459 (Electronic)
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ADDIN EN.CITE.DATA 2920169254.3%Pre-hospital5877LAMS Ischemic Stroke≥4Castillo ADDIN EN.CITE <EndNote><Cite><Author>Castillo</Author><Year>2016</Year><RecNum>33</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="z0fx9sdeaexvame9p0vvaxsnwd2wvzr0tx0a" timestamp="0">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castillo, N.K.</author><author>Angulo, M.</author><author>Hillmann, M. </author><author>Testai, F.D.</author></authors></contributors><auth-address>N.K. Castillo, ChicagoILUnited States</auth-address><titles><title>Large vessel occlusion predicted by stroke screening scales</title><secondary-title>Annals of Neurology</secondary-title><alt-title>Ann. Neurol.</alt-title></titles><pages>S40-S41</pages><volume>80</volume><keywords><keyword>aged</keyword><keyword>blood vessel occlusion</keyword><keyword>California</keyword><keyword>controlled study</keyword><keyword>diagnosis</keyword><keyword>diagnostic test accuracy study</keyword><keyword>emergency medicine</keyword><keyword>human</keyword><keyword>imaging</keyword><keyword>major clinical study</keyword><keyword>National Institutes of Health Stroke Scale</keyword><keyword>neurologist</keyword><keyword>neurology</keyword><keyword>recanalization</keyword><keyword>screening</keyword><keyword>sensitivity and specificity</keyword><keyword>stroke patient</keyword><keyword>symptom</keyword><keyword>telemedicine</keyword><keyword>tertiary care center</keyword></keywords><dates><year>2016</year><pub-dates><date>October</date></pub-dates></dates><isbn>1531-8249</isbn><accession-num>612892228 Status CONFERENCE ABSTRACT Author Castillo N.K.; Angulo M.; Hillmann M.; Testai F.D.</accession-num><work-type>Conference Abstract</work-type><urls></urls><electronic-resource-num>≥4NazlielPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXpsaWVsPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ADDIN EN.CITE.DATA 2920169254.3%Pre-hospital4790RACE Ischemic Stroke≥5Qureshi26201642N/APre-hospital6396≥5Turc3020161004N/AED6785Suspected Stroke≥3Heldner182016108517.1%ED0.837480≥4Sequeira2820151293UnclearPre-hospital5687≥5Carrera34201634131.7%Mixed0.828568≥5Qureshi20169254.3%Pre-hospital63853 item-SS Ischemic Stroke≥4Castillo132016113N/AED999Suspected Stroke≥1Heldner182016108517.1%ED0.797378≥4Singer36200583UnclearED6792CPSS Ischemic Stroke≥2Castillo132016113N/AED8670Suspected Stroke≥2Sequeira2820151293UnclearPre-hospital7854Table 4 Legend: See online supplement Table 3 for a full description of the scales. NIHSS, National Institutes of Health Stroke Scale; CPSSS, Cincinnati Prehospital Stroke Severity Scale; LAMS, Los Angeles Motor Scale; RACE, Rapid Arterial Occlusion Evaluation; 3-item SS, three item stroke scale; CPSS, Cincinnati Prehospital Stroke Screen; ED, emergency department; N/A, not applicable; AUC, area under the receiver operating characteristics curve.Figure 1. Flow diagramCitations identified through PubMed (n = 1087)Studies Included (n = 36) Citations screened after duplicates removed (n = 2719)Title/abstracts screened(n = 2719)Citations excluded after title/abstract screening (n =2584)Full-text articles screened for eligibility (n = 135)Full-text articles excluded (n = 99) Reasons for exclusions:11 Wrong population13 Wrong index test/stroke scale3 Wrong LVO data56 Wrong accuracy/prediction outcome(s)5 Insufficient Data3 Not a clinical study8 Duplicate publicationCitations identified through Embase (n = 2106)Citations identified through Cochrane (n = 164)Citations identified through PubMed (n = 1087)Studies Included (n = 36) Citations screened after duplicates removed (n = 2719)Title/abstracts screened(n = 2719)Citations excluded after title/abstract screening (n =2584)Full-text articles screened for eligibility (n = 135)Full-text articles excluded (n = 99) Reasons for exclusions:11 Wrong population13 Wrong index test/stroke scale3 Wrong LVO data56 Wrong accuracy/prediction outcome(s)5 Insufficient Data3 Not a clinical study8 Duplicate publicationCitations identified through Embase (n = 2106)Citations identified through Cochrane (n = 164)Figure 2. Summary Pooled Receiver Operating Characteristics (ROC) CurvesFigure 2 Legend: Summary pooled ROC curves and sensitivity and specificity for different scale thresholds for the NIH Stroke Scale (NIHSS) in suspected stroke (A)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb256YWxlejwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+
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ADDIN EN.CITE.DATA 33, 35, 36, 52, 53 Data are pooled from studies in the pre-hospital and ED settings. There were too few studies in the pre-hospital setting for separate meta-analysis. Each data point indicates a threshold value from an individual study, with different studies indicated by different colors. The red cross indicates the optimal model-calculated threshold value if sensitivity and specificity are weighted equally. Figure 3. Meta-analysis of Sensitivity and Specificity Figure 3 Legend: Data are pooled from studies in the pre-hospital and ED settings. There were too few studies in the pre-hospital setting for separate meta-analysis. CPSSS, Cincinnati Prehospital Stroke Severity Scale; LAMS, Los Angeles Motor Scale; RACE, Rapid Arterial Occlusion Evaluation; 3I-SS, three item stroke scale. (NIHSS pooled ROC curves are shown in Figure 2). Figure 4. Post-test ProbabilityFigure 4 Legend: Post-test probability (y-axis) of having LVO when the test is positive [Pos(+) Test] or when the test is negative [Neg(-) Test] for a range of true LVO prevalences (x-axis), for suspected stroke (A) and ischemic stroke (B). Data are pooled from studies in the pre-hospital and ED settings. There were too few studies in the pre-hospital setting for separate meta-analysis. CPSSS, Cincinnati Prehospital Stroke Screen; LAMS, Los Angeles Motor Scale; RACE, Rapid Arterial Occlusion Evaluation; 3I-SS, three item stroke scale; NIHSS, NIH Stroke Scale. ................
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