More Mnemonics! RACE, LAMS, LAPSS, CPSS – WTH! …

1 more mnemonics ! RACE, LAMS, LAPSS, CPSS WTH! OMG!: LVO stroke Screening Laura Heitsch, MD Assistant Professor, EM & Neurology Washington University, St Louis MO Disclosures Funding NIH/NINDS: POINT (local-PI) EMF Career Development Grant AHA/ASA Career Development Grant Pending K23 Career Development Grant (NINDS) Industry Relationship Genentech Speakers Bureau Off-Label Discussion None Objectives Understand what is meant by a LVO and why it s important Recognize several LVO stroke screening tools Understand the limitations of these screening tools A New Era in Acute stroke Treatment LVO = Large Vessel Occlusion Middle Cerebral Artery (MCA) Anterior Cerebral Artery (ACA) #a3 LVO = Large Vessel Occlusion Thrombectomy o f LVO Castano C et al. stroke 2010; 41:1836-1840.

2 M1 Dispatch EMS team Community Recognize signs and symptoms of stroke Recognize signs and symptoms of stroke Assessment and management Call 911 & Describe Dispatch EMS team Rapid transport to stroke ready hospital with pre-notification Dispatch EMS team Community Recognize signs and symptoms of stroke Recognize signs and symptoms of stroke Assessment and management Call 911 & Describe Dispatch EMS team PSC Possible LVO? CSC Well, you have (lots of) Cincinnati Prehospital stroke Scale (CPSS)* Cincinnati Prehospital stroke Severity Scale (CPSSS) Los Angeles Prehospital stroke Scale (LAPSS)* Los Angeles Motor Score (LAMS) Lots of modifications of the original NIHSS (0-42) sNIHSS-1, sNIHSS-5, sNIHSS-8, mNIHSS, aNIHSS, rNIHSS A to F, 3I-SS RACE ROSIER *Originally designed for stroke recognition (not LVO triage) Well, you have (lots of) Cincinnati Prehospital stroke Scale (CPSS)* Los Angeles Prehospital stroke Scale (LAPSS)* *Originally designed for stroke recognition (not LVO triage) Well, you have (lots of) Cincinnati Prehospital stroke Scale (CPSS)* Cincinnati Prehospital stroke Severity Scale (CPSSS) Los Angeles Prehospital stroke Scale (LAPSS)* Los Angeles Motor Score (LAMS)

3 Lots of modifications of the original NIHSS (0-42) sNIHSS-1, sNIHSS-5, sNIHSS-8, mNIHSS, aNIHSS, rNIHSS A t o F, 3I-SS RACE ROSIER *Originally designed for stroke recognition (not LVO triage) Cincinnati Prehospital stroke Severity Scale (CPSSS) Components (all clinical exam) Abnormal level of consciousness Conjugate gaze Arm weakness Scoring (0-4): 1 point: incorrectly answers 1 LOC plus 1 command not followed 2 points: conjugate gaze deviation 1 point: cannot hold arm up for 10 seconds How does it perform for LVO: (score 2) Sensitivity 83% Specificity 40% Katz et al. stroke 2015;46:1508-1512. Recognition of stroke in the Emergency Room (ROSIER) Components Interview Questions Clinical examination Scoring (0-9): Associated LOC (yes = -1; no = 0) Associated Seizure (yes = -1; no = 0) Asymmetrical face weakness (yes = +1; no = 0) Asymmetrical arm weakness (yes = +1; no = 0) Asymmetrical leg weakness (yes = +1; no = 0) Speech disturbance (yes = +1; no = 0) Visual field defect (yes = +1; no = 0) How does it perform for LVO: Was not originally designed for this purpose Nor et al.

4 Lancet Neurol 2005;4:727-34. What do we really care about? Easy to Use Performing the entire NIH stroke scale? Overwhelming the Comprehensive stroke Center Not sending ALL stroke patients to the CSC False Positive Rate = 1 - specificity Identify patients who likely have an LVO Not missing any potential candidates for thrombectomy False Negative Rate = 1 - sensitivity Turc G, et al. stroke . 2016;47:1466-1472. Field Assessment stroke Triage for Emergency Destination (FAST-ED) Components (all clinical exam) Scoring (0-9): Facial Palsy = 0-1 point Arm weakness = 0-2 points Speech changes = 0-2 points Eye deviation = 0-2 points Denial/neglect = 0-2 points How does it perform for LVO (score 4): Sensitivity (False Negative 40%) Specificity (False Positive 11%) Lima et al. 2016;47:1997-2002 So where does that leave us?

5 ? The specific scale chosen may be less important than the paradigm that some field severity score assessment should be done to screen for possible (E)LVO. - Jayaraman et al. J NeuroIntervent Surg. 2016 Endovascular Intervention Process Flow DAL 1-800-252-DOCS (3627) BJH stroke Neurology Community Hospital BJH ED Teleradiology BJH INR Current treatment protocols require inter-institutional transfers: IV tPA treatment, transfer, embolectomy, all within 6 hours! Many drip & ship cases are falling out of the therapeutic window