Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study.

BACKGROUND: Due to the time-sensitive effect of endovascular treatment, rapid prehospital identification of large-vessel occlusion in individuals with suspected stroke is essential to optimise outcome. Interhospital transfers are an important cause of delay of endovascular treatment. Prehospital stroke scales have been proposed to select patients with large-vessel occlusion for direct transport to an endovascular-capable intervention centre. We aimed to prospectively validate eight prehospital stroke scales in the field. METHODS: We did a multicentre, prospective, observational cohort study of adults with suspected stroke (aged ≥18 years) who were transported by ambulance to one of eight hospitals in southwest Netherlands. Suspected stroke was defined by a positive Face-Arm-Speech-Time (FAST) test. We included individuals with blood glucose of at least 2·5 mmol/L. People who presented more than 6 h after symptom onset were excluded from the analysis. After structured training, paramedics used a mobile app to assess items from eight prehospital stroke scales: Rapid Arterial oCclusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), Cincinnati Stroke Triage Assessment Tool (C-STAT), Gaze-Face-Arm-Speech-Time (G-FAST), Prehospital Acute Stroke Severity (PASS), Cincinnati Prehospital Stroke Scale (CPSS), Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST), and the FAST-PLUS (Face-Arm-Speech-Time plus severe arm or leg motor deficit) test. The primary outcome was the clinical diagnosis of ischaemic stroke with a proximal intracranial large-vessel occlusion in the anterior circulation (aLVO) on CT angiography. Baseline neuroimaging was centrally assessed by neuroradiologists to validate the true occlusion status. Prehospital stroke scale performance was expressed as the area under the receiver operating characteristic curve (AUC) and was compared with National Institutes of Health Stroke Scale (NIHSS) scores assessed by clinicians at the emergency department. This study was registered at the Netherlands Trial Register, NL7387. FINDINGS: Between Aug 13, 2018, and Sept 2, 2019, 1039 people (median age 72 years [IQR 61-81]) with suspected stroke were identified by paramedics, of whom 120 (12%) were diagnosed with aLVO. Of all prehospital stroke scales, the AUC for RACE was highest (0·83, 95% CI 0·79-0·86), followed by the AUC for G-FAST (0·80, 0·76-0·84), CG-FAST (0·80, 0·76-0·84), LAMS (0·79, 0·75-0·83), CPSS (0·79, 0·75-0·83), PASS (0·76, 0·72-0·80), C-STAT (0·75, 0·71-0·80), and FAST-PLUS (0·72, 0·67-0·76). The NIHSS as assessed by a clinician in the emergency department did somewhat better than the prehospital stroke scales with an AUC of 0·86 (95% CI 0·83-0·89). INTERPRETATION: Prehospital stroke scales detect aLVO with acceptable-to-good accuracy. RACE, G-FAST, and CG-FAST are the best performing prehospital stroke scales out of the eight scales tested and approach the performance of the clinician-assessed NIHSS. Further studies are needed to investigate whether use of these scales in regional transportation strategies can optimise outcomes of patients with ischaemic stroke. FUNDING: BeterKeten Collaboration and Theia Foundation (Zilveren Kruis).

Prediction of major vascular events in patients with transient ischemic attack or ischemic stroke: a comparison of 7 models.

BACKGROUND AND PURPOSE: In patients with a recent TIA or minor stroke, prediction of long-term risk of major vascular events is important, but difficult. We aimed to study the external validity of currently available prediction models. METHODS: We validated predictions from 3 population-based models (Framingham, SCORE, and INDIANA project) and 4 stroke cohort-based models (Stroke Prognosis Instrument II, Oxford TIA, Dutch TIA study, and the ABCD(2) study) in an independent cohort of patients with a recent TIA or minor stroke. The validation cohort consisted of 592 patients with TIA or minor stroke, with a mean follow-up of 2 years. The primary outcome was the 2-year risk of the composite outcome event of nonfatal stroke, myocardial infarction, or vascular death. We used calibration graphs and c-statistics to evaluate the 7 models. RESULTS: The 2-year risk of the primary outcome event was 12%. Calibration was adequate for stroke population-based studies. After adjustment for baseline risk and for prevalence of risk factors, calibration was adequate for the Dutch TIA, the ABCD(2), and Stroke Prognosis Instrument II models. Discrimination ranged from 0.61 to 0.68. CONCLUSIONS: Discrimination was poor for all currently available risk prediction models for patients with a recent TIA or minor stroke, indicating the need for stronger predictors. Clinical usefulness may be best for the ABCD(2) model, which had a limited number of easily obtainable variables, a reasonable c-statistic (0.64), and good calibration.

Prevention with low-dose aspirin plus dipyridamole in patients with disabling stroke.

BACKGROUND AND PURPOSE: The combination of low-dose aspirin and dipyridamole is more effective than aspirin alone in reducing the risk of recurrent stroke and other major cardiovascular events in patients with a recent transient ischemic attack or minor stroke. It is unknown whether this also applies to patients with a disabling stroke. METHODS: We reanalyzed the data of 5700 patients from ESPRIT and ESPS-2 to study the effect of aspirin and dipyridamole according to modified Rankin scale (mRS) score at baseline. Primary outcome was vascular events (stroke, myocardial infarction, or vascular death). We used proportional hazards regression to estimate the treatment effect across mRS strata at baseline, and we tested for interactions with treatment. RESULTS: In total, 426 patients (7.5%) had mRS score of 4 or 5 at baseline. The risk of an outcome event increased with mRS score. The relative risk associated with the combination of aspirin and dipyridamole compared to aspirin alone in patients with mRS score 0 to 5 was 0.79 (95% confidence interval, 0.69-0.91). The relative risk according to mRS subcategory score 0 to 4 at baseline varied between 0.73 and 0.96 for vascular events and between 0.62 and 0.96 for stroke. The number of patients with mRS score 5 was too small for reliable estimates, but the data suggest a beneficial effect. There was no evidence of interaction between treatment effect and mRS score at baseline. CONCLUSIONS: The beneficial effect of the combination of low-dose aspirin and dipyridamole was present in all subcategories of the mRS score.

Patients enrolled in large randomized clinical trials of antiplatelet treatment for prevention after transient ischemic attack or ischemic stroke are not representative of patients in clinical practice: the Netherlands Stroke Survey.

BACKGROUND AND PURPOSE: Many randomized clinical trials have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of new vascular events in patients with a recent transient ischemic attack or ischemic stroke. Evidence from these trials forms the basis for national and international guidelines for the management of nearly all such patients in clinical practice. However, abundant and strict enrollment criteria may limit the validity and the applicability of results of randomized clinical trials to clinical practice. We estimated the eligibility for participation in landmark trials of antiplatelet drugs of an unselected group of patients with stroke or transient ischemic attack from a national stroke survey. METHODS: Nine hundred seventy-two patients with transient ischemic attack or ischemic stroke were prospectively and consecutively enrolled in the Netherlands Stroke Survey. We applied 7 large antiplatelet trials' enrollment criteria. RESULTS: In total, 886 patients were discharged alive and available for secondary prevention. Mean follow-up was 2.5 years. The annual rate of transient ischemic attack, stroke, or nonfatal myocardial infarction was 6.7%. The proportions of patients fulfilling the trial enrollment criteria ranged from 25% to 67%. Mortality was significantly higher in ineligible patients (27% to 41%) than in patients fulfilling enrollment criteria (16% to 20%). Rates of vascular events were not higher in trial-eligible patients than in ineligible patients. CONCLUSIONS: Our data confirm that patients with ischemic attack and stroke enrolled in randomized clinical trials are only partially representative of patients in clinical practice. Use of less strict enrollment criteria could enhance "generalizability" and result in more efficient selection of patients for randomized clinical trials.

Health education in patients with a recent stroke or transient ischaemic attack: a comprehensive review.

Health education aims at the acquisition of skills and attitudes to modify behaviour that influences health, leads to a modification of risk factors and ultimately to a decrease in disability and case fatality from stroke. Health education is an underdeveloped but important aspect of stroke care. Health education could promote compliance and healthy behaviour, improve patients' understanding of their health status and treatment options and facilitate communication. We reviewed the effect of health education in stroke and transient ischaemic attack patients, aiming at feasibility, effectiveness at the level of knowledge, attitude and skills, health behaviour changes and stroke outcome. We also describe the current status of health education for patients with recent coronary artery disease and public health education in stroke. Basic knowledge of stroke and transient ischaemic attack patients of their disease and associated risk factors is not sufficient. This is also observed in patients with coronary artery disease and in the general population. A beneficial effect of health education in stroke and transient ischaemic attack patients on health behaviour, risk reduction or stroke outcome has not been proven. Trials in patients with coronary artery disease, however, have shown that health education could result in a change of lifestyle. No specific method is superior, although the individualised, repetitive and active methods appear more successful. More intervention studies of health education in stroke and transient ischaemic attack patients are needed. Future trials should be large, have a long follow-up, should use an intensive and repetitive approach and involve patients' relatives to induce and maintain a healthy lifestyle.

Knowledge and understanding of disease process, risk factors and treatment modalities in patients with a recent TIA or minor ischemic stroke.

BACKGROUND: Patients with acute stroke often have a striking lack of knowledge of causes, warning signs, and risk factors. Lack of knowledge may lead to inappropriate secondary prevention behavior. We investigated the knowledge of patients with a TIA or minor stroke about specific aspects of their disease 3 months after the event. METHODS: Patients with a TIA or minor stroke who participated in a randomized controlled trial of the effect of health education by an individualized multimedia computer program (IMCP) were included. All patients received information about their disease from their treating neurologist and half of the patients received extra information through the IMCP. The patients' knowledge was tested after 3 months by means of a questionnaire that contained items on pathogenesis, warning signs, vascular diseases, risk factors, lifestyle and treatment. The highest possible score was 71 points. RESULTS: The 57 patients had a mean total score of 41.2 points (SD 10.4) of the maximum 71. Only 15 (26%) correctly identified the brain as the affected organ in stroke and TIA, and only 21 (37%) could give a correct description of a TIA or stroke. In contrast, 80-90% of the patients identified hypertension and/or obesity as vascular risk factors. Knowledge of various treatment modalities of hypertension, hypercholesterolemia and obesity was moderate to high (40-91% adequate responses). CONCLUSION: The vast majority of patients with TIA or stroke lack specific knowledge about their disease, but they do have a reasonable knowledge of general vascular risk factors and treatment. This suggests that counseling by neurologists of patients with a TIA or stroke can be improved.