Stroke: Assessment

Introduction

“Time is brain”, i.e. we should not waste any time on evaluation.

Acute stroke is a medical emergency. Stroke is a leading cause of death and disability, and patient outcomes depend on how quickly blood flow is restored to damaged areas of the brain. The assessment of a stroke patient involves airway stabilization breathing and circulation (ABC). this is This is followed by a quick brief history and examination (e.g. NIHSS, see below), performed concurrently with the patient’s IV access telemetry and laboratory testing. Patients should then undergo a statistical non-contrast head CT or head CT combined with CT angiography and perfusion imaging.

The Prehospital and Acute Stroke Scale is a standardized assessment tool used to identify stroke and clear reperfusion pathways.

Treatment options for stroke include thrombolytic drugs designed to dissolve the clot and interventional endovascular surgery (similar to heart catheterization) to remove it. Successful stroke care requires early identification, transport of the patient to a designated stroke center, and Start your hospital’s stroke team early. 2018 saw a major paradigm shift in stroke care. The DAWN trial demonstrated a significant benefit of endovascular thrombectomy in patients with large vessel occlusions in proximal anterior circulation arteries. The test was extended Up to 24-hour stroke window in selected patients using perfusion imaging. As a result, more patients can even be treated up to 24 hours after an event. [1]

In addition to assessing the impact of therapeutic interventions in clinical trials, the Stroke Scale is also useful in routine clinical settings as an adjunct to improve diagnostic accuracy, to help determine the appropriateness of specific treatments, to monitor patients’ neurological Identify deficiencies, and predict and measure outcomes, across the continuum of care. Not only do these different purposes require different types of scales, but no single scale is suitable for capturing all the effects of stroke.

Diagnostic accuracy of clinical tools used to assess acute stroke

In recent years, a variety of clinical assessment tools for the selection of subjects with acute stroke have been developed. Assessment of cortical and motor function using RACE FAST-ED and NIHSS showed the highest diagnostic accuracy for subjects with selected large vessel occlusions.

• There are limited data on clinical tools that can be used to differentiate acute ischemia from hemorrhage.
• The diagnostic accuracy for differentiating acute stroke from stroke imminent appears to be low.
• Further prehospital studies are needed to improve the diagnostic utility of clinical assessment, possibly applying a two-step clinical assessment or involving simple brain imaging such as transcranial ultrasonography.

Pre Hospital Scales

Emergency medical services (EMS) provide the first medical contact for up to 70 percent of all stroke patients and are therefore uniquely positioned to reduce doctor visits and delays in treatment. Reliably identifying stroke patients in the field could reduce delays by allowing paramedics Notifying receiving hospitals of impending stroke cases ensures stroke teams are mobilized quickly and required scans are available early on arrival at the hospital. Prehospital assessment and determination of stroke severity is a new concept for which the optimal scale has yet to be determined. this The Cincinnati and Los Angeles scales have been validated in hospital trials, but have had mixed results when applied to EMS [2]. The RACE scale has had some positive results when it was tested among paramedics in Spain, more research is currently underway [3], and it is being adopted by many EMS systems in the US state.

ScaleProsConsCincinnati Prehospital Stroke Scale (CPSS) Easy to administer – 3 items < 1 minute Derived from NIHSSS Sensitivity 66% Specificity 87% Cannot measure posterior circulation stroke Does not assess stroke severity Face Arm Speech Test (Quick) Easy to use Can be used in medical and non-medical Assess stroke severity Los Angeles Prehospital Stroke Screening (LAPSS) < 3 minutes to perform Vessel Occlusion Sensitivity 81% Specificity 89% More Time Required to Complete Rapid Arterial Occlusion Evaluation (RACE) Assessing Stroke Severity Can Identify Large Vessel Occlusion Sensitivity 85% Specificity 69% More Time Required to Complete Miami Emergency Neurological Deficit ( MEND) combined with the Cincinnati scale Includes components of NIHSST < 3 minutes to complete unpublished research

Cincinnati Prehospital Stroke Scale (CPSS)

The Cincinnati Prehospital Stroke Scale (CPSS) was developed at the University of Cincinnati Medical Center in 1997 for prehospital use and was derived from the National Institutes of Health Stroke Scale [4][5]. CPSS is used in the prehospital setting to diagnose potential stroke with tests The following three flags [4]. If any of these tests show abnormal results, the person may have had a stroke and should be taken to the hospital as soon as possible. Patients who had 1 of these 3 findings as a new event had a 72% likelihood of having an ischemic stroke, whereas if all 3 findings met The current probability of acute stroke is greater than 85% [6].

FAST (Face, Arm, Speech Test)

FAST was developed in the UK in 1998 by a team of stroke doctor ambulance staff and emergency room doctors, and was intended to be an integral part of ambulance staff training packages. FAST is reviewing existing stroke recognition tools including Cincinnati Prehospital Stroke Scale (CPSS) and Los Angeles Prehospital Stroke Screening (LAPSS). FAST was created to expedite the administration of intravenous tissue plasminogen activator to patients within 3 hours of the onset of acute stroke symptoms. During the development process emphasized by FAST Scale It is placed to produce simple tests that will complement existing assessments used by UK nursing staff, such as the Glasgow Coma Scale. FAST incorporates the 3 key elements from the CPSS ((facial weakness, arm weakness, and speech impairment), but avoids the need to repeat sentences as a measure of speech Instead of using the caregiver’s assessment of language proficiency in normal conversations with the patient. The 3 assessments included in FAST are incorporated into the standard ambulance reporting form used to record all ambulance contacts across the UK [7]. Test now with FAST A campaign in many countries aims to help the public better understand the warning signs of a stroke, ensuring individuals get the medical attention they need more quickly.

Los Angeles Prehospital Stroke Screening (LAPSS) The Los Angeles Prehospital Stroke Screening (LAPSS) is a long-standing and widely used validated screening tool for the early identification of stroke by emergency medical technicians/paramedics. LAPSS showed 91% sensitivity and 97% specificity Following a prospective study of a field validation study of 19 UCLA paramedics following a 60-minute training session, the predictive value was 86% and the negative predictive value was 97% [8][9]. If items 1 – 6 below are all “yes” or items 5 – 7 are unknown, the LAPSS screening criteria are met. Note: A patient may still have a stroke even if the LAPSS criteria are not met. CriteriaYesNoUnknown1. Age greater than 45 years 2. Seizures or history of epilepsy 3. Neurologic symptoms onset less than 24 hours 4. Patient ambulatory prior to symptom onset 5. Blood glucose between 60 and 400 mg/dl 6. Motor exam: Check for motor asymmetry Based on the following exam in a patient with only unilateral “weakness”: Equal right facial smile/grimace drooping drooping grip strength Weak grip strength No Grip Weak Grip No Grip Arm Strength Drift Down Rapid Drift Down The Rapid Falls Los Angeles Motor Scale (LAMS) The Los Angeles Motor Scale (LAMS) is a brief 3-item stroke severity assessment measure designed for prehospital and emergency room use, derived from Los Angeles Prehospital Stroke Screening, that quantitatively describes the severity of the stroke The accuracy of domain and predicted function results was almost comparable to the full NIHSS. The Los Angeles Motor Scale (LAMS) was constructed by assigning point values to the LAPSS items of Facial Weakness (01) Arm Strength (012) and Grip Strength (012) to produce an overall 0-5 scale [10]. motor Scores from LAMS rapidly quantify stroke severity in the field and predict functional outcome with accuracy comparable to the full NIHSS and NIHSS [11]. A score ≥ 4 is highly predictive of large artery occlusion. Compared to other instruments suggested in prehospital Stroke severity assessment LAMS has the advantage of simpler and faster administration and can be derived immediately from a validated stroke recognition instrument without the need for separate examinations of stroke diagnosis and stroke severity assessment [12]. implement LAMS is an excellent strategy for identifying stroke patients in the field, assessing their severity, and determining their likelihood to be candidates for endovascular therapy. For patients with LAMS score ≥4, pre-arrival notification can be achieved by allowing early Mobilization of the endovascular team and preparation of the angiography suite [12]. The Rapid Arterial Occlusion Evaluation (RACE) Rapid Arterial Occlusion Evaluation (RACE) scale is a newly developed scale that was designed based on the National Institutes of Health Stroke Scale (NIH) to Accurate assessment of stroke severity and prehospital identification by medical emergency technicians of acute stroke patients with large artery occlusions may be candidates for endovascular techniques at a comprehensive stroke center [13]. The RACE scale needs slightly more Execution time than CPSS and LAPSS aims to more accurately identify stroke severity and localize affected regions [14]. The RACE scale is a simplification of the NIHSS scale, using those items with higher predictive power in the presence of large vessel occlusion. it Evaluation of 5 items: facial paralysis, arm paralysis, hand and foot paralysis, eye-head deviation and aphasia/agnosia, with a total score of 0-9 points. Stroke may have a score above 1 on the RACE scale, and if the cumulative score is >4 with sensitivity, emergency large vessel occlusion is possible 85% and 69% specificity. Miami Emergency Neurological Deficit (MEND) The Miami Emergency Neurological Deficit (MEND) is an easy-to-learn, easy-to-use checklist that provides key information from the three components of the Cincinnati Prehospital Stroke Scale (CPSS) and Additional components from the NIH Stroke Scale (NIHSS). MEND is designed to facilitate communication between healthcare providers throughout the stroke patient’s continuum of care, as it can be used in a prehospital setting to obtain a baseline examination followed by initial assessment and Follow-up in the emergency room or ICU. It is more thorough than CPSS, but takes less than 3 minutes to perform and requires no additional tools. In a pre-hospital setting, CPSS is performed on site and MEND examinations are performed en route to minimize transport delays.ABCD / ABCD2 ABCD / ABCD2 can be used to predict the risk of stroke in the first 7 days after a transient ischemic attack (TIA). Researchers found that TIA patients with an “ABCD score” of 6 had a greater than 30 percent risk of stroke compared with those without a stroke Low ABCD scores. Can be used in routine clinical practice to identify high-risk groups requiring urgent investigation and treatment. The ABCD2 score was created by merging two previously validated clinical decision rules – the ABCD and the California score. The ABCD score was created to Stroke risk was estimated 7 days after TIA, while the California score predicted 90-day risk. The ABCD2 score is a validated seven-point risk stratification tool for identifying patients at high risk of stroke after TIA. Patients with a score ≥4 had A stroke within 2 days of a TIA may require urgent intervention as an inpatient. The primary role of the Acute Hospital Scale is to measure deficits and stroke severity and predict patient discharge disposition. It provides a standardized neurological examination that can be used for Monitoring neurological status can also be used to match patients for comparison in clinical trials. National Institutes of Health Stroke Scale (NIHSS) The National Institutes of Health Stroke Scale (NHISS) is considered the gold standard for acute stroke assessment and is a systematic assessment Provides tools for the quantitative measurement of stroke-related neurological deficits. The NIHSS was originally designed as a research tool to measure baseline data from patients in acute stroke clinical trials. The scale is now also widely used as a clinical assessment tool to assess the severity of stroke The NIHSS can be used as a clinical stroke assessment tool to assess and document the neurologic status of acute stroke patients [15]. Stroke Scale Effectively Predicts Lesion Size and Can Be Used as a Stroke Measure seriousness. NIHSS is a predictor of short-term and long-term outcomes in stroke patients [16]. Additionally, stroke scales can be used as data collection tools for planning patient care and provide a common language for information exchange among healthcare providers. The scale is intended to be Simple, effective and reliable tool that can be used continuously at the bedside by a physician, nurse or therapist. Read more about NIHSS. Stroke severity can be stratified according to the NIHSS score as follows:[17] Very severe > 25 Severe 15 – 24 Mild to moderately severe 5 – 14 Mild 1 – 5 Scandinavian Stroke Scale (SSS) – 1985 The National Institutes of Health Stroke Scale (NIHSS) is the stroke scale of choice. The Scandinavian Stroke Scale (SSS) is an alternative stroke scale that is frequently used in clinics in Scandinavian countries and has also recently been Validated in Portuguese [18]. Inter-rater reliability of the items ranged from excellent for level of consciousness orientation and gait to moderate for facial palsy [18]. During the first week after stroke onset, neurological recovery as measured by the SSS change score showed independent predictor of good functional outcome [19]. The advantage of SSS is its simplicity, which makes it easy to perform repeated measurements in the very acute period after a stroke. In a 2016 prospective study including patients with acute stroke, the SSS was as good as the NIHSS in identifying Dead or dependent patients at 3-month follow-up [19]. According to Askim et al. (2016), although the measurement properties of the NIHSS and SSS are identical in their ability to identify results, the advantage of the SSS lies in its clinical simplicity and ease of use. one example is the difference between the two scales measuring motor function. Whereas in the NIHSS the patient is asked to hold the limb against gravity for 10 seconds which means you need a watch, in the SSS the patient has to hold the limb against manual resistance to get full marks. This advantage of SSS This is especially important when repeated measures of selected items are used to detect early neurological deterioration [19]. Canadian Neurological Scale (CNS) – 1986 The Canadian Neurological Scale (CNS) was developed in 1986 as one of the first scales to assess stroke patients Simple instrument It is used to assess and monitor the neurological status of stroke patients in the acute phase and is a valid score for assessing stroke severity [20]. A lower score indicates a more severe stroke. CNS assesses 10 clinical domains including mental status (level consciousness, direction and speech) and motor function (facial arms and legs). Previous studies have shown good to excellent agreement between raters [21][22]. CNS is transiently effective and reliable and can be completed in about five minutes [23], but should not be used for unconscious/comatose patients [24]. CNS can also be reliably converted to NIHSS using a simple conversion formula: NIHSS = 23 – 2 x CNS. This finding may have practical implications, allowing reliable comparisons with NIHSS-based assessments and simplifying routine assessment of acute stroke patients in more domains different settings [25]. CNS can be accessed here. Stroke severity can be stratified according to CNS score as follows: Mild ≥ 8 Moderate 5-7 Severe 1-4 European Stroke Scale (ESS) – 1994 European Stroke Scale (ESS) is selected according to its specificity The 14 items that make up and their prognosis This value was designed for clinical stroke trials in patients with middle cerebral artery stroke [26]. The scale can be used as a tool for matching treatment groups as well as assessing the level of impairment in patients. The scale consists of 14 items Regarding their specificity and prognostic value. The 14 items are Conscious Comprehension Level Speech Visual Field Gaze Facial Movement Arm Posture Arm Raise Wrist Extension Finger Strength Leg Flexion Dorsiflexion and Maintenance of Gait. because the gait is This item is included in the scale as part of a standard clinical neurological assessment and can be considered as a mixture of impairments at different prognostic levels (i.e., proximal and distal motor functions for postural control of the legs) [26]. This scale is weighted towards sports Function. The scale is reliable, sensitive and easy to use, with prognostic value for the outcome. Its concurrent validity was tested in terms of correlation with other neurological scales and with the Motor Function and Impairment scale. ESS can be used to assess recent A stroke involves the distribution of the middle cerebral artery. This can be used to measure treatment effects and match patients for comparison. Functional and outcome assessment scales Prehospital and acute scales focus more on impairments such as hemiplegia awareness gaze deviation Abnormal myotonic reflexes and intellectual function abnormalities in the acute phase are of great significance for auxiliary diagnosis and prognosis. During the recovery and more chronic phases of stroke, these types of measurements tend to be less important as the focus shifts more to Performance on functional tasks. For the patient, the most important aspect of his disease is not the specific degree of impairment, such as the grade of hemiplegia, but more their ability to carry out daily activities and fulfill social roles. As highlighted by Harrison et al. (2013), stroke is a Exemplary long-term conditional measures of disabling function are well suited as outcome assessments [27]. Functional assessment scales are used to assign numerical values to abstract concepts such as “disability” and they can be used to objectively quantify deficits and track changes time. This is especially useful in a rehabilitation setting. The following Physiopedia pages outline a range of outcome measures that provide the best available information on how outcome measures are categorized and selected for use based on measurement quality Outcome measurement overview. Here are some of the more common functional and outcome assessment scales currently in use in stroke care and management: Barthel IndexBerg BalanceChedoke Arm and Hand Activity InventoryDynamic Gait IndexFugl-Meyer Assessment of Motor Recovery after StrokeMotor Assessment Scale Rivermead Mobility Index Outcome Assessment Scale Summary There are a number of scoring systems available for on-site screening for acute ischemic stroke. EMS teams most often use the Face Arm Speech Test (FAST), the Cincinnati Prehospital Stroke Scale (CPSS), or the Los Angeles Prehospital Stroke Screening (mistake). Many of the more commonly used stroke scales are not designed to identify posterior circulation strokes [28]. The most commonly used scale in the hospital setting is the NIHSS. For prehospital assessment, a shortened version was developed, including assessment of gaze field movement Facial paralysis and dysarthria at the level of language function awareness of the left and right legs. It attempts to predict stroke severity, but is more complex than some other stroke scales. Due to its complexity, it can evaluate strokes other than the middle cerebral artery distribution [28]. Current prehospital management recommendations [28] Class A recommendation The A Stroke Scale should be used in the prehospital setting of any patient with an acute neurologic deficit to rapidly assess and classify patients at risk for stroke [28]. currently no practical A prehospital scale that accurately detects stroke outside the distribution of the middle cerebral artery [29]. CPSS and LAPSS are the most valid and commonly used scales [28]. World Health Organization International Classification of Disability and Health (WHO-ICF) A conceptual framework is given that can aid in the taxonomy of stroke assessment scales to identify appropriate measures for specific functional assessments. The ICF serves as a framework for addressing patient care, shifting the conceptual focus away from negative connotations such as Disability and place focuses on the individual’s ability to be active at the patient level rather than at the system level. The ICF framework is a taxonomy of the health components of functioning and disability, focusing on 3 perspectives: physical individual and social. These 3 perspectives Emphasize the importance of the interaction and influence of internal and external factors on the health status of each individual. Clinicians and researchers working with stroke survivors have access to a number of assessment tools that span different functional domains.