Analysis on the Predictive Value of Modified Cincinnati Prehospital Stroke Severity Scale for Acute Large Vessel Occlusion in Anterior Circulation

doi:10.3969/j.issn.1673-5765.2021.07.009

Abstract

Abstract: Objective To modify Cincinnati prehospital stroke severity scale (CPSSS) by adding atrial fibrillation (AF), and evaluate the predictive value of modified CPSSS (mCPSSS) for large vessel occlusion (LVO) in anterior circulation. Methods This retrospective analysis enrolled the patients with acute ischemic stroke in anterior circulation in Comprehensive Stroke Center, Yongchuan Hospital of Chongqing Medical University between May 2019 and April 2020. Univariate and multivariate logistic regression analysis were used to analyze the association of the items of CPSSS and AF with LVO, and the mCPSSS containing CPSSS and AF was formed. ROC curve and the area under the curve (AUC) were used to evaluate the predictive ability for LVO in anterior circulation of the mCPSSS, CPSSS and other stroke assessment scales such as vision, aphasia, neglect (VAN), 3 item stroke scale (3I-SS) and

rapid arterial occlusion evaluation (RACE).

Results A total of 263 patients were included in this study. Gaze deviation, consciousness and response, upper limb weakness and AF were independent predictors of LVO in anterior circulation. When the point value of AF was defined as 1 point, the AUC of mCPSSS was 0.955; when defined as 2 points, the AUC was 0.950. For mCPSSS, the optimal cut-off value for predicting LVO was 2 points, with a sensitivity of 90.16% and a specificity of 94.33%. The capability of predicting LVO in anterior circulation of mCPSSS was superior to CPSSS, VAN, 3I-SS and RACE scales (all P <0.05, Delong’s test). Conclusions For predicting LVO in anterior circulation, the mCPSSS was superior to the other common stroke scales, which can be used for pre-hospital identification, emergency and in-hospital triage of acute LVO in anterior circulation.

Key words: Stoke scale; Large vessel occlusion; Acute ischemic stroke; Atrial fibrillation;Cincinnati pre-hospital stroke severity scale

摘要： 目的在辛辛那提院前卒中严重程度量表（Cincinnati prehospital stroke severity scale，CPSSS）基础上加入心房颤动项目构建改良CPSSS（modified CPSSS，mCPSSS），评估mCPSSS对急性前循环大血管闭塞（large vessel occlusion，LVO）的预测能力。方法回顾性分析2019年5月-2020年4月在重庆医科大学附属永川医院国家高级卒中中心就诊的急性前循环脑梗死患者的临床资料，运用单因素和二元logistic回归分析检验CPSSS量表项目及心房颤动与LVO的相关性，构建加入心房颤动指标的mCPSSS。通过ROC曲线及曲线下面积（areas under the curve， AUC）评估mCPSSS及CPSSS，视野、失语、忽视量表（vision，aphasia，neglect，VAN），三项内容卒中量表（3 item stroke scale，3I-SS）和快速动脉闭塞量表（rapid arterial occlusion evaluation，RACE）等卒中量表对前循环LVO的预测价值。结果共纳入263例患者。凝视、意识水平及提问、上肢无力、心房颤动是前循环LVO的独立预测因素。将心房颤动纳入CPSSS，并根据ROC曲线分析结果将其取值为1分（心房颤动取值1分，AUC=0.955；心房颤动取值2分，AUC=0.950）。mCPSSS总分≥2分预测前循环LVO的灵敏度为90.16%，特异度为 94.33%。mCPSSS的预测价值高于CPSSS、VAN、3I-SS和RACE量表（均P＜0.05，DeLong's检验）。结论 mCPSSS量表对前循环LVO的预测价值优于其他常用卒中量表，可能有助于急性前循环LVO患者的院前识别、急救及院内分诊。

关键词: 卒中量表; 大血管闭塞; 急性缺血性卒中; 心房颤动; 辛辛那提院前卒中严重程度量表

LIU Ting, LIAO Juan, LIU Li, ZHAO Li-Bo, LIU Shu-Dong, XU Lu, ZHOU Ting, YANG De-Yu. Analysis on the Predictive Value of Modified Cincinnati Prehospital Stroke Severity Scale for Acute Large Vessel Occlusion in Anterior Circulation[J]. Chinese Journal of Stroke, 2021, 16(07): 687-693.

刘婷, 廖娟, 刘莉, 赵立波, 刘曙东, 徐露, 周婷, 杨德雨. 改良CPSSS量表对急性前循环大血管闭塞性脑梗死的预测价值分析[J]. 中国卒中杂志, 2021, 16(07): 687-693.

References

[1] BERKHEMER O A，FRANSEN P S S，BEUMER D，
et al. A randomized trial of intraarterial treatment
for acute ischemic stroke[J]. N Engl J Med，2015，372
（1）：11-20.
[2] GOYAL M，DEMCHUK A M，MENON B K，et
al. Randomized assessment of rapid endovascular
treatment of ischemic stroke[J]. N Engl J Med，2015，
372（11）：1019-1030.
[3] CAMPBELL B C V，MITCHELL P J，KLEINIG T J，
et al. Endovascular therapy for ischemic stroke with
perfusion-imaging selection[J]. N Engl J Med，2015，
372（11）：1009-1018.
[4] SAVER J L，GOYAL M，BONAFE A，et al. Stentretriever
thrombectomy after intravenous t-PA vs
t-PA alone in stroke[J]. N Engl J Med，2015，372
（24）：2285-2295.
[5] JOVIN TUDOR G，CHAMORRO ANGEL，COBO
ERIK，et al. Thrombectomy within 8 hours after
symptom onset in ischemic stroke[J]. N Engl J Med，
2015，372（24）：2296-2306.
[6] HELDNER M R，ZUBLER C，MATTLE H P，et al.
National Institutes of health stroke scale score and
vessel occlusion in 2152 patients with acute ischemic
stroke[J]. Stroke，2013，44（4）：1153-1157.
[7] KATZ B S，MCMULLAN J T，SUCHAREW H，et
al. Design and validation of a prehospital scale to
predict stroke severity：Cincinnati prehospital stroke
severity scale[J]. Stroke，2015，46（6）：1508-1512.
[8] SMITH ERIC E，KENT D M，BULSARA K
R，et al. Accuracy of prediction instruments for
diagnosing large vessel occlusion in individuals
with suspected stroke：a systematic review for the
2018 guidelines for the early management of patients
with acute ischemic stroke[J/OL]. Stroke，2018，49
（3）：e111-e122[2020-11-12]. https：//doi.org/10.1161/
str.0000000000000160.
[9] HELDNER M R，HSIEH K，BROEG-MORVAY A，
et al. Clinical prediction of large vessel occlusion in
anterior circulation stroke：mission impossible?[J]. J
Neurol，2016，263（8）：1633-1640.
[10] TURC G，MAÏER B，NAGGARA O，et al. Clinical
scales do not reliably identify acute ischemic stroke

patients with large-artery occlusion[J]. Stroke，2016，

47（6）：1466-1472.
[11] KUMMER B R，GIALDINI G，SEVUSH J L，et
al. External validation of the cincinnati prehospital
stroke severity scale[J]. J Stroke Cerebrovasc Dis，
2016，25（5）：1270-1274.
[12] HESHMATOLLAH A，FRANSEN P S
S，BERKHEMER O A，et al. Endovascular
thrombectomy in patients with acute ischaemic
stroke and atrial fibrillation：a MR CLEAN
subgroup analysis[J]. EuroIntervention，2017，13（8）：
996-1002.
[13] GO A S，HYLEK E M，PHILLIPS K A，et al.
Prevalence of diagnosed atrial fibrillation in adults：
National implications for rhythm management and
stroke prevention：the anticoagulation and risk
factors in atrial fibrillation（ATRIA）study[J]. JAMA，
2001，285（18）：2370-2375.
[14] NARWAL P，CHANG A D，GRORY B M，et al.
The addition of atrial fibrillation to the Los Angeles
motor scale may improve prediction of large vessel
occlusion[J]. J Neuroimaging，2019，29（4）：463-
466.
[15] OHTA T，NAKAHARA I，MATSUMOTO
S，et al. Optimizing in-hospital triage for large
vessel occlusion using a novel clinical scale
（GAIAA）[J/OL]. Neurology，2019，93（22）：
e1997-e2006[2020-11-12]. https：//doi.org/10.1212/
wnl.0000000000008550.
[16] 中华医学会神经病学分会，中华医学会神经病学分
会脑血管病学组. 中国急性缺血性脑卒中诊治指南
2018[J]. 中华神经科杂志，2018，51（9）：666-682.
[17] LIMA F O，SILVA G S，FURIE K L，et al. Field
assessment stroke triage for emergency destination：
a simple and accurate prehospital scale to detect
large vessel occlusion strokes[J]. Stroke，2016，47
（8）：1997-2002.
[18] SINGER O C，DVORAK F，DU MESNIL DE
ROCHEMONT R，et al. A simple 3-item stroke scale：
comparison with the National Institutes of Health
Stroke Scale and prediction of middle cerebral artery
occlusion[J]. Stroke，2005，36（4）：773-776.
[19] HASTRUP S，DAMGAARD D，JOHNSEN S P，et
al. Prehospital acute stroke severity scale to predict
large artery occlusion：design and comparison with
other scales[J]. Stroke，2016，47（7）：1772-1776.
[20] TELEB MOHAMED S，VER HAGE A，CARTER
J，et al. Stroke vision，aphasia，neglect（VAN）
assessment-a novel emergent large vessel occlusion
screening tool：pilot study and comparison with
current clinical severity indices[J]. J Neurointerv
Surg，2017，9（2）：122-126.
[21] PÉREZ DE LA OSSA N，CARRERA D，GORCHS
M，et al. Design and validation of a prehospital
stroke scale to predict large arterial occlusion：the
rapid arterial occlusion evaluation scale[J]. Stroke，
2014，45（1）：87-91.
[22] DELONG E R，DELONG D M，CLARKEPEARSON
D L. Comparing the areas under two or
more correlated receiver operating characteristic
curves：a nonparametric approach[J]. Biometrics，
1988，44（3）：837-845.
[23. RICHARDS C T，HUEBINGER R，TATARIS K L，
et al. Cincinnati prehospital stroke scale can identify
large vessel occlusion stroke[J]. Prehosp Emerg Care，
2018，22（3）：312-318.
[24] LANSBERG M G，CEREDA C W，MLYNASH M，
et al. Response to endovascular reperfusion is not
time-dependent in patients with salvageable tissue[J].
Neurology，2015，85（8）：708-714.
[25] NOGUEIRA R G，JADHAV A P，HAUSSEN D C，
et al. Thrombectomy 6 to 24 hours after stroke with
a mismatch between deficit and infarct[J]. N Engl J
Med，2018，378（1）：11-21.
[26] ALBERS G W，MARKS M P，KEMP S，et al.
Thrombectomy for stroke at 6 to 16 hours with
selection by perfusion imaging[J]. N Engl J Med，
2018，378（8）：708-718.
[27] GREWAL P，LAHOTI S，AROOR S，et al. Effect
of known atrial fibrillation and anticoagulation
status on the prehospital identification of large vessel
occlusion[J/OL]. J Stroke Cerebrovasc Dis，2019，28
（12）：104404[2020-11-12]. https：//doi.org/10.1016/j.
jstrokecerebrovasdis.2019.104404.
[28] PETER S，LEONHARD S，ALEXANDRA P，et al.
Prehospital and intra-hospital time delays in posterior
circulation stroke：results from the Austrian Stroke
Unit Registry[J]. J Neurol，2017，264（1）：131-138.