Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

Stroke. 2016 Jun;47(6):1466-72. doi: 10.1161/STROKEAHA.116.013144. Epub 2016 Apr 28.


Background and purpose: It remains debated whether clinical scores can help identify acute ischemic stroke patients with large-artery occlusion and hence improve triage in the era of thrombectomy. We aimed to determine the accuracy of published clinical scores to predict large-artery occlusion.

Methods: We assessed the performance of 13 clinical scores to predict large-artery occlusion in consecutive patients with acute ischemic stroke undergoing clinical examination and magnetic resonance or computed tomographic angiography ≤6 hours of symptom onset. When no cutoff was published, we used the cutoff maximizing the sum of sensitivity and specificity in our cohort. We also determined, for each score, the cutoff associated with a false-negative rate ≤10%.

Results: Of 1004 patients (median National Institute of Health Stroke Scale score, 7; range, 0-40), 328 (32.7%) had an occlusion of the internal carotid artery, M1 segment of the middle cerebral artery, or basilar artery. The highest accuracy (79%; 95% confidence interval, 77-82) was observed for National Institute of Health Stroke Scale score ≥11 and Rapid Arterial Occlusion Evaluation Scale score ≥5. However, these cutoffs were associated with false-negative rates >25%. Cutoffs associated with an false-negative rate ≤10% were 5, 1, and 0 for National Institute of Health Stroke Scale, Rapid Arterial Occlusion Evaluation Scale, and Cincinnati Prehospital Stroke Severity Scale, respectively.

Conclusions: Using published cutoffs for triage would result in a loss of opportunity for ≥20% of patients with large-artery occlusion who would be inappropriately sent to a center lacking neurointerventional facilities. Conversely, using cutoffs reducing the false-negative rate to 10% would result in sending almost every patient to a comprehensive stroke center. Our findings, therefore, suggest that intracranial arterial imaging should be performed in all patients with acute ischemic stroke presenting within 6 hours of symptom onset.

Keywords: basilar artery; middle cerebral artery; stroke; thrombectomy; triage.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arterial Occlusive Diseases / diagnosis*
  • Arterial Occlusive Diseases / diagnostic imaging
  • Arterial Occlusive Diseases / therapy
  • Brain Ischemia / diagnosis*
  • Brain Ischemia / diagnostic imaging
  • Brain Ischemia / therapy
  • Carotid Stenosis / diagnosis
  • Carotid Stenosis / diagnostic imaging
  • Cerebral Arteries / diagnostic imaging
  • Cohort Studies
  • Endovascular Procedures / statistics & numerical data
  • False Negative Reactions
  • Female
  • Humans
  • Magnetic Resonance Angiography
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Reproducibility of Results
  • Stroke / diagnosis*
  • Stroke / diagnostic imaging
  • Stroke / therapy
  • Thrombolytic Therapy / statistics & numerical data
  • Tomography, X-Ray Computed
  • Triage / methods