Turc Guillaume, Maïer Benjamin, Naggara Olivier, Seners Pierre, Isabel Clothilde, Tisserand Marie, Raynouard Igor, Edjlali Myriam, Calvet David, Baron Jean-Claude, Mas Jean-Louis, Oppenheim Catherine
From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.).
Stroke. 2016 Jun;47(6):1466-72. doi: 10.1161/STROKEAHA.116.013144. Epub 2016 Apr 28.
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.
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%.
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.
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.
临床评分能否有助于识别伴有大动脉闭塞的急性缺血性脑卒中患者，进而在血栓切除术时代改善分诊，这一问题仍存在争议。我们旨在确定已发表的临床评分预测大动脉闭塞的准确性。
我们评估了13种临床评分在连续的急性缺血性脑卒中患者中预测大动脉闭塞的性能，这些患者在症状发作≤6小时时接受了临床检查以及磁共振或计算机断层血管造影。当未公布临界值时，我们使用在我们的队列中使敏感性和特异性之和最大化的临界值。我们还为每个评分确定了与假阴性率≤10%相关的临界值。
在1004例患者中（美国国立卫生研究院卒中量表评分中位数为7；范围为0 - 40），328例（32.7%）患有颈内动脉、大脑中动脉M1段或基底动脉闭塞。美国国立卫生研究院卒中量表评分≥11且快速动脉闭塞评估量表评分≥5时观察到最高准确性（79%；95%置信区间，77 - 82）。然而，这些临界值的假阴性率>25%。美国国立卫生研究院卒中量表、快速动脉闭塞评估量表和辛辛那提院前卒中严重程度量表与假阴性率≤10%相关的临界值分别为5、1和0。
使用已公布的临界值进行分诊会导致≥20%的伴有大动脉闭塞的患者失去机会，这些患者会被不恰当地送往缺乏神经介入设施的中心。相反，使用将假阴性率降低到10%的临界值会导致几乎将每个患者都送往综合卒中中心。因此，我们的研究结果表明，所有在症状发作6小时内就诊的急性缺血性脑卒中患者均应进行颅内动脉成像。
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