Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Col. Sección XVI Belisario Domínguez, Tlalpan, C. P, 14080, Ciudad de México, Mexico.
Unidad de Biología Molecular, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico.
Neurol Sci. 2021 Aug;42(8):3217-3224. doi: 10.1007/s10072-020-04929-x. Epub 2020 Nov 25.
The prompt recognition of an acute neurovascular syndrome by the patient or a bystander witnessing the event can directly influence outcome. We aimed to study the predictive value of the medical history and clinical features recognized by the patients' bystanders to preclassify acute stroke syndromes in prehospital settings.
We analyzed 369 patients: 209 (56.6%) with acute ischemic stroke (AIS), 107 (29.0%) with intracerebral hemorrhage (ICH), and 53 (14.4%) with subarachnoid hemorrhage (SAH). All patients had neuroimaging as diagnostic gold standard. We constructed clinical prediction rules (CPRs) with features recognized by the bystanders witnessing the stroke onset to classify the acute neurovascular syndromes before final arrival to the emergency room (ER).
In all, 83.2% cases were referred from other centers, and only 16.8% (17.2% in AIS, 15% in ICH, and 18.9% in SAH) had direct ER arrival. The time to first assessment in ≤ 3 h occurred in 72.4% (73.7%, 73.8%, and 64.2%, respectively), and final ER arrival in ≤ 3 h occurred in 26.8% (32.1%, 15.9%, and 28.3%, respectively). Clinical features referred by witnesses had low positive predictive values (PPVs) for stroke type prediction. Language or speech disorder + focal motor deficit showed 63.3% PPV, and 77.0% negative predictive value (NPV) for predicting AIS. Focal motor deficit + history of hypertension had 35.9% PPV and 78.8% NPV for ICH. Headache alone had 27.9% PPV and 95.3% NPV for SAH. In multivariate analyses, seizures, focal motor deficit, and hypertension increased the probability of a time to first assessment in ≤ 3 h, while obesity was inversely associated. Final ER arrival was determined by age and a direct ER arrival without previous referrals.
CPRs constructed with the witnesses' narrative had only adequate NPVs in the prehospital classification of acute neurovascular syndromes, before neuroimaging confirmation.
患者或目睹事件发生的旁观者能够迅速识别出急性神经血管综合征，这可能直接影响到预后。我们旨在研究患者旁观者识别的病史和临床特征对预分类院前急性卒中综合征的预测价值。
我们分析了 369 名患者：209 名（56.6%）为急性缺血性卒中（AIS），107 名（29.0%）为脑出血（ICH），53 名（14.4%）为蛛网膜下腔出血（SAH）。所有患者均接受神经影像学检查作为诊断金标准。我们构建了临床预测规则（CPRs），使用旁观者目击卒中发作时识别的特征来对到达急诊室（ER）前的急性神经血管综合征进行分类。
共有 83.2%的病例来自其他中心，只有 16.8%（AIS 为 17.2%，ICH 为 15%，SAH 为 18.9%）直接到达 ER。≤3 小时内首次评估的时间占 72.4%（分别为 73.7%、73.8%和 64.2%），≤3 小时内最终到达 ER 的时间占 26.8%（分别为 32.1%、15.9%和 28.3%）。目击者报告的临床特征对卒中类型预测的阳性预测值（PPV）较低。语言或言语障碍+局灶性运动缺陷的 AIS 预测 PPV 为 63.3%，NPV 为 77.0%。局灶性运动缺陷+高血压史的 ICH 预测 PPV 为 35.9%，NPV 为 78.8%。单纯头痛的 SAH 预测 PPV 为 27.9%，NPV 为 95.3%。多变量分析显示，癫痫发作、局灶性运动缺陷和高血压增加了≤3 小时内首次评估的概率，而肥胖则呈负相关。最终到达 ER 是由年龄和直接到达 ER 而无前期转诊决定的。
在神经影像学确认之前，基于目击者描述构建的 CPR 在急性神经血管综合征的院前分类中仅有足够的 NPV。
