From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands.
Neurology. 2023 Dec 12;101(24):e2522-e2532. doi: 10.1212/WNL.0000000000207831. Epub 2023 Oct 17.
Endovascular thrombectomy (EVT) is standard treatment for anterior large vessel occlusion stroke (LVO-a stroke). Prehospital diagnosis of LVO-a stroke would reduce time to EVT by allowing direct transportation to an EVT-capable hospital. We aim to evaluate the diagnostic accuracy of dry electrode EEG for the detection of LVO-a stroke in the prehospital setting.
ELECTRA-STROKE was an investigator-initiated, prospective, multicenter, diagnostic study, performed in the prehospital setting. Adult patients were eligible if they had suspected stroke (as assessed by the attending ambulance nurse) and symptom onset <24 hours. A single dry electrode EEG recording (8 electrodes) was performed by ambulance personnel. Primary endpoint was the diagnostic accuracy of the theta/alpha frequency ratio for LVO-a stroke (intracranial ICA, A1, M1, or proximal M2 occlusion) detection among patients with EEG data of sufficient quality, expressed as the area under the receiver operating characteristic curve (AUC). Secondary endpoints were diagnostic accuracies of other EEG features quantifying frequency band power and the pairwise derived Brain Symmetry Index. Neuroimaging was assessed by a neuroradiologist blinded to EEG results.
Between August 2020 and September 2022, 311 patients were included. The median EEG duration time was 151 (interquartile range [IQR] 151-152) seconds. For 212/311 (68%) patients, EEG data were of sufficient quality for analysis. The median age was 74 (IQR 66-81) years, 90/212 (42%) were women, and the median baseline NIH Stroke Scale was 1 (IQR 0-4). Six (3%) patients had an LVO-a stroke, 109/212 (51%) had a non-LVO-a ischemic stroke, 32/212 (15%) had a transient ischemic attack, 8/212 (4%) had a hemorrhagic stroke, and 57/212 (27%) had a stroke mimic. AUC of the theta/alpha ratio was 0.80 (95% CI 0.58-1.00). Of the secondary endpoints, the pairwise derived Brain Symmetry Index in the delta frequency band had the highest diagnostic accuracy (AUC 0.91 [95% CI 0.73-1.00], sensitivity 80% [95% CI 38%-96%], specificity 93% [95% CI 88%-96%], positive likelihood ratio 11.0 [95% CI 5.5-21.7]).
The data from this study suggest that dry electrode EEG has the potential to detect LVO-a stroke among patients with suspected stroke in the prehospital setting. Toward future implementation of EEG in prehospital stroke care, EEG data quality needs to be improved.
ClinicalTrials.gov identifier: NCT03699397.
This study provides Class II evidence that prehospital dry electrode scalp EEG accurately detects LVO-a stroke among patients with suspected acute stroke.
血管内血栓切除术（EVT）是治疗前循环大血管闭塞性卒中（LVO-a 卒中）的标准治疗方法。前循环 LVO-a 卒中的院前诊断可通过直接将患者转运至 EVT 能力医院，从而缩短 EVT 时间。本研究旨在评估干电极脑电图（EEG）在院前环境中诊断 LVO-a 卒中的准确性。
ELECTRA-STROKE 是一项由研究者发起的、前瞻性的、多中心的诊断性研究，在院前环境中进行。如果疑似卒中（由救护车护士评估）且症状发作时间＜24 小时的成年患者符合入组条件。由救护车人员进行单次干电极 EEG 记录（8 个电极）。主要终点是 EEG 数据质量足够的患者中，θ/α 频率比检测 LVO-a 卒中（颅内 ICA、A1、M1 或近端 M2 闭塞）的诊断准确性，以受试者工作特征曲线下面积（AUC）表示。次要终点是量化频带功率的其他 EEG 特征和源自成对的脑对称指数的诊断准确性。神经影像学由一位对 EEG 结果不知情的神经放射科医生进行评估。
2020 年 8 月至 2022 年 9 月，共纳入 311 例患者。中位 EEG 持续时间为 151（四分位距 [IQR] 151-152）秒。对于 212/311（68%）例患者，有足够质量的 EEG 数据进行分析。中位年龄为 74（IQR 66-81）岁，90/212（42%）例患者为女性，中位基线 NIH 卒中量表评分为 1（IQR 0-4）。6 例（3%）患者有 LVO-a 卒中，109/212（51%）例患者有非 LVO-a 缺血性卒中，32/212（15%）例患者有短暂性脑缺血发作，8/212（4%）例患者有出血性卒中，57/212（27%）例患者为卒中模拟症。θ/α 比值的 AUC 为 0.80（95%CI 0.58-1.00）。在次要终点中，来自成对的脑对称指数在 delta 频带中的诊断准确性最高（AUC 0.91[95%CI 0.73-1.00]，敏感性 80%[95%CI 38%-96%]，特异性 93%[95%CI 88%-96%]，阳性似然比 11.0[95%CI 5.5-21.7]）。
本研究数据表明，干电极脑电图有可能在院前环境中检测疑似卒中患者的 LVO-a 卒中。为了将 EEG 应用于院前卒中护理，需要提高 EEG 数据质量。
本研究提供了 II 级证据，表明干电极头皮脑电图可准确诊断疑似急性卒中患者的 LVO-a 卒中。
