Background and purpose Most patients with stroke-like symptoms screened by advanced imaging for proximal occlusion will not have a thrombus accessible by neurointerventional techniques. Development of a sensitive clinical scoring system for rapidly identifying patients with an emergent large vessel occlusion could help target limited resources and reduce exposure to unnecessary imaging.
Methods This historical cohort study included patients who underwent non-contrast CT and CT angiography in the emergency department for stroke-like symptoms. NIH Stroke Scale (NIHSS) criteria were extended to include resolved symptoms and dichotomized as present or absent. Combinations of NIHSS criteria were considered as tests for proximal occlusion.
Results Proximal cerebral vascular occlusion was present in 19.2% (100/522) of the population and, of these, 13% (13/100) had an NIHSS score of 0. The presence on examination or history of diminished consciousness with inability to answer questions, leg weakness, dysarthria, or gaze deviation had 96% sensitivity and 39% specificity for proximal occlusion. If implemented in this population, the use of CT angiography would have been decreased by 32.4% (169/522 patients) while missing 0.76% with proximal occlusions (4/522). Half of those missed (2/4) would have been identified as large vessel infarcts on non-contrast CT, while the remainder (2/4) were transient ischemic attacks associated with carotid stenosis.
Conclusions In this cohort, specific NIHSS criteria were highly sensitive for emergent large vessel occlusion and, if validated, may allow for clinical screening prior to advanced imaging with CT angiography.
- CT Angiography
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Contributors RDM: study design, data collection, data analysis, manuscript authoring, editing, submission. JCJ: study design, data collection, manuscript authoring, editing. SLV: data collection, manuscript authoring, editing. SDQ: study design, analysis, editing. BWB: study design, manuscript authoring, editing. All authors have provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Competing interests None declared.
Ethics approval Ethics approval was obtained from the Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.