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Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke
  1. Lee Birnbaum1,
  2. David Wampler2,
  3. Arash Shadman3,
  4. Mateja de Leonni Stanonik3,
  5. Michele Patterson4,
  6. Emily Kidd5,
  7. Jeanette Tovar6,
  8. Ashley Garza6,
  9. Bonnie Blanchard7,
  10. Lara Slesnick8,
  11. Adam Blanchette7,
  12. David Miramontes2
  1. 1Neurosurgery, UTHSC at San Antonio, San Antonio, Texas, USA
  2. 2Emergency Health Sciences, UTHSC at San Antonio, San Antonio, Texas, USA
  3. 3Neurology, UTHSC at San Antonio, San Antonio, Texas, USA
  4. 4Clinical Services, Saint Luke's Baptist Hospital, San Antonio, Texas, USA
  5. 5Acadian Ambulance Service, San Antonio, Texas, USA
  6. 6Neurosciences, University Hospital, San Antonio, Texas, USA
  7. 7Methodist Healthcare System of San Antonio Ltd, San Antonio, Texas, USA
  8. 8School of Medicine, UTHSC at San Antonio, San Antonio, Texas, USA
  1. Correspondence to Dr Lee Birnbaum, Neurosurgery, UTHSC at San Antonio, San Antonio, TX 78229, USA; birnbaum{at}


Background Numerous stroke severity scales have been published, but few have been studied with emergency medical services (EMS) in the prehospital setting. We studied the Vision, Aphasia, Neglect (VAN) stroke assessment scale in the prehospital setting for its simplicity to both teach and perform. This prospective prehospital cohort study was designed to validate the use and efficacy of VAN within our stroke systems of care, which includes multiple comprehensive stroke centers (CSCs) and EMS agencies.

Methods The performances of VAN and the National Institutes of Health Stroke Scale (NIHSS) ≥6 for the presence of both emergent large vessel occlusion (ELVO) alone and ELVO or any intracranial hemorrhage (ICH) combined were reported with positive predictive value, sensitivity, negative predictive value, specificity, and overall accuracy. For subjects with intraparenchymal hemorrhage, volume was calculated based on the ABC/2 formula and the presence of intraventricular hemorrhage was recorded.

Results Both VAN and NIHSS ≥6 were significantly associated with ELVO alone and with ELVO or any ICH combined using χ2 analysis. Overall, hospital NIHSS ≥6 performed better than prehospital VAN based on statistical measures. Of the 34 cases of intraparenchymal hemorrhage, mean±SD hemorrhage volumes were 2.5±4.0 mL for the five VAN-negative cases and 17.5±14.2 mL for the 29 VAN-positive cases.

Conclusions Our VAN study adds to the published evidence that prehospital EMS scales can be effectively taught and implemented in stroke systems with multiple EMS agencies and CSCs. In addition to ELVO, prehospital scales such as VAN may also serve as an effective ICH bypass tool.

  • stroke
  • thrombectomy
  • hemorrhage
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  • Twitter @DavidWampler17, @mstanonik

  • Contributors LB: planning, conduct, and reporting. DW: planning, conduct, and reporting. AS: reporting. MdLS: conduct and reporting. MP: planning, conduct, and reporting. EK: planning, conduct, and reporting. JT: planning and conduct. AG: planning and conduct. BB: planning and conduct. LS: planning and conduct. AB: planning and conduct. DM: planning, conduct, and reporting.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either expressed or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The data is deidentified, retrospective from stroke alert patients in San Antonio, Texas. Reuse is permitted upon a reasonable request.

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