STROKE BY THE NUMBERS South Carolina Stroke RACE Rapid Arterial oCclusion Evaluation created by SCD DHEC Bureau of EMS History
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S T R O K E B Y T H E N U M B E R S
South Carolina Stroke RACERapid Arterial oCclusion Evaluation
created by SCD DHEC Bureau of EMSHistory
Historical Context EMS is the first medical contact in over 50% of all stroke victims in U.S.
Unless the patient had altered LOC, strokes were treated as non‐emergent events and transported routine to ER
Prehospital care seen only as supportive and permanent disability was seen as inevitable, much like cardiac arrest in the 70’s
Typically Cincinnati Stroke Scale used to confirm stoke event
MEND and NIHSS taught in school but rarely used in field
EMS & Strokes
System
Stroke Care in South Carolina
South Carolina now has the third best “door to balloon” time for STEMI care in the United States.1
No reason why stroke care should not follow suit Currently there are 21 designated stroke centers in South Carolina: HFAP – 1, DNV – 2 TJC – 18
Most EMS services have adopted State Stroke Protocol: “The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than 8 hours, scene times should be limited to 10 minutes, early destination notification / activation should be provided and transport times should be minimized based on the EMS System Stroke Plan.”
(1) SCHA, 2013Time issues
Time Context Greatest portion of delay between
onset of symptoms and emergency care is the time it takes for a patient to recognize the signs of stroke and decide to seek medical attention.
Between 50‐75% of ischemic stroke patients do not arrive at hospital within 3‐hours.
Value of early identifying an LVO in the field and pre‐notifying the stroke center
EMS & Strokes
Criteria
What criteria do we use / need?
Following the model and success of STEMI care in the field, (TIME =Cardiac muscle) prehospital pre‐notification is essential to advance stroke care since (TIME = Brain)
There are many developed stroke scale models available for field use. Most used by EMS only capture sensitivity for + or – to rule in/out a stroke
Early detection of LVO (or ELVO) is as essential to stroke care as ST elevation to STEMIs
Qualitative Score (+/‐) vs. Quantitative Score (# value) NIHSS is the “gold standard” by which all stroke scales are based.
Need for a quantitative SS that has been validated with EMS data and is correlated to the NIHSS (“gold standard”) that can detect an LVO.
12
“We need a 12 Lead for your head”
For the Record…
Stroke by the NumbersStroke Scale Items
NIHSS
CPSS
FAST
FAST-
ED
zNIHSS
sNIHSS5
sNIHSS8
MENDS
LAPSS
LAMS
MENS
AVPU
RACE
LOC X X X X X
LOC Questions X X X
LOC Commands X X X X X X
Gaze X X X X X X X X
Visual Fields X X X X X X
Facial Palsy X X X X X X X
Motor Arm Drift Left X X X X X X X X
Motor Arm Drift Right X X X X X X X X
Motor Leg Drift Left X X X X X X
Motor Leg Drift Right X X X X X X
Limb Ataxia X X
Sensory X X
Language X X X X X X X
Dysarthria X X X X X X X
Extinction X X X
Grip X
Stroke by the NumbersStroke Scale Items
NIHSS
CPSS
FAST
FAST-
ED
zNIHSS
sNIHSS5
sNIHSS8
MENDS
LAPSS
LAMS
MENS
AVPU
RACE
LOC X X X X X
LOC Questions X X X
LOC Commands X X X X X X
Gaze X X X X X X X X
Visual Fields X X X X X X
Facial Palsy X X X X X X X
Motor Arm Drift Left X X X X X X X X
Motor Arm Drift Right X X X X X X X X
Motor Leg Drift Left X X X X X X
Motor Leg Drift Right X X X X X X
Limb Ataxia X X
Sensory X X
Language X X X X X X X
Dysarthria X X X X X X X
Extinction X X X
Grip X
Stroke by the NumbersStroke Scale Items
NIHSS
FASTED
zNIHSS
sNIHSS5
sNIHSS8
LAMS
MENS
RACE
LOC X X X
LOC Questions X
LOC Commands X X X
Gaze X X X X X X X
Visual Fields X X X X X
Facial Palsy X X X X
Motor Arm Drift Left X X X X
Motor Arm Drift Right X X X X
Motor Leg Drift Left X X X X X
Motor Leg Drift Right X X X X X
Limb Ataxia X
Sensory X
Language X X X X X X X
Dysarthria X X X X
Extinction X X
Grip X
All NIHSS-based scales validated from ED admission or ED presentation; not prehospital collected.
RACE validated by EMS data.
Perez, et al; 2014
RACE: Stroke by the Numbers
The Rapid Arterial oCclusion Evaluation (RACE) scale was designed based on the National Institutes of Health Stroke Scale (NIHSS) – the validated neuroscience “gold standard”
It is a Quantitative Scale vs. Qualitative Scale More Objective (number value) vs. Less Subjective (+ or -)
Cincinnati Stroke Scale , LAPSS, and MENDS are all Qualitative
A scale based on the NIHSS that is more user-friendly for prehospital field usage
RACE would allow the State to capture quantifiable data for research
RACE: Stroke by the Numbers
The Tirschwell et al study (Stroke. 2002;33:2801-2806) noted that sNIHSS-8 and sNIHSS-5 (shortened versions of the full NIHSS or NIHSS-15) retained the predictive ability (90-day outcomes) of the original NIHSS and could be of value for prehospital use.
The Zandieh et al study (Clinical Neurology & Neurosurgery. 2012;10:034) developed an even shorter, parsimonious NIHSS-based tool with prehospital implications that was equally predictive (28-day mortality) as the original NIHSS.
Pérez de la Ossa et al study (Stroke. 2014;45:87-91.) validated RACE and recommended it for prehospital care usage.
Technically, the RACE is a mNIHSS-6.
RACE
1. Facial Palsy None present = 0 Mild = 1 Moderate to Severe = 2
2. Arm Motor Function Normal to Mild = 0 Moderate = 1 Severe = 2
3. Leg Motor Function Normal to Mild = 0 Moderate = 1 Severe = 2
SUBSCORE ____
RACE
4. Head Gaze Deviation Absent = 0 Present = 1
5. Aphasia* (if right side hemiparesis) Performs both tasks correctly = 0 Performs 1 task correctly = 1 Performs neither tasks = 2
6. Agnosia † (if left side hemiparesis) Patient recognizes his/her arm and the impairment = 0 Does not recognized his/her arm or the impairment = 1 Does not recognized his/her arm nor the impairment = 2
SUBSCORE ____* † see next slide for explanation
RACE
RACE is a 5 or 6 item scale based on the side of weakness* Aphasia (if right side hemiparesis) : Ask the patient and
evaluate if the patient obeys. 1. “Close your eyes” 2. “Make a fist”
† Agnosia (if left side hemiparesis): Ask the patient: 1. while showing him/her the paretic arm: “Whose arm is
this” and evaluate if the patient recognizes his own arm.2. “Can you lift both arms and clap” and evaluate if the
patient recognizes his functional impairment.
RACE: Stroke by the Numbers
Test Item RACE NIHSS Equivalent
Facial Palsy 0-1 0-3Arm Motor Function 0-2 0-4Leg Motor Function 0-2 0-4Head Gaze Deviation 0-1 0-2
Aphasia (R side) 0-2 0-2Agnosia (L side) 0-2 0-2
https://www.youtube.com/watch?v=9Sx0pJueV50
RACE: Stroke by the Numbers
The cut-score value of RACE for recommendation to divert to a CSC is ≥4
The global accuracy of the RACE for large vessel occlusion (LVO) is (c-statistic, 0.84; 95% Confidence Interval (CI), ρ = 0.79–0.89).
RACE is comparable with NIHSS to predict LVO (c-statistic, 0.85; 95% CI, ρ = 0.81–0.89).
RACE has a high sensitivity (89%) and specificity (55%) with a cutoff point of 4 for LVO. A sensitivity (85%) and specificity (65%) with a cutoff of 5 for LVO.
Last
RACE: Stroke by the Numbers
Questions?
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