Is There A Better Way To Triage Stroke?

Large Vessel Occlusion

Large vessel occlusion (LVO) strokes account for approximately 10% to 46% of all acute ischemic strokes, though the exact prevalence varies based on the specific definition used. LVOs are associated with a significantly higher risk of death and permanent disability compared to non-LVO strokes, contributing to a large proportion of stroke-related mortality and long-term impairment. 

LVO stroke triage faces issues with the accuracy and limitations of existing prehospital stroke detection scales, which have varying sensitivity and specificity, leading to misidentification of LVOs and potentially delaying time-critical treatments like endovascular thrombectomy (EVT). Another key issue is the optimal transport strategy, balancing direct transport to a thrombectomy-capable center versus bypassing a primary stroke center, which introduces complexities like potential delays for non-LVO patients and increased burden on stroke centers. Emerging technologies like telemedicine and machine learning show promise but require further study for diagnostic accuracy and feasibility in real-world settings. 

Key Triage Issues

• Inaccurate Detection Scales:
  While many scales (e.g., RACE, LAMS) exist, they often have limited accuracy, failing to correctly distinguish between LVOs, other strokes, and stroke mimics. 

• Trade-offs in Scale Selection:
  Different scales have strengths and weaknesses; a highly sensitive scale might misidentify many patients, while a highly specific scale could miss actual LVOs. 

• Delays in Treatment:
  Inaccurate or poorly implemented triage can cause critical delays. Either LVO patients are sent to the wrong hospital, delaying EVT, or non-LVO patients are sent to centers not equipped for their needs, delaying other necessary treatments. 

• Increased Burden on Stroke Centers:
  Direct transport strategies for LVO can lead to increased patient volumes at endovascular-capable centers, potentially overwhelming resources and impacting overall hospital systems. 

• Dilemma of Telemedicine and Clinical Judgment:
  While telemedicine can bring expert judgment to the prehospital setting, the diagnostic accuracy of this approach needs further evaluation compared to established scales.