Diagnostic accuracy of clinical tools for assessment of acute stroke: a systematic review

Daria Antipova* (Corresponding Author), Leila Eadie, Ashish Stephen MacAden, Philip Wilson

*Corresponding author for this work

Research output: Contribution to journalArticle

Abstract

Introduction
Recanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities.

Methods
Diagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015–2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected.

Results
Twenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23 to 99% whereas specificity was 24 to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44 to 91%, and specificity of 27 to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies.

Conclusions
A wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.
Original languageEnglish
Article number49
JournalBMC Emergency Medicine
Volume19
DOIs
Publication statusPublished - 4 Sep 2019

Fingerprint

Stroke
Ischemia
Aphasia
Cerebral Hemorrhage
PubMed
Neuroimaging
Sample Size
Atrial Fibrillation
Libraries
Ultrasonography
Hemorrhage
Hypertension
Sensitivity and Specificity
Research
Therapeutics

Keywords

  • Acute cerebral ischaemia
  • Clinical prediction rules
  • Emergency care
  • Intracerebral haemorrhage
  • Large vessel occlusion
  • Recanalization
  • Stroke
  • Scoring methods
  • Thrombectomy
  • Thrombolysis

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Diagnostic accuracy of clinical tools for assessment of acute stroke : a systematic review. / Antipova, Daria (Corresponding Author); Eadie, Leila; MacAden, Ashish Stephen; Wilson, Philip.

In: BMC Emergency Medicine, Vol. 19, 49, 04.09.2019.

Research output: Contribution to journalArticle

@article{c7887a857f8b498bb1b08ff47b767813,
title = "Diagnostic accuracy of clinical tools for assessment of acute stroke: a systematic review",
abstract = "IntroductionRecanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities.MethodsDiagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015–2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected.ResultsTwenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23 to 99{\%} whereas specificity was 24 to 97{\%}. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44 to 91{\%}, and specificity of 27 to 98{\%} with the best diagnostic performance demonstrated by FABS (90{\%} sensitivity, 91{\%} specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50{\%} of included studies.ConclusionsA wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.",
keywords = "Acute cerebral ischaemia, Clinical prediction rules, Emergency care, Intracerebral haemorrhage, Large vessel occlusion, Recanalization, Stroke, Scoring methods, Thrombectomy, Thrombolysis",
author = "Daria Antipova and Leila Eadie and MacAden, {Ashish Stephen} and Philip Wilson",
note = "Availability of data and materials Materials are available from the corresponding author upon request. This work is part of a PhD project supported by the University of Aberdeen’s Elphinstone Scholarship Programme. LE is funded by the European Space Agency SatCare grant. The authors would like to thank Hannah Thomas and Emma Foster for the help with assessing full text of articles for eligibility for the current review. Funding No specific funding was received for this work.",
year = "2019",
month = "9",
day = "4",
doi = "10.1186/s12873-019-0262-1",
language = "English",
volume = "19",
journal = "BMC Emergency Medicine",
issn = "1471-227X",
publisher = "BioMed Central",

}

TY - JOUR

T1 - Diagnostic accuracy of clinical tools for assessment of acute stroke

T2 - a systematic review

AU - Antipova, Daria

AU - Eadie, Leila

AU - MacAden, Ashish Stephen

AU - Wilson, Philip

N1 - Availability of data and materials Materials are available from the corresponding author upon request. This work is part of a PhD project supported by the University of Aberdeen’s Elphinstone Scholarship Programme. LE is funded by the European Space Agency SatCare grant. The authors would like to thank Hannah Thomas and Emma Foster for the help with assessing full text of articles for eligibility for the current review. Funding No specific funding was received for this work.

PY - 2019/9/4

Y1 - 2019/9/4

N2 - IntroductionRecanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities.MethodsDiagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015–2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected.ResultsTwenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23 to 99% whereas specificity was 24 to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44 to 91%, and specificity of 27 to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies.ConclusionsA wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.

AB - IntroductionRecanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities.MethodsDiagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015–2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected.ResultsTwenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23 to 99% whereas specificity was 24 to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44 to 91%, and specificity of 27 to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies.ConclusionsA wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.

KW - Acute cerebral ischaemia

KW - Clinical prediction rules

KW - Emergency care

KW - Intracerebral haemorrhage

KW - Large vessel occlusion

KW - Recanalization

KW - Stroke

KW - Scoring methods

KW - Thrombectomy

KW - Thrombolysis

UR - http://www.scopus.com/inward/record.url?scp=85071771031&partnerID=8YFLogxK

UR - http://www.mendeley.com/research/diagnostic-accuracy-clinical-tools-assessment-acute-stroke-systematic-review

U2 - 10.1186/s12873-019-0262-1

DO - 10.1186/s12873-019-0262-1

M3 - Article

VL - 19

JO - BMC Emergency Medicine

JF - BMC Emergency Medicine

SN - 1471-227X

M1 - 49

ER -