We thank Fabio Bandini and colleagues for their interest in our recent Article reporting results of the PRESTO study.1Duvekot MHC Venema E Rozeman AD et al.Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. They highlight that some patients with ischaemic stroke did not receive CT angiography to formally exclude large-vessel occlusion in the anterior circulation (aLVO). As shown in our results, these patients had a very low National Institutes of Health Stroke Scale (NIHSS) score and are therefore unlikely to have had aLVO, which limits any potential overestimation of the reported sensitivity. We also emphasise that the proportion of intracerebral haemorrhages among all patients with stroke in our study (12%) is similar to the proportion reported in the Dutch Acute Stroke Registry (11%).2Dutch Acute Stroke Audit
Annual report 2018. This finding supports that our study provides reliable estimates of the in-field performance of prehospital stroke scales in a population of patients with suspected stroke.Bandini and colleagues further state that the positive predictive value of 0·40 for a Rapid Arterial oCclusion Evaluation (RACE) score of 5 or greater might not be clinically significant for prehospital triage. They express concern about patients who have a RACE score equal to or higher than 5 but do not have aLVO, who might be harmed by the delay caused by direct transportation to an intervention centre. We fully agree with these concerns and reiterate that the trade-off between potential harm and benefit should be made at the patient level, as shown previously in our personalised decision model.3Venema E Lingsma HF Chalos V et al.Personalized prehospital triage in acute ischemic stroke. This model estimates the probability of a good outcome for the drip-and-ship versus mothership strategy based on the onset time, driving times, likelihood of aLVO, and hospital-specific workflow times. With this model, we showed that a positive predictive value of 0·40 can justify direct transport to an intervention centre in certain regions, as the treatment benefit for patients with aLVO outweighs the harm caused by delaying intravenous thrombolysis in patients with non-aLVO ischaemic stroke.3Venema E Lingsma HF Chalos V et al.Personalized prehospital triage in acute ischemic stroke. Because the optimal pathway is context-specific, health policy makers should estimate the impact and feasibility of prehospital triage strategies in their region before implementation, preferably using modelling-based approaches. We are currently preparing our prehospital personalised decision model for implementation in a mobile application, which will be evaluated in PRESTO-II. This application incorporates the RACE scale (range 0–9), time since symptom onset, real-time driving times, and hospital-specific workflow times.

Before additional interventions such as mobile stroke units or advanced large-vessel occlusion detection tools are sufficiently substantiated, validated prehospital stroke scales are our best option to improve personalised prehospital triage of patients with ischaemic stroke.

DWJD reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, and Health Holland Top Sector Life Sciences & Health, and unrestricted grants from Penumbra, Stryker, Stryker European Operations, Medtronic, Thrombolytic Science, and Cerenovus for research, all paid to their institution. All other authors declare no competing interests.

References1.Duvekot MHC Venema E Rozeman AD et al.

Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study.

Lancet Neurol. 20: 213-2212.

Annual report 2018.

3.Venema E Lingsma HF Chalos V et al.

Personalized prehospital triage in acute ischemic stroke.

Stroke. 50: 313-320Article InfoPublication HistoryIdentification

DOI: https://doi.org/10.1016/S1474-4422(21)00169-1

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© 2021 Elsevier Ltd. All rights reserved.

ScienceDirectAccess this article on ScienceDirect Linked ArticlesPrehospital scales in acute ischaemic stroke management

We read with much interest the Article by Martijne Duvekot and colleagues.1 Their goal was to compare and validate eight prehospital stroke scales to distinguish patients with large-vessel occlusion in the anterior circulation (aLVO), who must be directly transferred to a hospital capable of endovascular thrombectomy. Among the scales tested, Rapid Arterial oCclusion Evaluation (RACE) had the highest sensitivity (0·67, 95% CI 0·58–0·75). The most specific scale was Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST; specificity 0·89, 95% CI 0·87–0·91), but this scale had a low sensitivity (0·50, 0·41–0·59).

Full-Text PDF Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study

Prehospital stroke scales detect aLVO with acceptable-to-good accuracy. RACE, G-FAST, and CG-FAST are the best performing prehospital stroke scales out of the eight scales tested and approach the performance of the clinician-assessed NIHSS. Further studies are needed to investigate whether use of these scales in regional transportation strategies can optimise outcomes of patients with ischaemic stroke.

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