Appropriate use of thrombolytic therapy in patients with acute ischemic stroke requires rapid medical evaluation. Patients must be treated within 180 minutes of symptom onset for treatment to be effective. Having prehospital or emergency medical personnel notify the hospital of potentially treatable stroke patients seems to reduce evaluation time by prompting team preparation. Kothari and associates developed a three-item scale to be used by prehospital providers to identify potentially treatable stroke patients.
The Cincinnati Prehospital Stroke Scale (CPSS) was derived from a simplification of the 15-item National Institutes of Health (NIH) Stroke Scale. The CPSS evaluates facial palsy, asymmetric arm weakness and speech abnormalities (see the accompanying table). Patients with stroke or symptoms similar to stroke were identified from the neurology service and the emergency department. Study subjects were then evaluated using the CPSS, first by one of two physicians certified in the use of the NIH Stroke Scale and, immediately following, by a group of paramedics and emergency medical technicians (prehospital care providers) who were trained briefly about how to perform and score the CPSS. Only verbal instruction was given to the pre-hospital providers.
Excellent reproducibility was observed among prehospital care providers for total score and for each of the three scale items. There was also excellent correlation between the total scores compiled by the physician and the prehospital providers. The CPSS correctly identified 21 of the 24 patients with anterior circulation stroke. The three patients who were missed had minimal or atypical symptoms.
The authors conclude that the CPSS, which can be taught in approximately 10 minutes and performed in less than one minute, is a valid tool for identifying stroke patients, especially those with anterior circulation stroke, who may be candidates for thrombolytic therapy.
In an editorial in the same issue, Marler strongly supports rapid identification of treatable stroke patients, recommending a “door-to-needle” time of one hour, since full-dose thrombolytic therapy does not occur until four hours after initiation of treatment. Careful interpretation of computed tomographic scans remains essential for identification of patients with intracerebral hemorrhage before initiating thrombolytic therapy.