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      Clinical prediction of thrombectomy eligibility: A systematic review and 4-item decision tree

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          Abstract

          Background

          A clinical large anterior vessel occlusion (LAVO)-prediction scale could reduce treatment delays by allocating intra-arterial thrombectomy (IAT)-eligible patients directly to a comprehensive stroke center.

          Aim

          To subtract, validate and compare existing LAVO-prediction scales, and develop a straightforward decision support tool to assess IAT-eligibility.

          Methods

          We performed a systematic literature search to identify LAVO-prediction scales. Performance was compared in a prospective, multicenter validation cohort of the Dutch acute Stroke study (DUST) by calculating area under the receiver operating curves (AUROC). With group lasso regression analysis, we constructed a prediction model, incorporating patient characteristics next to National Institutes of Health Stroke Scale (NIHSS) items. Finally, we developed a decision tree algorithm based on dichotomized NIHSS items.

          Results

          We identified seven LAVO-prediction scales. From DUST, 1316 patients (35.8% LAVO-rate) from 14 centers were available for validation. FAST-ED and RACE had the highest AUROC (both >0.81, p < 0.01 for comparison with other scales). Group lasso analysis revealed a LAVO-prediction model containing seven NIHSS items (AUROC 0.84). With the GACE (Gaze, facial Asymmetry, level of Consciousness, Extinction/inattention) decision tree, LAVO is predicted (AUROC 0.76) for 61% of patients with assessment of only two dichotomized NIHSS items, and for all patients with four items.

          Conclusion

          External validation of seven LAVO-prediction scales showed AUROCs between 0.75 and 0.83. Most scales, however, appear too complex for Emergency Medical Services use with prehospital validation generally lacking. GACE is the first LAVO-prediction scale using a simple decision tree as such increasing feasibility, while maintaining high accuracy. Prehospital prospective validation is planned.

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          Most cited references24

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          Sparse inverse covariance estimation with the graphical lasso.

          We consider the problem of estimating sparse graphs by a lasso penalty applied to the inverse covariance matrix. Using a coordinate descent procedure for the lasso, we develop a simple algorithm--the graphical lasso--that is remarkably fast: It solves a 1000-node problem ( approximately 500,000 parameters) in at most a minute and is 30-4000 times faster than competing methods. It also provides a conceptual link between the exact problem and the approximation suggested by Meinshausen and Bühlmann (2006). We illustrate the method on some cell-signaling data from proteomics.
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            Stroke thrombolysis: save a minute, save a day.

            Stroke thrombolysis is highly time-critical, but data on long-term effects of small reductions in treatment delays have not been available. Our objective was to quantify patient lifetime benefits gained from faster treatment.
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              National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke.

              There is some controversy on the association of the National Institutes of Health Stroke Scale (NIHSS) score to predict arterial occlusion on MR arteriography and CT arteriography in acute stroke. We analyzed NIHSS scores and arteriographic findings in 2152 patients (35.4% women, mean age 66 ± 14 years) with acute anterior or posterior circulation strokes. The study included 1603 patients examined with MR arteriography and 549 with CT arteriography. Of those, 1043 patients (48.5%; median NIHSS score 5, median time to clinical assessment 179 minutes) showed an occlusion, 887 in the anterior (median NIHSS score 7/0-31), and 156 in the posterior circulation (median NIHSS score 3/0-32). Eight hundred sixty visualized occlusions (82.5%) were located centrally (ie, in the basilar, intracranial vertebral, internal carotid artery, or M1/M2 segment of the middle cerebral artery). NIHSS scores turned out to be predictive for any vessel occlusions in the anterior circulation. Best cut-off values within 3 hours after symptom onset were NIHSS scores ≥ 9 (positive predictive value 86.4%) and NIHSS scores ≥ 7 within >3 to 6 hours (positive predictive value 84.4%). Patients with central occlusions presenting within 3 hours had NIHSS scores <4 in only 5%. In the posterior circulation and in patients presenting after 6 hours, the predictive value of the NIHSS score for vessel occlusion was poor. There is a significant association of NIHSS scores and vessel occlusions in patients with anterior circulation strokes. This association is best within the first hours after symptom onset. Thereafter and in the posterior circulation the association is poor.
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                Author and article information

                Journal
                Int J Stroke
                Int J Stroke
                WSO
                spwso
                International Journal of Stroke
                SAGE Publications (Sage UK: London, England )
                1747-4930
                1747-4949
                13 September 2018
                July 2019
                : 14
                : 5
                : 530-539
                Affiliations
                [1 ]Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
                [2 ]Department of Medical Statistics, Leiden University Medical Center, Leiden, Netherlands
                [3 ]Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
                [4 ]Department of Research and Development, RAV Hollands Midden, Leiden, Netherlands
                [5 ]Department of Neurology, St. Antonius Hospital, Nieuwegein, Netherlands; Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht, Netherlands
                [6 ]Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
                [7 ]Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
                [8 ]Department of Neurology, Medisch Spectrum Twente; Department of Neurology, Isala Clinics, Zwolle, Netherlands
                [9 ]Department of Neurology, Academic Medical Center, Amsterdam, Netherlands
                [10 ]Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
                Author notes
                [*]Gaia T Koster, Leiden University Medical Center, Albinusdreef 2, Leiden 2333ZA, Netherlands. Email: g.t.koster@ 123456lumc.nl
                Author information
                https://orcid.org/0000-0001-7138-5313
                https://orcid.org/0000-0003-3545-3053
                Article
                10.1177_1747493018801225
                10.1177/1747493018801225
                6710617
                30209989
                320f0ce5-c15a-4fd9-b886-5886b72b5b08
                © 2018 World Stroke Organization

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 11 April 2018
                : 25 June 2018
                Funding
                Funded by: Hartstichting, FundRef https://doi.org/10.13039/501100002996;
                Award ID: 2008 T034
                Funded by: Hartstichting, FundRef https://doi.org/10.13039/501100002996;
                Award ID: 2012 T061
                Funded by: Hersenstichting, FundRef https://doi.org/10.13039/501100008358;
                Award ID: HA2015.01.02
                Funded by: Fonds NutsOhra, FundRef https://doi.org/10.13039/501100003142;
                Award ID: 0903-012
                Funded by: The Dutch Health Care Insurers Innovation Foundation, FundRef ;
                Award ID: 3240
                Categories
                Research

                Cardiovascular Medicine
                acute ischemic stroke,clinical scale,endovascular thrombectomy,intra-arterial thrombectomy,large vessel occlusion,prehospital

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