Validated pre-hospital stroke scales to predict large vessel occlusion: a systematic review


emergency medical service

How to Cite

Loudon W, Wong A, Disney M, Tippett V. Validated pre-hospital stroke scales to predict large vessel occlusion: a systematic review. Australasian Journal of Paramedicine [Internet]. 2019Jun.28 [cited 2022Jul.3];160. Available from:



Occlusions of large cerebral vessels, including the internal carotid artery and middle cerebral artery, result in significant burden of morbidity. Treatment was previously limited to intravenous thrombolysis, however multiple studies have shown significant improvements when patients undergo endovascular clot retrieval. Early identification and triage to centres capable of delivering this is likely to contribute to improved outcomes. This systematic review aims to compare clinical assessment tools and their performance ‘in-field’ to identify usability and reliability to assist pre-hospital providers with identification of this sub-group of stroke patients.


Several databases were reviewed to identify studies that have validated large vessel occlusion clinical assessment tools within the pre-hospital environment. Sensitivity, specificity and predictive value were compared along with any biases. Six studies met the study criteria and were included. A total of 1384 patients were involved in the studies with sensitivities ranging from 51.9% to 100% and specificities ranging from 68% to 90%.


There is significant variation among studies and the emergency medical systems they have been performed within. It is likely that no single tool will suit every system and further research is required to determine the best tool for the Australian pre-hospital environment.


AIHW. Stroke and its management in Australia: an update. Canberra: Australian Institute of Health and Welfare, 2013 978-1-74249-441-8; Cat. no. CVD 61; 156pp. Contract No.: CVD 61.

Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009-18.

Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. ibid. 2015;372:2285-95.

Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. ibid. 2015;372:1019-30.

Stroke Foundation. National stroke audit - acute services clinical audit report. Melbourne, Australia: Stroke Foundation, 2011.

Goyal M, Almekhlafi MA, Fan L, et al. Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the Interventional Management of Stroke III trial. Circulation 2014;130:265-72.

Jessalyn H, Tyler W, Andrew D, et al. Drip and ship vs. direct to comprehensive stroke center: the effect of large vessel occlusion screening tools on conditional probability modeling. International Journal of Stroke 2017;12:29-.[AUTHORS: PLEASE CHECK PAGE NUMBERS].

Persson M, Fhager A, Trefna HD, et al. Microwave-based stroke diagnosis making global prehospital thrombolytic treatment possible. IEEE Trans Biomed Eng 2014;61:2806-17.

Bowry R, Parker S, Rajan SS, et al. Benefits of stroke treatment using a mobile stroke unit compared with standard management: the BEST-MSU Study Run-In Phase. Stroke 2015;46:3370-4.

Ebinger M, Kunz A, Wendt M, et al. Effects of golden hour thrombolysis: a Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) Substudy. Jama Neurol 2015;72:25-30.

Schlachetzki F, Herzberg M, Hölscher T, et al. Transcranial ultrasound from diagnosis to early stroke treatment. Part 2: Prehospital neurosonography in patients with acute stroke - The Regensburg Stroke Mobile Project. Cerebrovasc Dis 2012;33:262-71.

Finnigan S, van Putten M. EEG in ischaemic stroke:qQuantitative EEG can uniquely inform (sub-)acute prognoses and clinical management. Clin Neurophysiol 2013;124:10-9.

de la Ossa NP, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the Rapid Arterial Occlusion Evaluation Scale. Stroke 2014;45:87-91.

Brandler ES, Sharma M, Sinert RH, Levine SR. Prehospital stroke scales in urban environments: a systematic review. Neurology 2014;82:2241-9.

Kesinger MR, Sequeira DJ, Buffalini S, Guyette FX. Comparing national institutes of health stroke scale among a stroke team and helicopter emergency medical service providers. Stroke 2015;46:575-8.

Carrera D, de la Ossa NP, Gorchs M, et al. Prehospital validation of a neurological scale to predict a large vessel occlusion in patients with an acute ischemic stroke. Cerebrovasc Dis 2013;35:91.

Demeestere J, Garcia-Esperon C, Lin L, et al. Validation of the National Institutes of Health Stroke Scale-8 to detect large vessel occlusion in ischemic stroke. J Stroke Cerebrovasc Dis 2017;26:1419-26.

Krebs W, Sharkey-Toppen TP, Cheek F, et al. Prehospital stroke assessment for large vessel occlusions: a systematic review. Prehosp Emerg Care 2018;22:180-8.

Smith EE, Kent DM, Bulsara KR, et al. Accuracy of prediction instruments for diagnosing large vessel occlusion in individuals with suspected stroke: a systematic review for the 2018 guidelines for the early management of patients with acute ischemic stroke. Stroke 2018;49:e111-22.

Hastrup S, Damgaard D, Johnsen SP, Andersen G. Prehospital acute stroke severity scale to predict large artery occlusion: design and comparison with other scales. ibid. 2016;47:1772-6.

Katz B, McMullan J, Sucharew H, Adeoye O, Broderick J. A novel prehospital stroke scale to predict large vessel occlusion: the Cincinnati Prehospital Stroke Severity Scale (CPSSS). Int J Stroke 2015;10:117.

Nazliel B, Starkman S, Liebeskind DS, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke 2008;39:2264-7.

Suzuki Y, Hasegawa Y, Tsumura K, et al. Prehospital triage for endovascular clot removal in acute stroke patients. Acute Med Surg 2017;4:68-74.

Carrera D, Campbell BCV, Cortes J, et al. Predictive value of modifications of the prehospital rapid arterial occlusion evaluation scale for large vessel occlusion in patients with acute stroke. J Stroke Cerebrovasc Dis 2017;26:74-7.

McMullan JT, Katz B, Broderick J, et al. Prospective prehospital evaluation of the Cincinnati Stroke Triage Assessment Tool. Prehos Emerg Care 2017;21:481-8.

Teleb MS, Ver Hage A, Carter J, Jayaraman MV, McTaggart RA. Stroke vision, aphasia, neglect (VAN) assessmenta novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J Neurointerv Surg 2017;9:122-6.

Vaclavik D, Bar M, Klecka L, Holes D, Cabal M, Mikulik R. Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion. Brain Behav 2018;8(9).

Noorian AR, Sanossian N, Shkirkova K, et al. Los Angeles motor scale to identify large vessel occlusion: prehospital validation and comparison with other screens. Stroke 2018;49:565-72.

Panic N, Leoncini E, de Belvis G, Ricciardi W, Boccia S. Evaluation of the endorsement of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement on the quality of published systematic review and meta-analyses. Plos One 2013;8(12).

Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at:

Higgins J, Lasserson T, Chandler J, Tovey D, Churchill R. Methodological expectations of Cochrane Intervention Reviews (MECIR). Cochrane, 2018. Available at:

Whiting PF, Rutjes AWS, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529-36.

Gupta R, Manuel M, Owada K, et al. Severe hemiparesis as a prehospital tool to triage stroke severity: a pilot study to assess diagnostic accuracy and treatment times. J Neurointerv Surg 2016;8:775-7.

Lima FO, Silva GS, Furie KL, et al. Field assessment stroke triage for emergency destination a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke 2016;47:1997-2002.

Taqi MA, Sodhi A, Suriya SS, et al. Design, application and infield validation of a pre-hospital emergent large vessel occlusion screening tool: ventura emergent large vessel occlusion score. J Stroke Cerebrovasc Dis 2019;28:728-34.

Sanchea W, Whelan KR, Michael EK, Gary H, Kimberly D. The FAST VAN tool for identifying large vessel occlusion in acute stroke. Int J Stroke 2017;12:37-8.

Purrucker JC, Hartig F, Richter H, et al. Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH stroke scale for emergency medical services. BMI Open 2017;7(9).

Zhao H, Pesavento L, Rodrigues E, et al. ACT-FAST algorithm: paramedic validation of a 3-step algorithmic approach to large vessel occlusion identification. Stroke 2018;49:945-51.

Demeestere J, Garcia-Esperon C, Lin LT, et al. Validation of the National Institutes of Health stroke scale-8 to detect large vessel occlusion in ischemic stroke. J Stroke Cerebrovasc Dis 2017;26:1419-26.

Andsberg G, Esbjornsson M, Olofsson A, Lindgren A, Norrving B, von Euler M. PreHospital ambulance stroke test - pilot study of a novel stroke test. Scand J Trauma Resusc Emerg Med 2017;25:37.

Zaidi SF, Shawver J, Morales AE, et al. Stroke care: initial data from a county-based bypass protocol for patients with acute stroke. J Neurointerv Surg 2017;9:631-5.

Rodriguez-Pardo J, Fuentes B, de Lecinana MA, et al. The direct referral to endovascular center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network. Eur J Neurol 2017;24:509-15.

Ng FC, Low E, Andrew E, et al. Deconstruction of Interhospital transfer workflow in large vessel occlusion real-world data in the thrombectomy era. Stroke 2017;48:1976-9.

Turc G, Maïer B, Naggara O, et al. Clinical scales do not reliably identify acute ischemic stroke patients with large-artery occlusion. ibid. 2016;47:1466-72.

Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin C. Paramedic identification of stroke: community validation of the Melbourne ambulance stroke screen. Cerebrovasc Dis 2005;20:28-33.

Karliński M, Gluszkiewicz M, Członkowska A. The accuracy of prehospital diagnosis of acute cerebrovascular accidents: an observational study. Arch Med Sci 2015;11:530-5.