The Prehospital Ambulance Stroke Test vs. the Cincinnati Prehospital Stroke Scale: a diagnostic accuracy study


emergency medical services
symptom assessment

How to Cite

Karimi S, Motamed H, Aliniagerdroudbari E, Babaniamansour S, Jami A, Baratloo A. The Prehospital Ambulance Stroke Test vs. the Cincinnati Prehospital Stroke Scale: a diagnostic accuracy study. Australasian Journal of Paramedicine [Internet]. 2020May19 [cited 2022Nov.30];17. Available from:



Immediate diagnosis of stroke is crucial in reducing its morbidity and mortality rate. There are various pre-hospital assessment tools, such as the Prehospital Ambulance Stroke Test (PreHAST) and the Cincinnati Prehospital Stroke Scale (CPSS) used to identify stroke early in the chain of care. The aim of this study is to compare the accuracy of PreHAST with CPSS in diagnosing stroke.


In this diagnostic accuracy study patients with suspicion of stroke were included in this study. In CPSS, the criterion used to indicate stroke are facial droop, speech and arm drift. In PreHAST it is eye position, visual field, facial palsy, right and left arms paresis, right and left legs paresis, sensory and speech. After data collection, sensitivity and specificity were calculated using standard formulae. Different cut-off points for the best diagnostic accuracy were examined in both CPSS and PreHAST.


In this study, 883 patients were investigated. The results demonstrated that in CPSS, the highest specificity and sensitivity was for facial droop (84.9%) and arm drift (82.7%); and in PreHAST it was eye position (99.6%) and facial palsy (49.2%). The best predictor of stroke in CPSS with highest sensitivity (78.5%) and specificity (66%) was a cut-off point of 1.5 (AUC: 0.744) (p<0.01(. In PreHAST, the highest sensitivity (68.4%) was a cut-off point of 2.5 and the highest specificity (90.2%) was a cut-off point of 5.5 (AUC: 0.775) (p<0.01).


Both PreHAST and CPSS are useful screening tools in the pre-hospital diagnosis of stroke. In addition to high sensitivity, these tests provide a grading system in which higher cut-off points lead to higher specificity.


Peisker T, Koznar B, Stetkarova I, Widimsky P. Acute stroke therapy: a review. Trends Cardiovasc Med 2017;27:59-66.

Sheppard JP, Mellor RM, Greenfield S, et al. The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study. Emerg Med J 2015;32:93-9.

Ebinger M, Harmel P, Nolte CH, et al. Berlin prehospital or usual delivery of acute stroke care - study protocol. Int J Stroke 2017;12:653-8.

Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics - 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2006;113:e85-151.

Baratloo A, Rahimpour L, Abushouk AI, et al. Effects of telestroke on thrombolysis times and outcomes: a meta-analysis. Prehosp Emerg Care 2018;22:472-84.

Baratloo A, Forouzanfar MM, Hashemi B, et al. Tissue plasminogen activator: a literature review. Arch Neurosci 2016;3:e30452.

Saver JL. Time is brain quantified. Stroke 2006;37:263-6.

Perez de la Ossa N, Ribo M, Jimenez X, Abilleira S. Prehospital scales to identify patients with large vessel occlusion: it is time for action. ibid. 2016;47:2877-8.

Fassbender K, Balucani C, Walter S, et al. Streamlining of prehospital stroke management: the golden hour. Lancet Neurol 2013;12:585-96.

Momeni M, Vahidi E, Seyedhosseini J, et al. Emergency overcrowding impact on the quality of care of patients presenting with acute stroke. Adv J Emerg Med 2018;2:e3.

Elfil M, Eldokmak M, Baratloo A, et al. Pathophysiologic mechanisms, neuroimaging and treatment in wake-up stroke. CNS Spectr 2019;1-8.

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018;49:e46-110.

Walter S, Kostopoulos P, Haass A, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 2012;11:397-404.

Garnett AR, Marsden DL, Parsons MW, et al. The rural Prehospital Acute Stroke Triage (PAST) trial protocol: a controlled trial for rapid facilitated transport of rural acute stroke patients to a regional stroke centre. Int J Stroke 2010;5:506-13.

Kasmaei HD, Baratloo A, Nasiri Z, Soleymani M, Yazdani MO. Recombinant tissue plasminogen activator administration in patients with cerebrovascular accident; a case series. Arch Neurosci 2015;2:e23315.

Andsberg G, Esbjornsson M, Olofsson A, et al. Prehospital ambulance stroke test - pilot study of a novel stroke test. Scand J Trauma Resusc Emerg Med 2017;25:37.

Rudd M, Buck D, Ford GA, Price CI. A systematic review of stroke recognition instruments in hospital and prehospital settings. Emerg Med J 2016;33:818-22.

Togher FJ, Davy Z, Siriwardena AN. Patients' and ambulance service clinicians' experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study. ibid. 2013;30:942-8.

Katz BS, McMullan JT, Sucharew H, Adeoye O, Broderick JP. Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke 2015;46:1508-12.

Itrat A, Taqui A, Cerejo R, et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol 2016;73:162-8.

Paybast S, Ashraf A, Sarshad H, Shakiba M, Moadabi Y. Propagating relationship of cerebral oximetric volume and the clinical outcome of recombinant tissue plasminogen activator (r-TPA) therapy on acute cerebral ischemic stroke Patients. Adv J Emerg Med 2020;4:e7.

Liberman AL, Prabhakaran S. Stroke chameleons and stroke mimics in the emergency department. Curr Neurol Neurosci Rep 2017;17:15.

Valenzuela Espinoza A, Van Hooff RJ, De Smedt A, et al. Development and pilot testing of 24/7 in-ambulance telemedicine for acute stroke: prehospital stroke study at the Universitair Ziekenhuis Brussel-Project. Cerebrovasc Dis 2016;42:15-22.

Purrucker JC, Hametner C, Engelbrecht A, et al. Comparison of stroke recognition and stroke severity scores for stroke detection in a single cohort. J Neurol Neurosurg Psychiatry 2015;86:1021-8.

Bergs J, Sabbe M, Moons P. Prehospital stroke scales in a Belgian prehospital setting: a pilot study. Eur J Emerg Med 2010;17:2-6.

Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Syst Rev 2019;4:Cd011427.

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

Zhao H, Coote S, Pesavento L, et al. Large vessel occlusion scales increase delivery to endovascular centers without excessive harm from misclassifications. Stroke 2017;48:568-73.

Studnek JR, Asimos A, Dodds J, Swanson D. Assessing the validity of the Cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care 2013;17:348-53.

Maddali A, Razack FA, Cattamanchi S, Ramakrishnan TV. Validation of the Cincinnati Prehospital Stroke Scale. J Emerg Trauma Shock 2018;11:111-4.

Kummer BR, Gialdini G, Sevush JL, et al. External validation of the Cincinnati Prehospital Stroke Severity Scale. J Stroke Cerebrovasc Dis 2016;25:1270-4.