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November 26, 2019; 93 (22) ArticleOpen Access

Optimizing in-hospital triage for large vessel occlusion using a novel clinical scale (GAI2AA)

Tsuyoshi Ohta, Ichiro Nakahara, Shoji Matsumoto, Daisuke Kondo, Sadayoshi Watanabe, Kenji Okada, Maki Fukuda, Noritaka Masahira, Takaya Tsuno, Toshiki Matsuoka, Mitsuhiro Takemura, Hitoshi Fukuda, Naoki Fukui, Tetsuya Ueba
First published October 24, 2019, DOI: https://doi.org/10.1212/WNL.0000000000008550
Tsuyoshi Ohta
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Ichiro Nakahara
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Shoji Matsumoto
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Daisuke Kondo
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Sadayoshi Watanabe
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Kenji Okada
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Maki Fukuda
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Noritaka Masahira
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Takaya Tsuno
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Toshiki Matsuoka
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Mitsuhiro Takemura
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Hitoshi Fukuda
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Naoki Fukui
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Tetsuya Ueba
From the Department of Neurosurgery (T.O., K.O., M.F., N.M., T.T., T.M., M.T.), Kochi Health Sciences Center; Department of Comprehensive Strokology (I.N., S.M., S.W.), Fujita Health University, Aichi; Department of Neurology (D.K.), Kokura Memorial Hospital, Fukuoka; and Department of Neurosurgery (H.F., N.F., T.U), Kochi Medical School, Japan.
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Citation
Optimizing in-hospital triage for large vessel occlusion using a novel clinical scale (GAI2AA)
Tsuyoshi Ohta, Ichiro Nakahara, Shoji Matsumoto, Daisuke Kondo, Sadayoshi Watanabe, Kenji Okada, Maki Fukuda, Noritaka Masahira, Takaya Tsuno, Toshiki Matsuoka, Mitsuhiro Takemura, Hitoshi Fukuda, Naoki Fukui, Tetsuya Ueba
Neurology Nov 2019, 93 (22) e1997-e2006; DOI: 10.1212/WNL.0000000000008550

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Abstract

Objective To identify a proximal anterior circulation occlusion for effectively administering immediate mechanical thrombectomy by developing a novel, simple diagnostic scale to predict the occlusion, to compare its validity with available scales, and to assess its utility.

Methods To develop a novel clinical scale, we retrospectively analyzed a cohort of 429 patients with acute ischemic stroke from a single center. The novel scale GAI2AA was applied to a prospective cohort of 259 patients from 3 stroke centers for external validation. The utility of the scale as an in-hospital triage was compared for the temporal factors of 158 patients with the occlusion.

Results In a scale-developmental phase, those with a proximal anterior circulation occlusion had significantly more frequent signs of hemispheric symptoms, including gaze palsy, aphasia, inattention, arm paresis, and atrial fibrillation. The GAI2AA scale was developed using consolidated hemispheric symptoms and was scored as follows: score = 2, arm paresis score = 1, and atrial fibrillation score = 1. A cutoff value ≥3 was optimal for the correlation between sensitivity (88%) and specificity (81%), with a C statistic of 0.90 (95% confidence interval 0.87–0.93). External validation indicated that discrimination was significantly better than or not different from that of available complex scales. Door-to-puncture time was significantly reduced (91 [82–111] vs 52 [32–75] minutes, p < 0.001).

Conclusion The GAI2AA scale showed high sensitivity and specificity when an optimal cutoff score was used and was useful as an in-hospital triage tool.

Glossary

DAWN=
DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo;
DEFUSE 3=
Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke;
GAI=
gaze palsy, aphasia, or inattention;
ICA=
internal carotid artery;
MRA=
magnetic resonance angiography;
NIHSS=
NIH Stroke Scale;
OR=
odds ratio;
PASS=
Prehospital Acute Stroke Severity;
ROC=
receiver operating characteristic;
3I-SS=
3-Item Stroke Scale

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • The Article Processing Charge was funded by the authors.

  • Editorial, page 951

  • Received February 25, 2019.
  • Accepted in final form July 15, 2019.
  • Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Disputes & Debates: Rapid online correspondence

  • Author response: Optimizing in-hospital triage for large vessel occlusion using a novel clinical scale (GAI2AA)
    • Tsuyoshi Ohta, Neurosurgeon, Kochi Health Sciences Center
    Submitted December 19, 2019
  • Reader response: Optimizing in-hospital triage for large vessel occlusion using a novel clinical scale (GAI2AA)
    • Parneet Grewal, Fellow, Vascular Neurology, Department of Neurology, RUSH University Medical Center
    • Larry B. Goldstein, Professor and Chairman, Department of Neurology, University of Kentucky Medical Center
    Submitted December 11, 2019
  • Author response: Optimizing in-hospital triage for large vessel occlusion using a novel clinical scale (GAI2AA)
    • Tsuyoshi Ohta, Neurosurgeon, Kochi Health Sciences Center
    Submitted October 30, 2019
  • Reader response: Optimizing in-hospital triage for large vessel occlusion using a novel clinical scale (GAI2AA)
    • Mirjam R. Heldner, Neurologist/Strokologist, Department of Neurology, Inselspital, University Hospital and University of Bern (Bern, Switzerland)
    Submitted October 26, 2019
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