Ischemic stroke J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2015-012131 on 17 February 2016. Downloaded from ORIGINAL RESEARCH Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Mohamed S Teleb,1 Anna Ver Hage,1 Jaqueline Carter,1 Mahesh V Jayaraman,2 Ryan A McTaggart2 1Neurosciences Department, ABSTRACT Effective and efficient prehospital triage of Banner Health, Mesa, Arizona, Background Identification of emergent large vessel patients with ELVO is now the holy grail of stroke USA 2Department of Diagnostic occlusion (ELVO) stroke has become increasingly care delivery innovation. Several stroke assessment Imaging Warren Alpert School important with the recent publications of favorable acute tools exist, including the 3 item stroke scale of Medicine at Brown stroke thrombectomy trials. Multiple screening tools exist (3I-SS),9 Cincinnati Prehospital Stroke Severity University, Rhode Island but the length of the examination and the false positive Scale (CPSSS),10 National Institutes of Health Hospital, Providence, Rhode rate range from good to adequate. A screening tool was Stroke Scale (NIHSS),11 face, arm, speech test Island, USA designed and tested in the emergency department using (FAST),12 Los Angeles Motor Scale (LAMS),13 legs, Correspondence to nurse responders without a scoring system. eyes, gaze, speech (Texas Stroke Intervention Dr M Teleb, Methods The vision, aphasia, and neglect (VAN) Prehospital Stroke Severity Scale) (LEGS),14 Neurointerventional Surgery, screening tool was designed to quickly assess functional Melbourne Ambulance Stroke Screen (MASS),15 Stroke and Neurocritical Care, neurovascular anatomy. While objective, there is no need Medic Prehospital Assessment for Code Stroke Banner Health, 1502 S Dobson 15 Rd, Suite 203, Mesa, AZ to calculate or score with VAN. After training (Med PACS), Ontario Prehospital Stroke 85202, USA; Mohamed. participating nurses to use it, VAN was used as an ELVO Screening (OPSS),16 Rapid Arterial oCclusion [email protected] screen for all stroke patients on arrival to our emergency Evaluation Scale (RACE),17 and Recognition room before physician evaluation and CT scan. Of Stroke In the Emergency Room (ROSIER),15 copyright. Received 23 October 2015 9 10 13 14 Revised 14 January 2016 Results There were 62 consecutive code stroke some of which (3I-SS, CPSSS, LAMS, LEGS, 17 18 Accepted 19 January 2016 activations during the pilot study. 19 (31%) of the RACE, or severe hemiparesis ) have been used Published Online First patients were VAN positive and 24 (39%) had a to specifically screen for ELVO but with limitations. 18 February 2016 National Institutes of Health Stroke Scale (NIHSS) score For example, the RACE17 scoring system is cumber- of ≥6. All 14 patients with ELVO were either VAN some for emergency medical technicians and positive or assigned a NIHSS score ≥6. While both nurses, takes almost as long as the NIHSS, and clinical severity thresholds had 100% sensitivity, VAN requires the user to calculate a score. The 3I-SS,9 was more specific (90% vs 74% for NIHSS ≥6). CPSS,10 LAMS,13 and RACE17 scores require the Similarly, while VAN and NIHSS ≥6 had 100% negative user to remember the test items; the name does not predictive value, VAN had a 74% positive predictive trigger testing or next steps. Using LAMS13 or a value while NIHSS ≥6 had only a 58% positive single deficit screen such as severe hemiparesis18 is http://jnis.bmj.com/ predictive value. a more simple approach but has somewhat limited Conclusions The VAN screening tool accurately sensitivity and specificity. identified ELVO patients and outperformed a NIHSS ≥6 Vision, aphasia, and neglect (VAN) is a novel severity threshold and may best allow clinical teams to ELVO screening tool we developed to assess func- expedite care and mobilize resources for ELVO patients. tional neurovascular anatomy. It is quick, reprodu- A larger study to both validate this screening tool and cible, easy to remember and, while objective, on September 28, 2021 by guest. Protected compare with others is warranted. requires no score calculations. We tested the ability of VAN to identify ELVO patients presenting to our center and compared it with an NIHSS threshold of ≥6. INTRODUCTION – Several recent clinical trials1 5 have established METHODS embolectomy as the standard of care67for patients Training with severe stroke who present with emergent large Our emergency room triage nurses, all of whom vessel occlusion (ELVO). Unfortunately, inefficient are NIHSS certified, were trained in how to prehospital and early hospital care can delay time perform the VAN assessment screen (table 1) to embolectomy (groin puncture), the treatment during a 2 h training session. The training session effect for which is time dependent.8 Our systems of included how to perform VAN, including visual fi To cite: Teleb MS, Ver care need to be designed to match the disease we eld testing, gaze assessment, aphasia testing, and Hage A, Carter J, et al. are treating so that patients both get to the right neglect testing, with simultaneous stimuli. They J NeuroIntervent Surg place the first time and ELVO team activation is also were briefly informed of why early stroke – 2017;9:122 126. early and appropriate. thrombectomy is so important for patient outcome Teleb MS, et al. J NeuroIntervent Surg 2017;9:122–126. doi:10.1136/neurintsurg-2015-012131 1of5 Ischemic stroke J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2015-012131 on 17 February 2016. Downloaded from an NIHSS score of 12 for face, arm, and leg weakness with dys- Table 1 Vision, aphasia, neglect emergent large vessel occlusion arthria but no aphasia, vision disturbance, or neglect, with screening tool follow-up imaging. Other patient examples included sensory Stroke VAN neglect, gaze preference, pure expressive and receptive aphasia, and visual field cut. How weak is the □ Mild (minor drift) patient? □ Moderate (severe drift—touches or nearly touches After the training was completed, the chair of medicine and Raise both arms up ground) chief medical officer approved the pilot quality control study □ Severe (flaccid or no antigravity) due to our prolonged door to puncture times. A formal institu- □ Patient shows no weakness. Patient is VAN negative tional review board protocol was approved after quality assur- (exceptions are confused or comatose patients with dizziness, focal findings, or ance data showed study feasibility and improved process time. no reason for their altered mental status then basilar artery thrombus must be For VAN positive patients, nurses were instructed to both considered; CTA is warranted) obtain CT angiography (CTA) at the time of the initial non- Visual disturbance □ Field cut (which side) (4 quadrants) □ contrast CT (NCCT) and activate the endovascular stroke team. Double vision (ask patient to look to right then left; fi evaluate for uneven eyes) If CTA con rmed an ELVO, the patient was triaged to the endo- □ Blind new onset vascular suite when the team was ready. Intravenous tissue plas- □ None minogen activator (tPA) candidacy for all patients was Aphasia □ Expressive (inability to speak or paraphasic errors); do determined by the stroke team either at CT scan or immediately not count slurring of words (repeat and name 2 objects) thereafter. Hemorrhages were excluded and treated appropri- □ Receptive (not understanding or following commands) ately after NCCT. (close eyes, make fist) □ Mixed All VAN negative patients also had acute vascular vessel □ None imaging. VAN negative patients received CTA or an MR angio- Neglect □ Forced gaze or inability to track to one side gram of head and neck after administration of tPA. See figure 1 □ Unable to feel both sides at the same time, or unable for our stroke triage process before and after the VAN study to identify own arm protocol. □ Ignoring one side □ None Performing the VAN examination Patient must have weakness plus one or all of the V, A, or N to be VAN positive. The initial and sine qua non of the VAN examination is to VAN positive patients had 100% sensitivity, 90% specificity, positive predictive value 74%, and negative predictive value 100% for detecting large vessel occlusion. conduct a motor weakness assessment (table 1). Patients are CTA, CT angiography; VAN, vision, aphasia, and neglect. asked to raise both arms up and hold them up for 10 s. If the patient has mild drift, severe weakness, or paralysis, the assess- copyright. ment continues. In their absence, the patient is VAN negative and emphasized the number needed to treat versus other emer- and the assessment ends. gencies in the emergency department, such as ST elevation myo- If weakness (mild drift, severe weakness, or paralysis) is cardial infarction (STEMI). Brain and vascular anatomy, as it observed, the VAN assessments are carried out (table 1). If the relates to VAN, was also taught. Functional anatomy of the patient has weakness and any other positive finding among the cortex, motor homunculous, and internal capsule were vision, aphasia, or neglect category, they are considered VAN reviewed. Lacunar syndromes and why they usually do not have positive. While forced gaze to one side might be considered a cortical symptoms based on anatomy was also emphasized. visual finding among users, we included it within the neglect Lastly, multiple examples of VAN negative and VAN positive category. Table 2 compares elements of the VAN ELVO screen- patients were presented, including a pure lacunar patient with ing with others that have been published. http://jnis.bmj.com/ Figure 1 Stroke process before and after the VAN protocol was initiated. CTA, CT angiography; tPa, tissue plasminogen activator; VAN, vision, aphasia, neglect. on September 28, 2021 by guest. Protected 2 of 5 Teleb MS, et al. J NeuroIntervent Surg 2017;9:122–126. doi:10.1136/neurintsurg-2015-012131 Ischemic stroke J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2015-012131 on 17 February 2016.