Journal of Neurology

, Volume 263, Issue 8, pp 1633–1640 | Cite as

Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?

  • Mirjam R. Heldner
  • Kety Hsieh
  • Anne Broeg-Morvay
  • Pasquale Mordasini
  • Monika Bühlmann
  • Simon Jung
  • Marcel Arnold
  • Heinrich P. Mattle
  • Jan Gralla
  • Urs FischerEmail author
Original Communication


Simple clinical scores to predict large vessel occlusion (LVO) in acute ischemic stroke would be helpful to triage patients in the prehospital phase. We assessed the ability of various combinations of National Institutes of Health Stroke Scale (NIHSS) subitems and published stroke scales (i.e., RACE scale, 3I-SS, sNIHSS-8, sNIHSS-5, sNIHSS-1, mNIHSS, a-NIHSS items profiles A–E, CPSS1, CPSS2, and CPSSS) to predict LVO on CT or MR arteriography in 1085 consecutive patients (39.4 % women, mean age 67.7 years) with anterior circulation strokes within 6 h of symptom onset. 657 patients (61 %) had an occlusion of the internal carotid artery or the M1/M2 segment of the middle cerebral artery. Best cut-off value of the total NIHSS score to predict LVO was 7 (PPV 84.2 %, sensitivity 81.0 %, specificity 76.6 %, NPV 72.4 %, ACC 79.3 %). Receiver operating characteristic curves of various combinations of NIHSS subitems and published scores were equally or less predictive to show LVO than the total NIHSS score. At intersection of sensitivity and specificity curves in all scores, at least 1/5 of patients with LVO were missed. Best odds ratios for LVO among NIHSS subitems were best gaze (9.6, 95 %-CI 6.765–13.632), visual fields (7.0, 95 %-CI 3.981–12.370), motor arms (7.6, 95 %-CI 5.589–10.204), and aphasia/neglect (7.1, 95 %-CI 5.352–9.492). There is a significant correlation between clinical scores based on the NIHSS score and LVO on arteriography. However, if clinically relevant thresholds are applied to the scores, a sizable number of LVOs are missed. Therefore, clinical scores cannot replace vessel imaging.


Acute ischemic stroke Stroke management Triage CT MRI Clinical neurological examination 



We thank Pietro Ballinari, PhD; for statistical advice.

Sources of funding concerning this paper

Swiss Heart Foundation Grant 2013/2014 (main applicant: MR Heldner, 1st joint applicant: U Fischer, 2nd joint applicant: HP Mattle).

Compliance with ethical standards

Ethical standard

The study protocol was approved by our institutional ethics committee in Bern, and the study has, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all patients.

Conflicts of interest

Dr. Heldner reports a grant from the Swiss Heart Foundation. Dr. Hsieh reports no disclosures. Dr. Broeg-Morvay reports no disclosures. PD Dr. Mordasini reports no disclosures. Dr. Bühlmann reports no disclosures. PD Dr. Jung reports no disclosures. Prof. Dr. Arnold received honoraria for lectures and advisory boards from Bayer, Boehringer Ingelheim, Bristol Meyer Squibbs, Pfizer and Covidien. Prof. Dr. Mattle reports a grant from the Swiss Heart Foundation. Prof. Dr. Gralla reports a consultant agreement with Medtronic. Prof. Dr. Fischer reports a grant from the Swiss Heart Foundation and received a speaker’s honorarium from Covidien.

Supplementary material

415_2016_8180_MOESM1_ESM.pdf (124 kb)
Supplementary material 1 (PDF 124 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Mirjam R. Heldner
    • 1
  • Kety Hsieh
    • 2
  • Anne Broeg-Morvay
    • 1
  • Pasquale Mordasini
    • 2
  • Monika Bühlmann
    • 1
  • Simon Jung
    • 1
    • 2
  • Marcel Arnold
    • 1
  • Heinrich P. Mattle
    • 1
  • Jan Gralla
    • 2
  • Urs Fischer
    • 1
    Email author
  1. 1.Department of Neurology, InselspitalUniversity of BernBernSwitzerland
  2. 2.Institute of Diagnostic and Interventional Neuroradiology, InselspitalUniversity of Bern3010 BernSwitzerland

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