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Performance of bedside stroke recognition tools in discriminating childhood stroke from mimics
Mark T Mackay1, Leonid Churilov2, Geoffrey A Donnan2
1From the Department of Neurology (M.T.M.), Emergency Department (F.E.B.), and Department of Haematology (P.M.), Royal Children's Hospital; Florey Institute of Neurosciences and Mental Health (L.C., G.A.D.); Murdoch Childrens Research Institute (M.T.M., F.E.B., P.M.); and University of Melbourne (M.T.M., L.C., G.A.D., F.E.B., P.M.), Parkville, Australia. mark.mackay@rch.org.au.
Insights
The Cincinnati Prehospital Stroke Scale (CPSS) and Recognition of Stroke in the Emergency Room (ROSIER) tools are not effective for identifying pediatric stroke in the emergency department. These adult-focused scales show poor accuracy and reliability in children with brain attack symptoms.
Area of Science:
- Pediatric Neurology
- Emergency Medicine
- Diagnostic Accuracy Studies
Background:
- Accurate and timely diagnosis of stroke in children is crucial for effective treatment and improved outcomes.
- Existing stroke recognition tools, such as the Cincinnati Prehospital Stroke Scale (CPSS) and Recognition of Stroke in the Emergency Room (ROSIER), were developed and validated primarily in adult populations.
- The utility of these adult-derived scales in the pediatric population presenting with acute neurological deficits, often termed 'brain attack,' remains uncertain.
Purpose of the Study:
- To evaluate the diagnostic accuracy and reliability of the CPSS and ROSIER scales in identifying stroke among children presenting to the emergency department.
- To compare the performance of these scales for differentiating various stroke subtypes (arterial stroke, hemorrhagic stroke) from stroke mimics in pediatric patients.
Main Methods:
- A retrospective and prospective study design was employed, analyzing data from children with confirmed stroke and those with stroke mimics.
- The CPSS and ROSIER tools were applied to assess their ability to correctly identify stroke cases versus non-stroke conditions.
- Statistical analyses, including kappa (κ) statistics for interrater agreement and receiver operating characteristic (ROC) curves for accuracy, were performed.
Main Results:
- Both the CPSS and ROSIER tools demonstrated poor reliability and accuracy when applied to children with combined stroke types versus mimics (CPSS κ=0.36, ROC=0.66; ROSIER κ=0.32, ROC=0.60).
- Performance remained inadequate for differentiating arterial stroke (AIS) and hemorrhagic stroke (HS) from mimics (AIS: CPSS κ=0.37, ROC=0.79; ROSIER κ=0.30, ROC=0.77; HS: CPSS κ=-0.03, ROC=0.51; ROSIER κ=-0.02, ROC=0.52).
- The study provides Class II evidence that these scales do not accurately distinguish pediatric strokes from mimics.
Conclusions:
- The current adult-calibrated stroke recognition scales, CPSS and ROSIER, exhibit poor performance in the pediatric emergency department setting.
- Significant modifications are necessary for these tools to become effective in identifying stroke in children.
- Further research is warranted to develop and validate pediatric-specific stroke recognition instruments.
Objective:
To assess the utility of the Cincinnati Prehospital Stroke Scale (CPSS) and Recognition of Stroke in the Emergency Room (ROSIER) tools in children presenting to the emergency department (ED) with brain attack symptoms.
Methods:
The ROSIER and CPSS tools were retrospectively applied to 101 children with stroke, presenting from 2003 to 2010, and prospectively to 279 children with mimics, presenting from 2009 to 2010. Positive CPSS was defined as ≥1 positive sign (face/asymmetrical arm weakness, speech disturbance). Positive ROSIER was defined as a score of ≥1. Accuracy and interrater agreement between the tools and patients' true status were assessed for combined stroke types and arterial stroke (AIS) and hemorrhagic stroke (HS) subtypes vs mimics.
Results:
Stroke subtypes included AIS (55), HS (34), TIA (10), and sinovenous thrombosis (2). Mimic diagnoses included migraine (84), first seizure (45), Bell palsy (29), and conversion disorders (18). Both tools had poor reliability and accuracy for combined strokes vs mimics (CPSS κ 0.36, receiver operator characteristic curve [ROC] 0.66; ROSIER κ 0.32, ROC 0.60) and for AIS vs mimics (CPSS κ 0.37, ROC 0.79; ROSIER κ 0.30, ROC 0.77). Both tools performed inadequately for HS vs mimics (CPSS κ -0.03, ROC 0.51; ROSIER κ -0.02, ROC 0.52).
Conclusions:
Adult stroke recognition tools perform poorly in children and require modification to be useful for pediatric stroke identification.
Classification Of Evidence:
This study provides Class II evidence that, for children presenting to the ED with brain attack symptoms, the CPSS and ROSIER tools do not accurately distinguish strokes from mimics.
