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Multicenter Study
. 2023 Dec 12;101(24):e2522-e2532.
doi: 10.1212/WNL.0000000000207831. Epub 2023 Oct 17.

Prehospital Detection of Large Vessel Occlusion Stroke With EEG

Maritta N van Stigt  1 , Eva A Groenendijk  1 , Laura C C van Meenen  1 , Anita A G A van de Munckhof  1 , Monique Theunissen  1 , Gaby Franschman  1 , Martin D Smeekes  1 , Joffry A F van Grondelle  1 , Geertje Geuzebroek  1 , Arjen Siegers  1 , Marieke C Visser  1 , Sander M van Schaik  1 , Patricia H A Halkes  1 , Charles B L M Majoie  1 , Yvo B W E M Roos  1 , Johannes H T M Koelman  1 , Miou S Koopman  1 , Henk A Marquering  1 , Wouter V Potters  1 , Jonathan M Coutinho  1
Affiliations
Multicenter Study

Prehospital Detection of Large Vessel Occlusion Stroke With EEG

Maritta N van Stigt et al. Neurology. .

Erratum in

  • Corrections to Received Date Information.
    [No authors listed] [No authors listed] Neurology. 2024 Jul 9;103(1):e209596. doi: 10.1212/WNL.0000000000209596. Epub 2024 Jun 3. Neurology. 2024. PMID: 38830175 Free PMC article. No abstract available.

Abstract

Background and objectives: Endovascular thrombectomy (EVT) is standard treatment for anterior large vessel occlusion stroke (LVO-a stroke). Prehospital diagnosis of LVO-a stroke would reduce time to EVT by allowing direct transportation to an EVT-capable hospital. We aim to evaluate the diagnostic accuracy of dry electrode EEG for the detection of LVO-a stroke in the prehospital setting.

Methods: ELECTRA-STROKE was an investigator-initiated, prospective, multicenter, diagnostic study, performed in the prehospital setting. Adult patients were eligible if they had suspected stroke (as assessed by the attending ambulance nurse) and symptom onset <24 hours. A single dry electrode EEG recording (8 electrodes) was performed by ambulance personnel. Primary endpoint was the diagnostic accuracy of the theta/alpha frequency ratio for LVO-a stroke (intracranial ICA, A1, M1, or proximal M2 occlusion) detection among patients with EEG data of sufficient quality, expressed as the area under the receiver operating characteristic curve (AUC). Secondary endpoints were diagnostic accuracies of other EEG features quantifying frequency band power and the pairwise derived Brain Symmetry Index. Neuroimaging was assessed by a neuroradiologist blinded to EEG results.

Results: Between August 2020 and September 2022, 311 patients were included. The median EEG duration time was 151 (interquartile range [IQR] 151-152) seconds. For 212/311 (68%) patients, EEG data were of sufficient quality for analysis. The median age was 74 (IQR 66-81) years, 90/212 (42%) were women, and the median baseline NIH Stroke Scale was 1 (IQR 0-4). Six (3%) patients had an LVO-a stroke, 109/212 (51%) had a non-LVO-a ischemic stroke, 32/212 (15%) had a transient ischemic attack, 8/212 (4%) had a hemorrhagic stroke, and 57/212 (27%) had a stroke mimic. AUC of the theta/alpha ratio was 0.80 (95% CI 0.58-1.00). Of the secondary endpoints, the pairwise derived Brain Symmetry Index in the delta frequency band had the highest diagnostic accuracy (AUC 0.91 [95% CI 0.73-1.00], sensitivity 80% [95% CI 38%-96%], specificity 93% [95% CI 88%-96%], positive likelihood ratio 11.0 [95% CI 5.5-21.7]).

Discussion: The data from this study suggest that dry electrode EEG has the potential to detect LVO-a stroke among patients with suspected stroke in the prehospital setting. Toward future implementation of EEG in prehospital stroke care, EEG data quality needs to be improved.

Trial registration information: ClinicalTrials.gov identifier: NCT03699397.

Classification of evidence: This study provides Class II evidence that prehospital dry electrode scalp EEG accurately detects LVO-a stroke among patients with suspected acute stroke.

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Conflict of interest statement

M.N. van Stigt, E.A. Groenendijk, L.C.C. van Meenen, A.A.G.A. van de Munckhof, M. Theunissen, G. Franschman, M.D. Smeekes, J.A.F. van Grondelle, G. Geuzebroek, A. Siegers, M.C. Visser, S.M. van Schaik, and P.H.A. Halkes report no disclosures relevant to the manuscript. C.B.L.M. Majoie reports grants from CVON/Dutch Heart Foundation, European Commission, TWIN Foundation, Stryker, and Healthcare Evaluation Netherlands, all outside the submitted work (paid to institution), and is shareholder of Nicolab. Y.B.W.E.M. Roos is minor shareholder of Nicolab. J.H.T.M. Koelman and M.S. Koopman report no disclosures relevant to the manuscript. H.A. Marquering is co-founder and minor shareholder of Nicolab and TrianecT. W.V. Potters is co-founder, employee and shareholder of TrianecT. J.M. Coutinho received related research support from the Dutch Heart Foundation and Medtronic and unrelated research support from Bayer and Boehringer (all fees were paid to his employer), and is co-founder and shareholder of TrianecT. Go to Neurology.org/N for full disclosures.

Figures

Figure 1
Figure 1. EEG Setup as Used in the ELECTRA-STROKE Study
(A) EEG equipment stored in a portable and lightweight bag. (B) Dry electrode EEG cap (Waveguard touch, Eemagine, Berlin, Germany). (C) EEG recording in the ambulance.
Figure 2
Figure 2. Patient Flowchart
LVO-a stroke = anterior circulation large vessel occlusion stroke.
Figure 3
Figure 3. ROC Curves for LVO-a Stroke Detection
(A) ROC curve of the theta/alpha ratio with, at optimal cutoff, a sensitivity of 50% and specificity of 83% for LVO-a stroke. (B) ROC curve of the pairwise derived Brain Symmetry Index in the delta frequency band with, at optimal cutoff, a sensitivity of 80% and specificity of 93% for LVO-a stroke. (C) Contingency table of LVO-a stroke prediction by the theta/alpha ratio. (D) Contingency table of LVO-a stroke prediction by the pairwise derived Brain Symmetry Index in the delta frequency band. LVO-a stroke = anterior circulation large vessel occlusion stroke; ROC = receiver operating characteristic.
See this image and copyright information in PMC

References

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