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. 2024 Nov 27;37(3):311-320.
doi: 10.4103/tcmj.tcmj_191_24. eCollection 2025 Jul-Sep.

Comparison of prehospital stroke assessment scales for acute ischemic stroke with large vessel occlusion within six hours of onset: A single-center study in Eastern Taiwan

Phyo-Wai Thu  1 , Yu-Ping Yu  1 , Jen-Hung Wang  2 , Chooi-Lan Liew  1
Affiliations

Comparison of prehospital stroke assessment scales for acute ischemic stroke with large vessel occlusion within six hours of onset: A single-center study in Eastern Taiwan

Phyo-Wai Thu et al. Tzu Chi Med J. .

Abstract

Objectives: In Taiwan, acute ischemic stroke (AIS) with large vessel occlusion (LVO) remains a significant health concern. Reperfusion therapy is more effective if the patient arrives at the medical center within the early time window, emphasizing the importance of prehospital stroke assessment to identify LVO and rapid transfer. This study focused on Eastern Taiwan, where the Hualien Tzu Chi Hospital is the sole comprehensive stroke center. We compared different prehospital stroke assessment scales in identifying LVO.

Materials and methods: We reviewed 598 patients with acute stroke admitted to our hospital's emergency department between April 1, 2021, and March 31, 2022. Of these, 110 AIS cases presenting within 6 h of symptom onset were retrospectively analyzed using the medical records and National Institute of Health Stroke Scale (NIHSS) scores to evaluate the efficacies of prehospital stroke scales, including our institution's Tzu Chi Stroke Severity Scale and its modified version. LVO was defined as occlusion of the anterior cerebral artery, middle cerebral artery, and its main branches, intracranial carotid arteries, and vertebrobasilar arteries.

Results: Among 110 patients, 39.1% had LVO, which showed a higher mortality rate and prevalence of atrial fibrillation. LVO had higher NIHSS scores and longer hospital stays. The Vision Aphasia Neglect (VAN) Scale and Modified Tzu Chi Stroke Severity Scale showed the highest sensitivity, with the latter also exhibiting the highest sensitivity for posterior circulation LVO.

Conclusion: The VAN and the modified Tzu Chi Stroke Severity Scale offer comparable sensitivity for detecting LVO in the prehospital setting. Our study supports the adoption of the modified Tzu Chi scale in the regional emergency medical service transfer algorithm for LVO detection for timely intervention.

Keywords: Acute ischemic stroke; Eastern Taiwan; Large vessel occlusion; Prehospital stroke assessment; Vascular neurology.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
The figure shows the flow chart of the emergency medical service transfer algorithm with the Tzu Chi Stroke Severity Scale. It illustrates the transfer algorithm for patients with stroke utilized in Eastern Taiwan incorporating the Tzu Chi stroke severity scale. In addition, a modified version of the Tzu Chi stroke severity scale is proposed for enhanced sensitivity in detecting large vessel occlusion. EMT: Emergency medical technician, EVT: Endovascular thrombectomy, tPA: tissue plasminogen activator, LVO: Large vessel occlusion
Figure 2
Figure 2
The receiver operating characteristic (ROC) curves comparing the Vision Aphasia Neglect (VAN) scale, Tzu Chi stroke severity scale, and its modified version demonstrated comparable discrimination ability for detecting large vessel occlusion. The patients in our study population are already confirmed to have acute stroke symptoms. Hence, in our study, the ROC curve analysis of VAN, Tzu Chi stroke severity scale, and its modified version did not include the items of the first step to screen for acute stroke symptoms. Tzu Chi: Tzu Chi stroke severity scale, Tzu Chi (M): modified Tzu Chi stroke severity scale, VAN: Vision aphasia neglect scale
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