Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke

Funding The authors have not declared a specific grant for this research from any

funding agency in the public, commercial or not-for-profit sectors.

Map disclaimer The inclusion of any map (including the depiction of any

boundaries therein), or of any geographic or locational reference, does not imply the

expression of any opinion whatsoever on the part of BMJ concerning the legal status

of any country, territory, jurisdiction or area or of its authorities. Any such expression

remains solely that of the relevant source and is not endorsed by BMJ. Maps are

provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient consent for publication Not required.

Ethics approval The institutional review boards of all participating hospitals

approved the study protocol.

Provenance and peer review Not commissioned; internally peer reviewed.

Data availability statement Data are available upon reasonable request.

Supplemental material This content has been supplied by the author(s). It

has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have

been peer-reviewed. Any opinions or recommendations discussed are solely those

of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and

responsibility arising from any reliance placed on the content. Where the content

includes any translated material, BMJ does not warrant the accuracy and reliability

Open access This is an open access article distributed in accordance with the

Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which

permits others to distribute, remix, adapt, build upon this work non-commercially,

and license their derivative works on different terms, provided the original work is

properly cited, appropriate credit is given, any changes made indicated, and the use

is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

ORCID iD

Takeshi Morimoto http://orcid.org/0000-0002-6844-739X

1 Adeoye O, Nyström KV, Yavagal DR, et al. Recommendations for the establishment of

stroke systems of care: a 2019 update. Stroke 2019;50:e187–210.

2 Koster GT, Nguyen TTM, van Zwet EW, et al. Clinical prediction of thrombectomy

eligibility: a systematic review and 4-item decision tree. Int J Stroke 2019;14:530–9.

3 Saver JL, Goyal M, van der Lugt A, et al. Time to treatment with endovascular

thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA

2016;316:1279–88.

4 Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after

subarachnoid hemorrhage. JAMA 2004;291:866–9.

5 Oostema JA, Chassee T, Baer W, et al. Accuracy and implications of hemorrhagic

stroke recognition by emergency medical services. Prehosp Emerg Care 2020:1–6.

6 Uchida K, Yoshimura S, Hiyama N, et al. Clinical prediction rules to classify types of

stroke at prehospital stage. Stroke 2018;49:1820–7.

7 Uchida K, Yoshimura S, Sakakibara F, et al. Simplified prehospital prediction rule to

estimate the likelihood of 4 types of stroke: the 7-Item Japan Urgent Stroke Triage

(JUST-7) score. Prehosp Emerg Care 2021;25:465–74.

8 van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the

assessment of handicap in stroke patients. Stroke 1988;19:604–7.

9 Lyden P, Brott T, Tilley B, et al. Improved reliability of the NIH Stroke Scale using video

training. NINDS TPA Stroke Study Group. Stroke 1994;25:2220–6.

10 Tomsick T. Timi, TIBI, TICI: I came, I saw, I got confused. AJNR Am J Neuroradiol

2007;28:382–4.

11 Abboud ME, Band R, Jia J, et al. Recognition of stroke by EMS is associated with

improvement in emergency department quality measures. Prehosp Emerg Care

2016;20:729–36.

12 Spaite DW, Bobrow BJ, Keim SM, et al. Association of statewide implementation of the

prehospital traumatic brain injury treatment guidelines with patient survival following

traumatic brain injury: the Excellence in Prehospital Injury Care (EPIC) study. JAMA

Surg 2019;154:e191152.

13 Schlemm L, Ebinger M, Nolte CH, et al. Impact of prehospital triage scales to

detect large vessel occlusion on resource utilization and time to treatment. Stroke

2018;49:439–46.

Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi:10.1136/neurintsurg-2021-017863

J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2021-017863 on 19 August 2021. Downloaded from http://jnis.bmj.com/ on December 1, 2021 by guest. Protected by copyright.

Clinical neurology

Supplemental material

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

placed on this supplemental material which has been supplied by the author(s)

J NeuroIntervent Surg

6XSSOHPHQWDOPDWHULDO



Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi: 10.1136/neurintsurg-2021-017863

Supplemental material

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

placed on this supplemental material which has been supplied by the author(s)

J NeuroIntervent Surg

Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi: 10.1136/neurintsurg-2021-017863

Supplemental material

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

placed on this supplemental material which has been supplied by the author(s)

J NeuroIntervent Surg

Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi: 10.1136/neurintsurg-2021-017863

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

placed on this supplemental material which has been supplied by the author(s)

Supplemental material

J NeuroIntervent Surg

6XSSOHPHQWDO7DEOH+LURVKLPD&LW\)LUH'HSDUWPHQW 

)LUH'HSDUWPHQW

1DND

6XEGLYLVLRQ

2WH +DNXVKLPD 0RWRPDFKL (ED

+LJDVKL

+LNDUL )XNXGD 1XNXVKLQD +HVDND

0LQDPL

'DQEDUD 6XLM\R $RVDNL +LJDVKLKRQXUD 8MLQD 1LQRVKLPD

1LVKL

$VDPLQDPL

$VDNLWD

$NL

6DHNL

0L\DNR 0LVDVD .RL .RJR ,QRNXFKL

6DWR .DPL\DVX *LRQ 1XPDWD

1DNDVKLPD .DEH 6KLUDNL .R\R $VD $NLRWD

.DLWD 6HQRJDZD <DQR .XPDQR 6DND

,WVXNDLFKL <XNL <DKDWD .DLURHQ ,VKLXFKL



Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi: 10.1136/neurintsurg-2021-017863

Supplemental material

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

placed on this supplemental material which has been supplied by the author(s)

J NeuroIntervent Surg

6XSSOHPHQWDO7DEOH'LIIHUHQFHLQSDWLHQWVZKRWULDJHGDQGQRWWULDJHGZLWK-867VFRUHDIWHU

LPSOHPHQWDWLRQRI-867VFRUH

7ULDJHGZLWK

1RWWULDJHGZLWK

-867VFRUH

-867VFRUH

Q 

Q 

$JH\HDUVPHDQ6'



 



0HQQ







 











7RWDOFRKRUWQ 

6\VWROLFEORRGSUHVVXUHPP+JPHDQ6'

'LDVWROLFEORRGSUHVVXUHPP+JPHDQ6'

)LQDOGLDJQRVLV

39DOXH

     /92Q





     ,&+Q



 

     6$+Q





     &,Q





     1RVWURNHQ

 



6XFFHVVRIWKHILUVWUHTXHVWWRKRVSLWDOQ

 





2QVFHQHWLPHPLQPHGLDQ>,45@

>@

>@



7UDQVSRUWWLPHPLQPHGLDQ>,45@

>@

>@



7ULDJHGZLWK

1RWWULDJHGZLWK

-867VFRUH

-867VFRUH

Q 

Q 

  











6\VWROLFEORRGSUHVVXUHPP+JPHDQ6'



 

 

'LDVWROLFEORRGSUHVVXUHPP+JPHDQ6'







>@

>@



>@

>@



> @

>@



 

 

 







6XFFHVVRIWKHILUVWUHTXHVWWRKRVSLWDOQ







2QVFHQHWLPHPLQPHGLDQ>,45@

>@

>@



7UDQVSRUWWLPHPLQPHGLDQ>,45@

>@

>@



>@

>@

 

3DWLHQWVZLWK/92Q 

$JH\HDUVPHDQ6'

0HQQ

P56EHIRUHRQVHWPHGLDQ>,45@

1,+66PHGLDQ>,45@

$63(&76&7RU05,PHGLDQ>,45@

2FFOXVLRQVLWH

     $QWHULRUFLUFXODWLRQQ

     ,QWHUQDOFDURWLGDUWHU\RU0VHJPHQWRIWKH 

     PLGGOHFHUHEUDODUWHU\Q

2QVHWWRGRRUWLPHPLQPHGLDQ>,45@



39DOXH



Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi: 10.1136/neurintsurg-2021-017863

Supplemental material

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

placed on this supplemental material which has been supplied by the author(s)

6HFRQGWUDQVIHUWRDQRWKHUKRVSLWDOQ

J NeuroIntervent Surg







UW3$Q

 





7KURPEHFWRP\Q

 





     '3PLQPHGLDQ>,45@

> @

>@



     35PLQPHGLDQ>,45@

>@

 >@



     7,&,EQ 

  





P56DW GD\VQ

 





'HDWKXSWR GD\VQ







-867-DSDQ8UJHQW6WURNH7ULDJH 6'VWDQGDUGGHYLDWLRQ ,45LQWHUTXDUWLOHUDQJH /92ODUJH

YHVVHORFFOXVLRQ ,&+LQWUDFUDQLDOKHPRUUKDJH 6$+VXEDUDFKQRLGKHPRUUKDJH &,FHUHEUDO

LQIDUFWLRQRWKHUWKDQ/92 P56PRGLILHG5DQNLQ6FDOH 1,+661DWLRQDO,QVWLWXWHVRI+HDOWK6WURNH

6FDOH $63(&76$OEHUWD6WURNH3URJUDP(DUO\&76FRUH UW3$UHFRPELQDQWWLVVXHSODVPLQRJHQ

DFWLYDWRU '3GRRUWRSXQFWXUHWLPH 35SXQFWXUHWRUHSHUIXVLRQWLPH 7,&,WKURPERO\VLVLQ

FHUHEUDOLQIDUFWLRQ &7FRPSXWHGWRPRJUDSK\ 05,PDJQHWLFUHVRQDQFHLPDJLQJ 



Araki H, et al. J NeuroIntervent Surg 2021;0:1–6. doi: 10.1136/neurintsurg-2021-017863

...