PHWR Public Health Weekly Report

Stroke recognition systems have been developed to reduce time delays, however, a comprehensive triaging score identifying stroke subtypes is needed to guide appropriate management. This study aimed to develop a prehospital scoring system for rapid stroke recognition and identify stroke subtype simultaneously.
In the prospective database of the regional emergency and stroke center, the Clinical Information, Vital signs, and Initial Labs (CIVIL) of 1,599 patients suspected of acute stroke was analyzed from an automatically-stored electronic health record. Final confirmation was performed with neuroimaging. Using multiple regression analyses, this study determined independent predictors of tier 1 (true-stroke or not), tier 2 (hemorrhagic stroke or not), and tier 3 (emergent large vessel occlusion [ELVO] or not). The diagnostic performance of the stepwise CIVIL scoring system was investigated using internal validation. A new scoring system characterized by a stepwise clinical assessment was developed in three tiers.
Tier 1: Seven CIVIL-AS3A2P items (total score from –7 to +6) were deduced for true stroke as age (>60 years); stroke risks without seizure or psychiatric disease, extreme sugar; “any asymmetry”, “not ambulating”; abnormal blood pressure at a cut-off point +1 with diagnostic sensitivity of 82.1%, specificity of 56.4%. Tier 2: Four items for hemorrhagic stroke were identified as the CIVIL-MAPS indicating mental change, Age below 60 years, high blood Pressure, no Stroke risks with cut-point +2 (sensitivity 47.5%, specificity 85.4%). Tier 3: For ELVO diagnosis: we applied with CIVIL-GFAST items (Gaze, Face, Arm, Speech) with cut-point >3 (sensitivity 66.5%, specificity 79.8%) were applied.
The CIVIL score is a comprehensive and versatile system that recognizes strokes and identifies the stroke subtype simultaneously.

Key words Stroke, Stroke mimic, Hemorrhagic stroke, Ischemic stroke, Emergent large vessel occlusion

1. Feigin VL, Roth GA, Naghavi M, Parmar P, Krishnamurthi R, Chugh S, et al. Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet Neurology 2016;15(9):913-24.
   
2. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati prehospital stroke scale: reproducibility and validity. Annals of emergency medicine 1999;33(4):373-8.
   
3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke 2000;31(1):71-6.
   
4. Nor AM, Davis J, Sen B, Shipsey D, Louw SJ, Dyker AG, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. The Lancet Neurology 2005;4(11):727-34.
   
5. Lee SE, Choi MH, Kang HJ, Lee S-J, Lee JS, Lee Y, et al. Stepwise stroke recognition through clinical information, vital signs, and initial labs (CIVIL): Electronic health record-based observational cohort study. PloS one 2020;15(4):e0231113.