Validating the TeleStroke Mimic Score: A Prediction Rule for Identifying Stroke Mimics Evaluated Over Telestroke Networks.

Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score for use during telestroke encounters to differentiate stroke mimics from ischemic cerebrovascular disease derived and validated in the Partners TeleStroke Network. Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TeleStroke Mimic (TM) score in a broader population. We evaluated the TM score in 1930 telestroke consults from the University of Utah, Georgia Regents University, and the German TeleMedical Project for Integrative Stroke Care Network. We report the area under the curve in receiver-operating characteristic curve analysis with 95% confidence interval for our previously derived TM score in which lower TM scores correspond with a higher likelihood of being a stroke mimic. Based on final diagnosis at the end of the telestroke consultation, there were 630 of 1930 (32.6%) stroke mimics in the external validation cohort. All 6 variables included in the score were significantly different between patients with ischemic cerebrovascular disease versus stroke mimics. The TM score performed well (area under curve, 0.72; 95% confidence interval, 0.70-0.73; P<0.001), similar to our prior external validation in the Partners National Telestroke Network. The TM score's ability to predict the presence of a stroke mimic during telestroke consultation in these diverse cohorts was similar to its performance in our original cohort. Predictive decision-support tools like the TM score may help highlight key clinical differences between mimics and patients with stroke during complex, time-critical telestroke evaluations.

Ali SF ，Hubert GJ ，Switzer JA ，Majersik JJ ，Backhaus R ，Shepard LW ，Vedala K ，Schwamm LH ... -  《-》

The TeleStroke mimic (TM)-score: a prediction rule for identifying stroke mimics evaluated in a Telestroke Network.

Up to 30% of acute stroke evaluations are deemed stroke mimics (SM). As telestroke consultation expands across the world, increasing numbers of SM patients are likely being evaluated via Telestroke. We developed a model to prospectively identify ischemic SMs during Telestroke evaluation. We analyzed 829 consecutive patients from January 2004 to April 2013 in our internal New England-based Partners TeleStroke Network for a derivation cohort, and 332 cases for internal validation. External validation was performed on 226 cases from January 2008 to August 2012 in the Partners National TeleStroke Network. A predictive score was developed using stepwise logistic regression, and its performance was assessed using receiver-operating characteristic (ROC) curve analysis. There were 23% SM in the derivation, 24% in the internal, and 22% in external validation cohorts based on final clinical diagnosis. Compared to those with ischemic cerebrovascular disease (iCVD), SM had lower mean age, fewer vascular risk factors, more frequent prior seizure, and a different profile of presenting symptoms. The TeleStroke Mimic Score (TM-Score) was based on factors independently associated with SM status including age, medical history (atrial fibrillation, hypertension, seizures), facial weakness, and National Institutes of Health Stroke Scale >14. The TM-Score performed well on ROC curve analysis (derivation cohort AUC=0.75, internal validation AUC=0.71, external validation AUC=0.77). SMs differ substantially from their iCVD counterparts in their vascular risk profiles and other characteristics. Decision-support tools based on predictive models, such as our TM Score, may help clinicians consider alternate diagnosis and potentially detect SMs during complex, time-critical telestroke evaluations.

Ali SF ，Viswanathan A ，Singhal AB ，Rost NS ，Forducey PG ，Davis LW ，Schindler J ，Likosky W ，Schlegel S ，Solenski N ，Schwamm LH ，Partners Telestroke Network ... -  《-》

Validation of the Telestroke Mimic Score in Mayo Clinic Population.

Telestroke consultations enable hospital providers to administer intravenous (IV) alteplase to patients who would otherwise not receive it due to lack of an in-hospital stroke team. However, up to 30% of acute stroke patient evaluations are deemed to be stroke mimics. Mimics present a challenge with the limitations of a virtual neurological exam. The administration of IV alteplase in these patients is not without risk. With the cost and risk associated with IV alteplase, there are both ethical and practical incentives to avoid administering alteplase to a patient manifesting a stroke-mimic. Recently a retrospective analysis validated a TeleStroke Mimic Score (TM-Score) to help detect stroke mimics. We retrospectively applied this tool to Mayo Clinic Stroke Telemedicine for Arizona Rural Residents (STARR) telestroke database to provide external validation in an independent study population. We analyzed 339 patients in the STARR database for validation of the TM-Score, which was applied retrospectively to determine whether it predicted stroke-mimic, using data available during each patient's telestroke consult. We assessed the TM-Score's performance with a receiver-operating characteristic (ROC) curve. A scatter plot of the data was assembled to demonstrate the relationship between the TM-Score and the likelihood of having a stroke mimic, and was compared to the nomogram in the original TM-Score study. When the TM-Score was applied to Mayo Clinic STARR validation cohort, the area under the ROC curve was 0.78, larger than that of the derivation cohort in the original study (0.75). Further analysis suggested that a TM-Score > 25 or < 10 provided a greater degree of confidence that the patient had presented with stroke or stroke mimic, respectively.  In STARR cohort, additional variables were significantly different between stroke and stroke mimic populations, including a history of sleep apnea and diabetes. We determined that the original TM-Score was valid when applied to Mayo Clinic STARR telestroke population.

Carlin R ，Zhang N ，Demaerschalk BM 《-》

Evaluation of a score for the prehospital distinction between cerebrovascular disease and stroke mimic patients.

Geisler F ，Ali SF ，Ebinger M ，Kunz A ，Rozanski M ，Waldschmidt C ，Weber JE ，Wendt M ，Winter B ，Schwamm LH ，Audebert HJ ... -  《-》

External validation of stroke mimic prediction scales in the emergency department.

Tu TM ，Tan GZ ，Saffari SE ，Wee CK ，Chee DJMS ，Tan C ，Lim HC ... -  《BMC Neurology》