Cincinnati Prehospital Stroke Severity Scale (CP-SSS)

Why Use

Acute stroke caused by LVO may be amenable to additional treatment beyond intravenous tissue plasminogen activator (tPA), including mechanical thrombectomy. Benefit from mechanical thrombectomy in acute stroke from LVO is time-dependent, so early recognition may help timely mobilization of neurosurgical or endovascular care teams. Based on three items from the NIH Stroke Scale (NIHSS), which is familiar to and easily administered by many emergency physicians and neurologists, as opposed to the LAMS , which is made up of three clinical items, one of which (grip strength) is not included in the NIHSS, and the RACE Scale , which includes more (six) clinical items.

When to Use

Patients in a hospital setting with signs and symptoms of acute ischemic stroke.

Formula

Pearls / Pitfalls

May be used to determine both severity of stroke, as quantified by NIHSS ≥15, and presence of LVO. Accuracy at detecting LVO or severe stroke has not been evaluated when administered by EMS providers.

Management

In cases of suspected acute ischemic stroke from LVO, the following is recommended: STAT neurological consultation. STAT CT head without contrast. STAT CTA head and neck with contrast. STAT laboratory testing (complete blood count, coagulation profile, basic metabolic panel, type and screen, troponin-I).

Critical Actions

Intravenous tissue plasminogen activator (IV tPA) is the standard-of-care treatment for adult patients presenting with acute ischemic stroke within 4.5 hours of symptom onset if no exclusion criteria are met, irrespective of whether LVO is the cause or not. Endovascular (mechanical) thrombectomy is the standard-of-care treatment for selected adult patients presenting with acute ischemic stroke due to LVO. A patient’s appropriateness for endovascular intervention depends on multiple factors, such as time since onset of symptoms, neuroimaging, baseline functional status, and others. Appropriateness for intravenous thrombolysis or mechanical thrombectomy should be determined by neurological/neurosurgical consultant whenever available.

Advice

Neurological consultation should be obtained immediately in suspected acute ischemic stroke. Acute ischemic stroke is a neurological emergency that is amenable to time-sensitive treatments (e.g. tPA, mechanical thrombectomy) if certain clinical conditions are met. Should not be used as a substitute for clinical judgment, and is intended for use as an adjunct to medical decision-making.

More Information

Interpretation: CP-SSS LVO and NIHSS 0–1 LVO and NIHSS ≥15 less likely 2–4 LVO and NIHSS ≥15 likely