Rapid Arterial oCclusion Evaluation (RACE) Scale for Stroke

RACE Scale for Stroke

Facial Palsy

Arm Motor Function

Leg Motor Function

Head & Gaze Deviation

Aphasia (if right hemiparesis) or Agnosia (if left hemiparesis)

Score:–

–

Predicts large vessel occlusion (LVO) in patients with acute stroke.

Why Use

Data show that patients with LVO have better outcomes at Comprehensive Stroke Centers with endovascular options such as mechanical thrombectomy. Not all stroke patients fit into this category. A sensitive, predictive tool for LVOs that provides a quantitative stroke assessment helps prehospital providers and medical control plan for faster, better care of stroke patients coming via EMS.

When to Use

Use in the prehospital setting (i.e., by EMS providers) in patients with stroke symptoms.

Formula

Addition of selected points: 0 1 2 Facial palsy Absent Mild Moderate to severe Arm motor function Normal to mild Moderate Severe Leg motor function Normal to mild Moderate Severe Head and gaze deviation Absent Present --- Aphasia (if right hemiparesis) Performs both tasks correctly Performs 1 task correctly Performs neither tasks Agnosia (if left hemiparesis) Patient recognizes his/her arm and the impairment Does not recognize his/her arm or the impairment Does not recognize his/her arm nor the impairment

Pearls / Pitfalls

The RACE Scale for Stroke is based on the well-known NIH Stroke Scale assessment and predicts stroke caused by large vessel occlusion (LVO). Provides quicker assessment than NIHSS for use in the prehospital environment to help predict LVO. While there are 11 points on the scale itself, the assessment is done based on the side of the patient’s neurologic deficits, so it is important to remember that the maximum score is 9. Depending on the patient’s deficits, testing is done for either aphasia or agnosia, not both. While not as comprehensive as the NIHSS assessment, the RACE Scale is a much more rapid tool that still retains sensitivity for severe strokes. Several other well-known prehospital stroke scales exist, such as the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS), but they are all qualitative scales designed to rule in or rule out a stroke. The RACE Scale is the first major quantitative assessment to help predict LVO and thus identify which patients may be best served at a Comprehensive Stroke Center.

Management

Consider consultation with a neurologist, early CT imaging (non-contrast and CT angiography), blood pressure and blood glucose control. Consider tPA after an assessment of contraindications and possible transfer to a Comprehensive Stroke Center if indicated.

Critical Actions

The RACE Scale is not a substitute for a full neurologic exam and NIHSS assessment in the ED. Emergency physicians and hospital personnel should still think of and try to exclude other causes of neurologic deficits such as intracerebral hemorrhage (ICH), hypoglycemia, Todd’s paralysis, complex migraines, exacerbation of prior deficits from a new metabolic source, etc. Early imaging and consultation with a neurologist are important. If the neurologic deficit is deemed to be from an ischemic event, then IV thrombolysis should be considered and definitive care at a Comprehensive Stroke Center should be considered.

Advice

For patients with RACE Scale scores ≥5, an LVO should be considered as the cause and a plan put in place to get them definitive care at a Comprehensive Stroke Center as quickly as possible. For patients with a RACE Scale scores ≤4, an acute stroke should still be considered. However, as lower score correlates with lower NIHSS score, these patients may not be candidates for invasive therapies.

More Information

Interpretation: RACE Score Sensitivity Specificity ≥1 100% 13% ≥2 97% 27% ≥3 93% 40% ≥4 89% 55% ≥5 85% 68% ≥6 72% 77% ≥7 53% 89% ≥8 32% 95% 9 7% 99% RACE Scale scores ≥5 were found to have the best predictive value and while protocols vary, it is generally recommended that patients with scores ≥5 are directly referred to a stroke center with endovascular capabilities.