ISSN: 0034-8376
eISSN: 2564-8896






Reliability of Bystander Recognition of Clinical Features in Pre-Hospital Classification of Acute Cerebrovascular Syndromes: Preliminary Findings



Erwin Chiquete, Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Valeria Sandoval-Rodríguez, Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Miguel García-Grimshaw, Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Amado Jiménez-Ruiz, Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Juan J. Gómez-Piña, Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Eduardo Ruiz-Ruiz, Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Guillermo Ramírez-García, Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Fernando Flores-Silva, Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Carlos Cantú-Brito, Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Ana Ochoa-Guzmán, Molecular Biology Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
José L. Ruiz-Sandoval, Neurology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jal.; Department of Neuroscience, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jal., Mexico


Background: The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease. Objective: The objective of the study was to assess the predictive value of the medical history and clinical features recognized by the patients’ bystanders to classify neurovascular syndromes in pre-hospital settings. Methods: We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients’ bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed. Results: Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onsetto-door time <6 h, even when the first medical assessment had occurred in <-1 h in 75% of cases. Clinical features noticed by the patients’ bystanders had low positive predictive values (PPV) for any stroke type. The CPR “language or speech disorder + focal motor deficit” had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, headache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not associated with final onset-to-door time. Altered consciousness, age >-65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality. Conclusion: Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical referrals.



Keywords: Acute ischemic stroke. Clinical manifestations. Intracerebral hemorrhage. Prognosis. Subarachnoid hemorrhage.