The role of the Cincinnati Prehospital Stroke Scale in the emergency department: evidence from a systematic review and meta-analysis

Figures & data

Figure 1 Flow diagram of included studies.

Abbreviations: WOS, Web of Science; TP, true positives; TN, true negatives; FP, false positives; FN, false negatives.

Table 1 Summary of study characteristics

Author, year, country	Source	Study design	Setting	Administrator	Stroke scale training	Sample size (n)	Population characteristics	Types of stroke investigated	CPSS (performed or derived)
Asimos AW, 2014, US^Citation33	Annals of Emergency Medicine	Retrospective Observational	Prehospital	EMS	–	1,217	Mean age =66 Males 41%	IS, HS, TIA	Performed
Bergs J, 2010, Belgium^Citation49	European Journal of Emergency Medicine	Prospective Observational	Prehospital	EMS	–	31	Mean age =77 Males 61% Stroke and TIA prevalence 61.3%	IS, HS, TIA	Derived
Bray JE, 2005, Australia^Citation42	Cerebrovascular Disease	Prospective Observational	Prehospital	EMS	1 hr on pathogenesis and management of acute stroke and instructions in the assessment and documentation of items used in the prehospital stroke tools	100	Stroke and TIA prevalence 73%	IS, HS, TIA	Derived
Bray JE, 2010, Australia^Citation43	Stroke	Prospective Observational	Prehospital	EMS	1-hr stroke education program	850	Stroke prevalence 23%	IS, HS, TIA	Derived
English SW, 2018, USA^Citation34	Journal of Stroke and Cerebrovascular Disease	Retrospective Observational	Prehospital	EMS	1-hr online module annually	130	Mean age =75,42 Stroke and TIA prevalence 73.8%	IS, HS, TIA	Performed
Frendl DM, 2009, USA^Citation35	Stroke	Retrospective Observational	Prehospital	EMS	1-hr interactive presentation focusing on stroke recognition and CPSS use as part of standard monthly continuing education required for all EMS personnel.	154	Mean age =67 Males 44.16% Black 44.16%; White 55.84%	IS, HS, TIA	Performed
Heldner MR, 2016, Germany^Citation45	Journal of Neurology	Prospective Observational	Hospital	Physician	NIHSS- training	1,085	Mean age =67.7 Males 60.65% Ischemic stroke or TIA in anterior circulation prevalence 70%	IS or TIA (in anterior circulation)	Derived
Keenan KJ, 2018, USA^Citation36	Journal of Neurointerventional Surgery	Prospective Observational	–	Physician	NIHSS- training	735	Ischemic stroke and TIA prevalence 91.84%	IS, TIA	Derived
Kothari RU, 1999, USA^Citation37	Annals of Emergency Medicine	Prospective Observational	Hospital	Physicians and EMS	Before each session, physician conducted a 10 mins review on CPSS and how to score it with only verbal instructions	171	Mean age =57.8 Males 42.11% Black 59.65%; White 40.35% Stroke and TIA prevalence 28.7%	IS, HS, TIA	Performed
Maddali A, 2017, India^Citation47	Journal of Emergency, Trauma, Shock	Prospective Observational	Prehospital and Hospital	–	–	66	Stroke and TIA prevalence 93%	IS, HS, TIA	Performed
Mingfeng H, 2012, China^Citation48	Annals of Indian Academy of Neurology	Prospective Observational	Prehospital	Physicians	6-hr course on performing ROSIER and CPSS before the study	540	Mean age =63 67.59% Males Stroke and TIA prevalence 70.37%	IS, HS, TIA	Performed
Nor AM, 2005, UK^Citation17	Lancet Neurology	Prospective Observational	Hospital	Physicians	NIHSS-training	160	Males 6.93% Stroke and TIA prevalence 71.25%	IS, HS, TIA	Derived
Oostema JA, 2015, USA^Citation38	Stroke	Prospective Observational	Prehospital	EMS	–	441	Median age =78 Males 40.36% Ischemic stroke and TIA prevalence 59.9%	IS, TIA	Performed
Purrucker JC, 2014, Germany^Citation46	Journal of Neurology, Neurosurgery, and Psychiatry	Prospective Observational	Hospital	Physicians	–	88	Stroke and TIA prevalence 29%	IS, HS, TIA	Derived
Ramanujam P, 2008, USA^Citation39	Prehospital Emergency Care	Retrospective Observational	Prehospital	EMS	1-hr formal instruction per year	477	Stroke and TIA prevalence 40%	IS, HS, TIA	Performed
Richards CT, 2018, USA^Citation40	Prehospital Emergency Care	Retrospective Observational	Prehospital	EMS	–	138	Mean Age =69 Males 50.72% White 31.88%; African American 18.84%; Hispanic 1,44%; Asian 0,72%; other 1.17%. LVO prevalence 43.7%	LVO	Performed
Studnek JR, 2012, USA^Citation41	Prehospital Emergency Care	Retrospective Observational	Prehospital	EMS	2-hr continuing education lecture regarding neurologic emergencies	416	Mean Age =66.8 Males 45.67% White 50.95% Stroke and TIA prevalence 44.70%	IS, HS, TIA	Derived
Vanni S, 2011, Italy^Citation44	The Journal of Emergency Medicine	Prospective Observational	Hospital	EMS	–	155	Mean Age =72 Males 59% Stroke prevalence 56.13%	IS, HS	Performed

Abbreviations: EMS, Emergency Medical Staff; LVO, large vessel occlusion; IS, ischemic stroke; HS, hemorrhagic stroke; TIA, transient ischemic attack; DP, directly performed; OS, derived from other sources; NIHSS, National Institutes of Health Stroke Scale; ROSIER, Recognition of Stroke in the Emergency Room; CPSS, Cincinnati Prehospital Stroke Scale..

Table 2 Results of the quality assessment according to the Revised Quality Assessment of Diagnostic Accuracy Studies -2 (QUADAS-2) tool

Notes: Low Risk; High Risk; Unclear Risk.

Figure 2 Stacked bar charts of Revised Quality Assessment of Diagnostic Accuracy Studies -2 (QUADAS-2) scores, presenting a quick overview of the methodological quality of the 18 included studies expressed as a percentage of studies that met each criterion.

Figure 3 Data from meta-analyzed studies and forest plot for sensitivity and specificity of Cincinnati Prehospital Stroke Scale.

Abbreviations: TP, true positives; FP, false positives; FN, false negatives; TN, true negatives.

Figure 4 Summary receiving operating characteristic (sROC) curve.

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