EMS Stroke Severity Scales – Use of Stroke VAN by ED Providers

EMS Stroke Severity Scales – Use of Stroke VAN by ED Providers       May 2021   

By Julie Fussner BSN, RN, CPHQ, SCRN, Stroke Operations Manager   

Prehospital stroke screening tools remain a critical aspect of stroke care. Both the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LASPSS) have shown better performance than other stroke recognitionscales.  However, with the thrombectomy window extending out to 24 hours of last known well for an ischemic stroke patient with a large vessel occlusion (LVO), multiple severity scoring scales have been developed to try and identify this population in the field.    

You may have heard of some of these severity tools available now such as RACE, LAMS, LEGS, CPSSS, VAN, etc.   

Per the AHA Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update published in October 2019; it specifically states there is insufficient evidence to recommend one of these severity tools over another. Length of the examination and false positive rates have been barriers. 

In our UH system, we have educated EMS to perform the CPSS on scene, keep your scene time to < 15 mins, and perform the MEND en route. Our system protocol is to provide advanced notification, transport to the nearest UH hospital to administer IV tPA as soon as possible, if eligible, and get advanced diagnostic imaging, a CT Angiogram, to identify a large vessel occlusion in which the patient may benefit from a thrombectomy procedure.  

In April, a new initiative was piloted at all UH community emergency departments where the ED provider is using the VAN assessment to identify the patient with an LVO and determine the immediate need for obtaining the CT angiogram. VAN assesses vision, aphasia, and neglect. It is quick and easy. There is no need to calculate any score. If the patient has any unilateral arm weakness, the VAN assessment will be completed by the ED provider. If there are ANY positive VAN signs, the patient will be scanned for the non-contrast CT and then also get the CT Angiogram immediately. When you provide handoff to the hospital team, please communicate any observations related to vision, speech, and neglect. See the table below for details. The MEND exam includes all of the VAN components except neglect. 

We expect this initiative will help improve our Door in > Door out times at the community stroke centers and get the appropriate patients transferred to CMC quicker. Our goal as a system stroke program is to always provide the highest quality of care to our stroke patients regardless of where they arrive in our UH system.  

If you are interested in learning more about VAN, please review this certification training video or download the App.


Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Mohamed S Teleb and et al. Journal of Neurointerventional Surgery, http://dx.doi.org/10.1136/neurintsurg-2015-012131

Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update A Policy Statement From the American Stroke Association Opeolu Adeoye, MD, MS, FAHA, Chair; and et al. Stroke. 2019;50:e187-e210. DOI: 10.1161/STR.0000000000000173.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association William J. Powers, MD, FAHA, Chair; and et al. Stroke. 2019;50:e1–e 75.doi: 10.1161/STR.0000000000000211.

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