Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 h

Who fucking cares about recovery predictions? Except for researchers needing a subject to study? Survivors care about one thing, 100% recovery. If your research doesn't get closer to that, why the hell are you doing it?

Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 hours

Anke Wouters^1,2,3†, Céline Nysten^3†, Vincent Thijs^4,5 and Robin Lemmens^1,2,3*

• ¹Department of Neurosciences, Experimental Neurology, KU Leuven – University of Leuven, Leuven, Belgium
• ²Laboratory of Neurobiology, Center for Brain and Disease Research, VIB, Leuven, Belgium
• ³Department of Neurology, University Hospitals Leuven, Leuven, Belgium
• ⁴Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
• ⁵Department of Neurology, Austin Health, Heidelberg, VIC, Australia

Introduction: Stroke severity measured by the baseline National Institutes of Health Stroke Scale (NIHSS) is a strong predictor of stroke outcome. Early change of baseline severity may be a better predictor of outcome. Here, we hypothesized that the change in NIHSS in the first 24 h after stroke improved stroke outcome prediction.

Materials and methods: Patients from the Leuven Stroke Genetics Study were included when the baseline NIHSS (B-NIHSS) was determined on admission in the hospital and NIHSS after 24 h could be obtained from patient files. The delta NIHSS, relative reduction NIHSS, and major neurological improvement (NIHSS of 0–1 or ≥8-point improvement at 24 h) were calculated. Good functional outcome (GFO) at 90 days was defined as a modified Rankin Scale of 0–2. Independent predictors of outcome were identified by multivariate logistic regression. We performed a secondary analysis after excluding patients presenting with a minor stroke (NIHSS 0–5) since the assessment of change in NIHSS might be more reliable in patients presenting with a moderate to severe deficit.

Results: We analyzed the outcome in 369 patients. B-NIHSS was associated with GFO (odds ratio: 0.82; 95% CI 0.77–0.86). In a multivariate model with B-NIHSS and age as predictors, the accuracy [area under the curve (AUC): 0.82] improved by including the delta NIHSS (AUC: 0.86; p < 0.01). In 131 patients with moderate to severe stroke, the predictive multivariate model was more accurate when including the RR NIHSS (AUC: 0.83) to the model which included B-NIHSS, age and ischemic heart disease (AUC: 0.77; p = 0.03).

Conclusion: B-NIHSS is a predictor of stroke outcome. In this cohort, the prediction of GFO was improved by adding change in stroke severity after 24 h to the model.

Introduction

Stroke is one of the leading causes of disability and death worldwide (1, 2). Patients who are experiencing deficits as a result of an ischemic stroke are worried about their expected outcome. Identifying predictors of functional outcome may be of assistance to physicians when confronted with these concerns from stroke patients. Stroke severity and evolution of the clinical symptoms during the first days after initial presentation are potential valuable predictors of outcome. Improvement in the estimation of clinical outcomes could result in more specific management of stroke rehabilitation as well as clearer informing of patients and their relatives. Multiple studies have focused on the baseline National Institutes of Health Stroke Scale (B-NIHSS) as a predictor of functional outcome (3–8), but only some data are available on the evolution of the National Institutes of Health Stroke Scale (NIHSS) in the first 24 h after stroke onset (6, 9–11). Different parameters have been described to assess this change in stroke severity: Delta NIHSS (B-NIHSS–24 h NIHSS), relative reduction in NIHSS (RR NIHSS; delta NIHSS/B-NIHSS), and major neurological improvement (MNI; NIHSS of 0–1 or ≥8-point improvement at 24 h).

Other identified, independent predictors of outcome are age, sex, mean arterial pressure, history of diabetes, baseline glucose levels, baseline NIHSS score, CT findings, time to treatment and recanalization, current smoking, atrial fibrillation (AF), and statin intake before stroke (3, 12–14).

The aim of this study was to investigate if the prediction of functional outcome after 3 months could be improved by adding the improvement in the first 24 h into a predictive model.