New Picture Stimuli for the NIH Stroke Scale: A Validation Study

 You might want to study this picture now, so when you have a stroke you can answer correctly. You might want to study the old sexist picture also in case your hospital is out-of-date.

New Picture Stimuli for the NIH Stroke Scale: A Validation Study

Melissa D. Stockbridge,

Lindsey Kelly,

Sarah Newman-Norlund,

Brian White,

Marianne Bourgeois,

Elizabeth Rothermel,

Julius Fridriksson,

Patrick D. Lyden and

Argye E. Hillis

Originally published22 Jan 2024https://doi.org/10.1161/STROKEAHA.123.044384Stroke. 2024;55:443–451

• This article is commented on by the following:

Abstract

BACKGROUND:

The National Institutes of Health Stroke Scale is a widely accepted tool for structured graded neurological examination of stroke or suspected stroke in the hyperacute setting. Concerns have arisen about the use of its picture stimuli in a contemporary and global health context. Here, we present new stimuli prepared to serve the needs of stroke providers worldwide: the precarious painter image description and updated objects for naming.

METHODS:

This was a validation study of 101 healthy fluent English speakers. Participants were reached by the Johns Hopkins Outpatient Center, the University of South Carolina, and Prisma Health from 2022 to 2023 and included residents of the United States, Germany, Canada, the United Kingdom, Australia, and Zambia. Participants were recorded in person or via video conferencing when asked to describe the new picture, while a subset named seven illustrations. Multivariate analyses of variance were used for primary analyses. In a complementary investigation, 299 attendees of the 2023 International Stroke Conference were asked about their preference for the existing or new stimuli and why.

RESULTS:

Each of the 44 content units from the picture description was included by at least 5% of respondents in the demographically representative subsample. Performance was similar across healthy participants irrespective of age, sex, race, ethnicity, or education. Typical descriptions were characterized by an average of 23 content units (SD=5) conveyed with 167 syllables (SD=79). The new naming stimuli were recognized by 100% of participants from many countries as being familiar and identifiable, and names provided in response to the task were highly convergent. The majority of stroke health care providers preferred both the precarious painter and naming stimuli.

CONCLUSIONS:

The description of the new National Institutes of Health Stroke Scale picture, the precarious painter, results in rich samples among healthy speakers that will provide an appropriate basis for the detection of language deficits.

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Stroke Recovery After 2 Years: Making Sense of Milestones from Flint Rehab

My NIH stroke scale would have been a 10 - moderate. 

Stroke Recovery After 2 Years: Making Sense of Milestones from Flint Rehab

This line from there is damming: In our article on stroke recovery after 5 years, we highlighted how the severe lack of quality therapy after discharge from inpatient therapy has impeded recovery for many stroke patients.  

So NO PROTOCOLS, so you are screwed. 

DOUBT Study Clarifies Role of MRI for TIA or Stroke

Your action point on this is to make damn sure you have all the classic symptoms, lost sensation, slurred speech, lack of movement on one side, dropped mouth. You don't want to be classified as too good to treat.

Every single stroke coming into your stroke hospital should have a protocol to follow. There is never a stroke that is too good to treat. You never magically recover from a stroke. Your doctor should never have to make a subjective decision. You have an objective damage diagnosis(The NIH Stroke Scale is not objective so we have a problem right from the start.). What should follow directly from that is a stroke protocol to remove the clot or stop the bleeding and then a protocol to stop the neuronal cascade of death or the hemorrhage cascade of death.  This is so fucking simple, why can't it be done?  Laziness? Incompetence? Or just don't care? No leadership? No strategy? Not my job?

DOUBT Study Clarifies Role of MRI for TIA or Stroke

Diagnosis changed for 30% of study participants after MRI findings

by Zeena Nackerdien PhD, CME Writer, MedPage Today October 4, 2019

Study Authors: Shelagh B. Coutts, Francois Moreau, et al.; Margy E. McCullough-Hicks, Gregory W. Albers
Target Audience and Goal Statement: Neurologists, radiologists, emergency department physicians, hospitalists, internists
The goal of this study was to establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI).
Question Addressed:

• What was the rate of stroke defined by diffusion restriction detected on MRI scans among patients with low-risk suspected transient ischemic attack (TIA) or minor stroke presentations?

Study Synopsis and Perspective:
Patients with low-risk suspected TIA and minor stroke had a higher-than-expected rate of true ischemia on MRI, suggesting neurologists' clinical assessment alone did not reliably produce the correct diagnosis, researchers for the prospective observational DOUBT study reported.

Action Points

• Patients with low-risk suspected transient ischemic attack (TIA) or minor stroke had a higher-than-expected rate of true ischemia on MRI, in a prospective, observational, international, multicenter cohort study, suggesting neurologists' clinical assessment alone did not reliably produce the correct diagnosis.
• Realize that these data argue that an MRI is a necessary component of clinical evaluation in virtually all patients presenting with symptoms suggestive of a TIA or minor stroke, including those with short-duration motor or language deficits or persistent low-risk neurologic symptoms.

Hope Dies Last—Evidence Again Fails to Support a Neuroprotectant Cerebrolysin for Acute Ischemic Stroke

Then whom is going to analyze and explain why these neuroprotectant trials failed so the stroke strategy can be updated for this failure? Using the Barthel Index, Rankin Scale and National Institutes of Health Stroke Scale means they were using subjective endpoints rather than objective ones like scans showing 3d size and location of dead and damaged areas. Don't these people know how to run research at all?  With a thousand failures someone should be able to identify the commonality so a new direction in strategy can be undertaken. Does no one in the stroke medical world have two functioning neurons to rub together to create a spark of intelligence?
http://stroke.ahajournals.org/content/48/9/2343?etoc=

Daniel Bereczki

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https://doi.org/10.1161/STROKEAHA.117.018202

Stroke. 2017;48:2343-2344

Originally published July 26, 2017

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• Editorials
• effectiveness
• neuroprotectant
• outcome
• stroke
• systematic review

See related article, p e245

It has been a long-lasting hope in basic and clinical research to identify neuroprotectant agents that improve clinical outcome after an ischemic stroke. Over a thousand compounds have been tested in the western world¹ without identifying a single compound supported by firm evidence for use in acute stroke. Although 21 traditional Chinese medicines evaluated in clinical trials claimed to improve clinical outcome after stroke and 7 of them also allegedly decreased case fatality,² because of methodological flaws in these trials, no recommendations can be made on these treatments until properly designed trials are completed.³ None of the Cochrane reviews recommends the use of any neuroprotectants for the treatment of acute stroke,⁴ and current guidelines are also against the use of such agents.⁵

Cerebrolysin is an extract of porcine brain containing a mixture of free amino acids and oligopeptides.⁶ Randomized clinical trials addressed its safety and efficacy in several conditions like Alzheimer’s disease⁷ and traumatic brain injury.⁸ One recent Cochrane review based on 6 trials evaluates the effects of cerebrolysin in acute ischemic stroke and concludes that the use of cerebrolysin has no effect on fatality.^9,10 Five of the included trials were small, and in the largest trial, the comparison groups were not balanced for prognostic factors. The loss to follow-up was considerable in the trials. None of the 6 trials, including overall 1501 participants, had low risk of bias.

The predefined primary outcome is one of the most important issues in clinical trials. Death is certainly an important outcome, but dependency on others is also a bad outcome after stroke. Death or dependency, the preferred composite primary outcome after stroke, was not a primary outcome in any of the 6 trials. Although subgroup and post hoc analyses suggested potential benefit, the largest study with over 1000 patients¹¹ had neutral results regarding the predefined primary outcome: a combined test of the modified Rankin Scale, the Barthel Index, and the National Institutes of Health Stroke Scale at the end of follow-up. No significant effect on neurological signs or disability was reported in 2 smaller trials with over 100 participants.^12,13 The rest 3 trials included <50 patients each.

Despite the lack of evidence from systematic reviews for efficacy regarding both fatality⁹ and functional outcome,¹⁴ cerebrolysin has been used in several countries, with limited healthcare resources in Asia and Eastern Europe. Although subgroup- and post hoc analyses suggested potential benefit of cerebrolysin, these claims should be currently considered only hypotheses. The routine use of cerebrolysin in acute stroke is not justified until randomized well-designed trials indeed prove efficacy in these patient groups. In these trials, patient-centered predefined outcomes will have to be used.¹⁵