Evaluating the use of vision-face-arm-speech-time in stroke admissions: A comparative study with national institutes of health stroke scale and orthoptist assessment in an emergency department.

To the Editor: Before new therapies for ischemic stroke are established, their safety and effectiveness must be proved. In particular, the numerous multicenter acute stroke trials currently being performed require a valid, efficient, and reliable measure of patient status and outcome after treatment. Interrater variation in the assessment of neurological deficits could imply that important effects of the treatment remain concealed, which in turn may have a misleading influence on therapeutic decisions. A commonly used yardstick for measuring the outcome of neurological deficits in stroke patients is the National Institutes of Health Stroke Scale (NIHSS).1 2 3 Not only experienced neurologists can reliably apply the NIHSS; it can be used as well by nonneurologists or even nonphysicians (eg, study nurses),4 5 6 7 provided the raters are well trained and given detailed instructions. As far as the NINDS study is concerned, the investigators were video trained and required to take an examination.1 The question, however, of whether the NIHSS provides precise and reliable data when applied without an intensive training program has not yet been raised. We therefore investigated the reliability of the NIHSS as used by trained and untrained raters in 22 stroke patients in the Neurological Department at …

Introduction Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further. Methods This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables. Results A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection. Discussion Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.

International management of acute ischemic stroke patients treated with intravenous tissue plasminogen activator frequently includes 24-h head imaging. These recommendations stem from the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial protocol regarding the risk of intracerebral hemorrhage post-tissue plasminogen activator administration. Follow-up computed tomography scans on select patients, however, may not effect clinical management, resulting in unnecessary radiation exposure and healthcare costs. Our study questions the utility of routine 24-h computed tomography imaging and looks at the National Institute of Health Stroke Scale as a possible clinical screen for selecting candidates for 24-h imaging. Such a tool would result in decreased radiation exposure to the patient and decreased cost to the hospital. Consecutive patients with acute ischemic stroke given intravenous tissue plasminogen activator between June 2008 and December 2011 were retrospectively identified and dichotomized based on change in 24-h National Institute of Health Stroke Scale from baseline. Initial analysis compared patients with National Institute of Health Stroke Scale worsening to those without worsening. Subsequent analysis was limited to patients with a baseline National Institute of Health Stroke Scale ≤10. Baseline demographics and medical history, baseline and 24-h computed tomography findings, medical and/or surgical orders within six-hours of imaging, and antithrombotic administration within 24-48-h postintravenous tissue plasminogen activator were compared between the two groups. Two-hundred patients met inclusion criteria: No 24-h National Institute of Health Stroke Scale worsening (n = 167) vs. 24-h National Institute of Health Stroke Scale worsening (n = 33). No baseline demographic or admission data differed significantly between the two groups. Patients without 24-h National Institute of Health Stroke Scale worsening had significantly lower incidence of hemorrhagic infarction (10·8% vs. 31·3%, P = 0·0014) on follow-up imaging. Less than 2% of all patients without 24-h National Institute of Health Stroke Scale worsening had a parenchymal hematoma. No patient with baseline National Institute of Health Stroke Scale ≤10 and without 24-h National Institute of Health Stroke Scale worsening had parenchymal hematoma. Patients with 24-h worsening were significantly less likely to receive timely antithrombotic therapy (60·6% vs. 77·8%, odds ratio 0·44, 95% confidence interval 0·20-0·96). Our results demonstrate that routine 24-h computed tomography scan in patients without 24-h National Institute of Health Stroke Scale worsening (especially those with baseline National Institute of Health Stroke Scale ≤10) is less likely to yield information that results in a deviation from standard acute stroke care. No patient without worsening and baseline National Institute of Health Stroke Scale ≤10 had parenchymal hematoma on 24-h computed tomography. Application of the National Institute of Health Stroke Scale to distinguish patients who should have 24-h follow-up imaging from those who will not benefit is a potential avenue for improving utilization of resources and warrants further study.

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

Scientific guidelines recommend the National Institutes of Health Stroke Scale for ischemic stroke assessment. However, many nurses find "slim" National Institutes of Health Stroke Scale versions or the Glasgow Coma Scale easier to use. To compare 3 "slim" versions of the National Institutes of Health Stroke Scale and the Glasgow Coma Scale with the full National Institutes of Health Stroke Scale. Components of the full National Institutes of Health Stroke Scale and Glasgow Coma Scale were abstracted from records of consecutive stroke patients. Items were subtracted from the full National Institutes of Health Stroke Scale, with items contained in "slim" versions retained. False-negative rates for neurological disability were calculated for the "slim" versions and the Glasgow Coma Scale. Data were collected from 172 acute stroke patients (median [interquartile range] 6 [3-12] for National Institutes of Health Stroke Scale, 15 [12-15] for Glasgow Coma Scale): 143 (83%) were ischemic stroke patients (27% posterior circulation strokes) and 29 (17%) were intracerebral hemorrhage patients. The value of "slim" scales and the Glasgow Coma Scale declined in a stepwise manner as the full National Institutes of Health Stroke Scale decreased because of false-negative results despite the presence of a measurable disabling deficit. False-negative rates were 5% to 19% on "slim" versions and 56% with the Glasgow Coma Scale. Use of "slim" scales, and in particular the Glasgow Coma Scale, substantially decreases the value of a structured neurological assessment, particularly in patients with low National Institutes of Health Stroke Scale scores.

Vasculocentricity Versus Cerebrocentricity: What Stroke-Related Baroreceptor Reflex Sensitivity Changes Might Be Telling Us

Thrombolysis of ischemic stroke patients presenting with mild symptoms is controversial. We aimed to describe the clinical outcome and frequency of infarcts and symptomatic intracerebral hemorrhages on follow-up imaging of such thrombolysis-treated patients. Our cohort included 1398 consecutive ischemic stroke patients treated with intravenous thrombolysis at the Helsinki University Central Hospital, years 1995-2010. We analyzed the patients according to baseline National Institutes of Health Stroke Scale: ≤2, 3-4, 5-6, and >6. In our institution, visualization of an artery occlusion or perfusion deficit is required for thrombolysis with National Institutes of Health Stroke Scale ≤ 2. We used univariate and multivariable methods to describe the cohort and study associations between the variables. Excellent three-month outcome was defined as modified Rankin Scale 0-1. Fifty-eight (4·1%) patients were treated with National Institutes of Health Stroke Scale ≤ 2, another 194 (13·6%) with 3-4 points, and 236 (16·5%) with 5-6 points. With National Institutes of Health Stroke Scale ≤ 2, 45 (78%) of the patients had excellent three-month outcome, achieved in 116 (59%) patients with National Institutes of Health Stroke Scale 3-4, in 130 (55%) with National Institutes of Health Stroke Scale 5-6, and in 241 (26%) with National Institutes of Health Stroke Scale > 6. Frequencies of symptomatic intracerebral hemorrhage (European Cooperative Acute Stroke Study-2) were 0%, 2·6%, 2·1%, and 8·1%, and visible infarcts on follow-up imaging 48%, 43%, 48%, and 74%, respectively. In patients with baseline National Institutes of Health Stroke Scale ≤ 6, poor outcome was associated with previous stroke, diabetes, elevated admission blood glucose, and development of intracerebral hemorrhage. Half of patients presenting with National Institutes of Health Stroke Scale 0-6 developed an infarction despite thrombolysis, and 40% had poor outcome, which was associated with glucose metabolism and hemorrhagic complications. Managing thrombolysis candidates with mild symptoms warrants individual consideration often supported by multimodal imaging.

Stroke is an important cause of death and disability among children. Clinical trials for childhood stroke require a valid and reliable acute clinical stroke scale. We evaluated interrater reliability (IRR) of a pediatric adaptation of the National Institutes of Health Stroke Scale. The pediatric adaptation of the National Institutes of Health Stroke Scale was developed by pediatric and adult stroke experts by modifying each item of the adult National Institutes of Health Stroke Scale for children, retaining all examination items and scoring ranges of the National Institutes of Health Stroke Scale. Children 2 to 18 years of age with acute arterial ischemic stroke were enrolled in a prospective cohort study from 15 North American sites from January 2007 to October 2009. Examiners were child neurologists certified in the adult National Institutes of Health Stroke Scale. Each subject was examined daily for 7 days or until discharge. A subset of patients at 3 sites was scored simultaneously and independently by 2 study neurologists. IRR testing was performed in 25 of 113 a median of 3 days (interquartile range, 2 to 4 days) after symptom onset. Patient demographics, total initial pediatric adaptation of the National Institutes of Health Stroke Scale scores, risk factors, and infarct characteristics in the IRR subset were similar to the non-IRR subset. The 2 raters' total scores were identical in 60% and within 1 point in 84%. IRR was excellent as measured by concordance correlation coefficient of 0.97 (95% CI, 0.94 to 0.99); intraclass correlation coefficient of 0.99 (95% CI, 0.97 to 0.99); precision measured by Pearson ρ of 0.97; and accuracy measured by the bias correction factor of 1.0. There was excellent IRR of the pediatric adaptation of the National Institutes of Health Stroke Scale in a multicenter prospective cohort performed by trained child neurologists.

The influence of lesion size and laterality on each component of the National Institutes of Health Stroke Scale has not been delineated. The objective of this study was to use perfusion-weighted imaging to characterize the association of ischaemic volume and laterality on each component item and the total score of the <National Institutes of Health Stroke Scale. We analysed consecutive right-handed patients with first-ever supratentorial acute ischaemic strokes who underwent acute perfusion-weighted imaging at a single centre. Perfusion deficits were defined as mean transit time > 10 s. Ordinal regression was used to clarify the relationship between ischaemic volume, laterality, and <National Institutes of Health Stroke Scale scores. Among 111 patients, 58 were left-hemisphere stroke, and 53 right-hemisphere stroke. Median ischaemic volume was 53 ml in left-hand stroke and 65 ml in right-hand stroke and median total National Institutes of Health Stroke Scale was 10 in left-hand stroke and eight in right-hand stroke. For individual National Institutes of Health Stroke Scale items, ischaemic volume correlated most closely with commands and visual field and most weakly with ataxia and neglect. Left-hand stroke predicted higher scores of total National Institutes of Health Stroke Scale and National Institutes of Health Stroke Scale items of questions, commands, right limb weakness, and language. Right-hand stroke predicted higher scores of left limb weakness and extinction. Larger perfusion defects contribute to higher scores on the total and most individual items of the National Institutes of Health Stroke Scale. However, lesion laterality contributes substantially to half the item scores, with greater association of left than right-brain side. These findings indicate that imaging-deficit correlations will be improved by designating lesions into an atlas, taking into account side in addition to size.

Data are limited on optimal threshold for baseline National Institutes of Health Stroke Scale in predicting outcome after stroke thrombolysis (intravenous thrombolysis). Finding thresholds for baseline National Institutes of Health Stroke Scale scores that predict functional outcome and baseline vessel occlusion. We analyzed 44 331 patients with available modified Rankin Scale score at three-months and 11 632 patients with computed tomography/magnetic resonance angiography documented vessel occlusion at baseline in the SITS-International Stroke Thrombolysis Register. Main outcomes were functional independency (modified Rankin Scale 0-2) at three-months and baseline vessel occlusion. We obtained area under the curves by receiver operating characteristic analysis and calculated multivariately adjusted odds ratio for the outcomes of interest based on baseline National Institutes of Health Stroke Scale scores. For functional independency, National Institutes of Health Stroke Scale scores of 12 (area under the curve 0·775) and for baseline vessel occlusion, scores of 11 (area under the curve 0·678) were optimal threshold values. For functional independency, adjusted odds ratio decreased to 0·07 (95% CI 0·05-0·11), and for presence of baseline occlusion, aOR increased to 3·28 (95% CI 3·04-3·58) for National Institutes of Health Stroke Scale scores 12 and 11, respectively, compared with National Institutes of Health Stroke Scale score 0. National Institutes of Health Stroke Scale thresholds decreased with time from stroke onset to imaging, with 2-3 points, respectively, if time to imaging exceeded three-hours. Ideally, all acute stroke patients should have immediate access to multimodal imaging. In reality these services are limited. Baseline National Institutes of Health Stroke Scale scores of 11 and 12 were identified as markers of baseline vessel occlusion and functional independency after intravenous thrombolysis, respectively. These values are time dependent; therefore, a threshold of National Institutes of Health Stroke Scale 9 or 10 points may be considered in the prehospital selection of patients for immediate transfer to centers with multimodal imaging and availability of highly specialized treatments.

Personalized prediction of stroke outcome using lesion imaging markers is still too imprecise to make a breakthrough in clinical practice. We performed a combined prediction and brain mapping study on topographic and connectomic lesion imaging data to evaluate (i) the relationship between lesion-deficit associations and their predictive value and (ii) the influence of time since stroke. In patients with first-ever ischaemic stroke, we first applied high-dimensional machine learning models on lesion topographies or structural disconnection data to model stroke severity (National Institutes of Health Stroke Scale 24 h/3 months) and functional outcome (modified Rankin Scale 3 months) in cross-validation. Second, we mapped the topographic and connectomic lesion impact on both clinical measures. We retrospectively included 685 patients [age 67.4 ± 15.1, National Institutes of Health Stroke Scale 24 h median(IQR) = 3(1; 6), modified Rankin Scale 3 months = 1(0; 2), National Institutes of Health Stroke Scale 3 months = 0(0; 2)]. Predictions for acute stroke severity (National Institutes of Health Stroke Scale 24 h) were better with topographic lesion imaging (R² = 0.41) than with disconnection data (R² = 0.29, P = 0.0015), whereas predictions at 3 months (National Institutes of Health Stroke Scale/modified Rankin Scale) were generally close to chance level. In the analysis of lesion-deficit associations, the correlates of more severe acute stroke (National Institutes of Health Stroke Scale 24 h > 4) and poor functional outcome (modified Rankin Scale 3 months ≥ 2) were left-lateralized. The lesion location impact of both variables corresponded in right-hemisphere stroke with peaks in primary motor regions, but it markedly differed in left-hemisphere stroke. Topographic and disconnection lesion features predict acute stroke severity better than the 3-months outcome. This suggests a likely higher impact of lesion-independent factors in the longer term and highlights challenges in the prediction of global functional outcome. Prediction and brain mapping diverge, and the existence of statistically significant associations—as here for 3-months outcomes—does not imply predictive value. Routine neurological scores better capture left- than right-hemispheric lesions, further complicating the challenge of outcome prediction.

A large diffusion-weighted imaging lesion ≤six-hours of symptom onset was found to predict the development of 'malignant' middle cerebral artery infarction with high specificity, positive predictive value, and negative predictive value, but sensitivity was low. We tested the hypothesis that sensitivity can be improved by adding information from clinical follow-up examination after 24 h. We analyzed data from a prospective, multicenter, observational cohort study of patients with acute ischemic stroke and middle cerebral artery occlusion studied by stroke magnetic resonance imaging ≤six-hours of symptom onset. We used the National Institutes of Health Stroke Scale to assess severity of symptoms after 24 h. We used the Classification and Regression Trees analysis to define the optimal thresholds of diffusion-weighted imaging lesion volume and the National Institutes of Health Stroke Scale after 24 h in patients developing 'malignant' middle cerebral artery infarction. We calculated sensitivity, specificity, positive predictive value, and negative predictive value for two simple predictive models based on acute diffusion-weighted imaging lesion volume alone and acute diffusion-weighted imaging lesion volume together with the National Institutes of Health Stroke Scale after 24 h. Of 135 patients, 27 (20%) developed a 'malignant' middle cerebral artery infarction. The Classification and Regression Trees analysis identified acute diffusion-weighted imaging lesion ≥78 ml and the National Institutes of Health Stroke Scale score after 24 h ≥22 as optimal cut-offs. Inclusion of the National Institutes of Health Stroke Scale score after 24 h in a simple two-step decision tree increased sensitivity from 0·59 to 0·79, while specificity, positive predictive value, and negative predictive value remained largely unchanged. Clinical follow-up examination after 24 h helps identify patients at risk of 'malignant' middle cerebral artery infarction that are missed by predictive algorithms based on early diffusion-weighted imaging lesion volume alone.

National Institutes of Health Stroke Scale (NIHSS) as An Early Predictor of Poststroke Dysphagia

Objectives: Endovascular treatment for acute ischemic stroke with a large vessel occlusion was recently shown to be effective. We aimed to develop a score capable of predicting large vessel occlusion eligible for endovascular treatment in the early hospital management. Design: Retrospective, cohort study. Setting: Two tertiary, Swiss stroke centers. Patients: Consecutive acute ischemic stroke patients (1,645 patients; Acute STroke Registry and Analysis of Lausanne registry), who had CT angiography within 6 and 12 hours of symptom onset, were categorized according to the occlusion site. Demographic and clinical information was used in logistic regression analysis to derive predictors of large vessel occlusion (defined as intracranial carotid, basilar, and M1 segment of middle cerebral artery occlusions). Based on logistic regression coefficients, an integer score was created and validated internally and externally (848 patients; Bernese Stroke Registry). Interventions: None. Measurements and Main Results: Large vessel occlusions were present in 316 patients (21%) in the derivation and 566 (28%) in the external validation cohort. Five predictors added significantly to the score: National Institute of Health Stroke Scale at admission, hemineglect, female sex, atrial fibrillation, and no history of stroke and prestroke handicap (modified Rankin Scale score, &lt; 2). Diagnostic accuracy in internal and external validation cohorts was excellent (area under the receiver operating characteristic curve, 0.84 both). The score performed slightly better than National Institute of Health Stroke Scale alone regarding prediction error (Wilcoxon signed rank test, p &lt; 0.001) and regarding discriminatory power in derivation and pooled cohorts (area under the receiver operating characteristic curve, 0.81 vs 0.80; DeLong test, p = 0.02). Conclusions: Our score accurately predicts the presence of emergent large vessel occlusions, which are eligible for endovascular treatment. However, incorporation of additional demographic and historical information available on hospital arrival provides minimal incremental predictive value compared with the National Institute of Health Stroke Scale alone.

Background and Purpose- Imaging is frequently used to select acute stroke patients for intra-arterial therapy. Quantitative cerebral blood flow can be measured noninvasively with arterial spin labeling magnetic resonance imaging. Cerebral blood flow levels in the contralateral (unaffected) hemisphere may affect capacity for collateral flow and patient outcome. The goal of this study was to determine whether higher contralateral cerebral blood flow (cCBF) in acute stroke identifies patients with better 90-day functional outcome. Methods- Patients were part of the prospective, multicenter iCAS study (Imaging Collaterals in Acute Stroke) between 2013 and 2017. Consecutive patients were enrolled after being diagnosed with anterior circulation acute ischemic stroke. Inclusion criteria were ischemic anterior circulation stroke, baseline National Institutes of Health Stroke Scale score ≥1, prestroke modified Rankin Scale score ≤2, onset-to-imaging time <24 hours, with imaging including diffusion-weighted imaging and arterial spin labeling. Patients were dichotomized into high and low cCBF groups based on median cCBF. Outcomes were assessed by day-1 and day-5 National Institutes of Health Stroke Scale; and day-30 and day-90 modified Rankin Scale. Multivariable logistic regression was used to test whether cCBF predicted good neurological outcome (modified Rankin Scale score, 0-2) at 90 days. Results- Seventy-seven patients (41 women) met the inclusion criteria with median (interquartile range) age of 66 (55-76) yrs, onset-to-imaging time of 4.8 (3.6-7.7) hours, and baseline National Institutes of Health Stroke Scale score of 13 (9-20). Median cCBF was 38.9 (31.2-44.5) mL per 100 g/min. Higher cCBF predicted good outcome at day 90 (odds ratio, 4.6 [95% CI, 1.4-14.7]; P=0.01), after controlling for baseline National Institutes of Health Stroke Scale, diffusion-weighted imaging lesion volume, and intra-arterial therapy. Conclusions- Higher quantitative cCBF at baseline is a significant predictor of good neurological outcome at day 90. cCBF levels may inform decisions regarding stroke triage, treatment of acute stroke, and general outcome prognosis. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02225730.