Abstract
Background:The National Institutes of Health Stroke Scale (NIHSS) has been criticized for limited representation of cognitive dysfunction and bias towards dominant hemisphere functions. Patients may therefore receive a low NIHSS score despite a fairly large stroke. A broader scale including simple cognitive tests would improve the clinical and research utility of the NIHSS.Methods:We studied 200 patients with acute non-dominant hemispheric stroke who underwent cognitive testing and had MRI with diffusion-weighted imaging (DWI) within 5 days of presentation. We measured DWI volumes and retrospectively calculated NIHSS scores. We used linear regression to determine the role of selected cognitive tests, when added to the NIHSS, in predicting DWI volume.Results:The NIHSS predicted DWI volume in a univariate analysis, as did total line cancellation and a visual perception task. In a multivariate model, using log-transformed variables, the NIHSS (p= 0.0002), line cancellation errors (p= 0.02) and visual perception (p= 0.004) each improved prediction of total infarct volume.Conclusion:The addition of line cancellation and visual perception tasks significantly adds to the model of NIHSS alone in predicting DWI volume. We propose that these two cognitive tests, which together can be completed in 2–3 minutes, could be combined with the NIHSS to create an “NIHSS-plus” that more accurately represents a patient’s ischemic tissue volume after a stroke. This scale requires further validation in a prospective study.
Highlights
The National Institutes of Health Stroke Scale (NIHSS) has been criticized for limited representation of cognitive dysfunction and bias towards dominant hemisphere functions
Subjects were a consecutive series of patients with acute nondominant stroke symptoms who were admitted to Johns Hopkins Hospital between 1999 and 2006 and met the following inclusion criteria: (1) able to provide informed consent or indicate a family member who provided informed consent; (2) no contraindication to MRI; (3) no prior diagnosis of neurological disease, significant hearing loss, or blindness; (4) no hemorrhage on admission CT; (4) neuroimaging with diffusion-weighted imaging (DWI) MRI and completion of at least part of the neglect battery within 24 hours of admission
Of the remaining patients with DWI imaging at the same time as a neglect battery, results were primarily analyzed for 200 with right hemisphere stroke (119 were excluded: 60 had TIAs’s, had left-hemispheric stroke, and had some infratentorial DWI lesion)
Summary
The National Institutes of Health Stroke Scale (NIHSS) has been criticized for limited representation of cognitive dysfunction and bias towards dominant hemisphere functions. Conclusion: The addition of line cancellation and visual perception tasks significantly adds to the model of NIHSS alone in predicting DWI volume. We propose that these two cognitive tests, which together can be completed in 2–3 minutes, could be combined with the NIHSS to create an “NIHSS-plus” that more accurately represents a patient’s ischemic tissue volume after a stroke. The National Institutes of Health Stroke Scale (NIHSS) was designed primarily as a research tool [1], and is used in acute clinical practice It has been criticized for its limited representation of cognitive dysfunction and bias towards the functions of the dominant hemisphere (language). Right-hemispheric stroke patients are less likely to receive tPA than left-hemispheric stroke patients [6]
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