Lower NIHSS Score Research Articles

Abstract WP390: Stroke Severity Threshold For Acute Stroke Trials

Introduction: The planning of a thrombolysis trial presents a typical clinical research problem: what lower threshold of baseline stroke severity will identify an informative population? Applying representative trial entry criteria for patients lodged within Virtual International Stroke Trials Archive (VISTA), we undertook to identify a lower threshold for baseline (b)NIHSS at which thrombolysis was associated with improved outcomes in all patients, and in patients with left or right hemisphere stroke. Methods: We selected patients with an age-range of 18-85 and baseline (b)NIHSS 4-24. Outcomes were defined as mRS 0-1 (Excellent Functional Outcome), mRS 0-2 (Good Functional Outcome) and either NIHSS improvement of 8 points, or NIHSS of 0-1, or both, on day 90 (Neurological Outcome). We undertook age-adjusted comparison of outcomes between thrombolysed and non-thrombolysed patients that belonged to each bNIHSS level. Results: Functional and neurological outcome data were available for 7811 patients and 7696 patients respectively. Thrombolysed patients were younger than non-thrombolysed patients (66.7 ± 12.4 vs. 68.7 ± 11.5, p<0.001, N=7811). bNIHSS was greater among thrombolysed patients compared to non-thrombolysed patients (median 13 vs.12, p<0.0001, N=7811). OR for outcomes after thrombolysis were >1 for b-NIHSS ≥8 in all patients, and in patients with right and left hemisphere stroke. Stroke laterality significantly interacted with b-NIHSS, and with thrombolysis, in a prediction model of functional outcomes (p<0.05), and OR for all outcome measures were greater for left hemisphere stroke (p<0.05). Conclusions: Outcomes were consistently improved among patients whose bNIHSS was ≥8, with inconsistency or neutral findings at lower NIHSS scores.

Abstract TP279: Effect of Pre-Treatment with Statins on Ischemic Stroke Severity: Does the Doses Matter?

OBJECTIVE: To examine the effect of pre-treatment with statins, at high (80 mg) and non-high (<80 mg) doses, on ischemic stroke (IS) severity in clinical practice. METHODS: prospective study of IS admissions to our Stroke Unit during a 3-year period (2008-2010). Demographic data, vascular risk factors, previous treatments (statins, ACE inhibitors, ARB, antithrombotic drugs), stroke severity (NIHSS), stroke subtype, in-hospital complications, length of stay and functional status at discharge (mRS) were collected. Mild stroke severity was defined as NIHSS <=5 on admission. Good outcome was defined as mRS <= 2 at discharge. Multivariable regression models and matched propensity score analyses were used to quantify the association of statins pretreatment, at high and non-high doses, with a mild stroke severity. RESULTS: Of 969 IS patients, 23% were using non-high doses and 4.1% high doses of statins before the stroke event. Statins were associated with lower NIHSS scores on admission (median [IQR], 4 [9] for non-statins patients; 4 [9] for non-high doses of statins and 2 [4] for high doses of statins; p =0.010). The frequency of mild stroke on admission was higher in the statin groups (57.9% for non-statins, 63.2% for non-high doses of statins and 77.5% for high doses of statins, p =0.026). High doses of statins were related with favourable outcomes at discharge, although this was not statistically significant (66.6% for non-statins group, 64.7% for non-high doses of statins and 75% for high doses of statins, p =0.443). After multivariable adjustment, pretreatment with statins was associated with higher odds of mild stroke severity and this effect was greater at high doses (OR=1.637, 95% CI 1.156-2.319 for the non-high doses and OR=3.297, 95% CI 1.480-7.345, for the high doses of statins). CONCLUSION: Petreatment with statins is associated with lower stroke severity and this effect could be greater at higher doses.

Abstract 3603: Emergency Pre-hospital Stroke Triage In Washington State, Understood Through A Cohort

BACKGROUND: Washington State (WA) has legislated an emergency pre-hospital stroke triage system, with 3 levels of self-identified stroke centers. Our objective is to describe the new system using an existing cohort of pre-hospital patients and to extrapolate our findings to all of WA. METHODS: The cohort consisted of a population-based sample of patients whom emergency medical service (EMS) personnel treated over a 30-month period. All patients whose Seattle Fire Department records suggested a possible pre-hospital stroke diagnosis had hospital records reviewed for final diagnosis: TIA, ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or “not a stroke.” These patients were also classified according to the FAST (Face, Arm, Speech, Time last normal) stroke screen. The WA pre-hospital stroke triage tool divides patients into 4 groups: FAST-, FAST+/>6h (arrived at hospital > 6 or unknown hours after last known normal), FAST+/>3.5-6h (arrived in window for intra-arterial (IA) therapies) and FAST+/<=3.5h (arrived in window for IV tPA). RESULTS: The cohort included 1,682 possible stroke patients, mean age 76 years, 60% women. We applied the stroke triage tool to our cohort with results shown in the Table . Assuming similar stroke presentations and given the population of WA is ∼11 times that of Seattle, we estimate that ∼2500 patients/yr would be triaged as possible IV tPA candidates; ∼450 patients/yr would be triaged as possible IA candidates with possibly longer transport to a Level 1 stroke center. There was significant heterogeneity in final diagnoses by triage tool categorization ( Table , P < 0.0005). The triage tool identified combined IV or IA candidates with a sensitivity of 90% (95% CI 83-94%), specificity 91% (90-93%) and C statistic of .90 (.88-.93). Of the 10% of IV or IA candidates missed, 81% had initial NIHSSs < 3. CONCLUSION: These are the first estimates of how the WA pre-hospital stroke triage tool will parse patients. Discrimination of acute ischemic stroke patients eligible for time dependent interventions was excellent; the low NIHSS scores in 81% of those missed suggests an even higher clinically relevant sensitivity. A small proportion (2.4%) of the possible stroke patients presenting to EMS will meet criteria for transport to Level 1 stroke centers, suggesting the additional burden on EMS should be minimal.

Abstract 2378: Right Hemisphere Ischemia is Overrepresented in Patients with Poor Outcomes After tPA is Not Given Because of “Rapidly Improving or Mild Symptoms”

Background and Purpose: Recombinant tissue-type plasminogen activator (tPA) is currently the only FDA approved treatment for acute ischemic stroke. Rapidly improving or minor symptoms is the most common reason for not treating with tPA, based on the presumption that these patients will have good outcomes without thrombolysis. We reviewed hospital course and discharge outcomes for patients excluded from tPA because of rapidly improving or mild symptoms, with the aim of being better able to identify patients in this group who may benefit from thrombolysis. Methods: We used the AHA/ASA “Get with the Guidelines” database to identify consecutive patients between April 2006 and June 2010 from our tertiary care academic medical center who did not receive tPA with “rapidly improving or mild symptoms” indicated as the reason for exclusion. Poor outcome was defined as hospital discharge to location other than home or inability to ambulate independently at discharge. The medical record was reviewed to determine details of hospital course, infarct location, and reasons for poor outcome. Results: There were 66 patients excluded from tPA treatment because of rapidly improving or mild symptoms. Eleven patients (16.7%) had poor outcomes. In 6 patients (9%), poor outcome was due to neurologic deficit and in 5 poor outcome was secondary to general medical conditions or deconditioning. Of the 6 patients with continued neurologic deficit, 4 were not treated due to “improvement”. All 6 patients with continued neurologic deficits had right hemisphere strokes, and one also had cerebellar infarcts. Conclusions: Patients presenting with rapidly improving or mild symptoms do not universally have good outcomes. This may be particularly true in the case of right hemispheric ischemia where deficits are not fully reflected by NIHSS score. In conclusion, if a patient with a low NIHSS score is otherwise a candidate for tPA, a more detailed exam is warranted to better identify potentially disabling deficits that would be an indication for thrombolysis.

Abstract 99: Impact of Acute Perihematomal Edema on Long Term Outcomes Following Primary Intracerebral Hemorrhage

Introduction: The impact of acute perihematomal edema (PHE) as an independent predictor of clinical outcomes following an intracerebral hemorrhage (ICH) has been controversial. To date, some studies have reported that PHE is associated with poorer outcomes, while others have found an association with good outcomes. The goals of the current analysis were to 1) identify predictors of acute PHE, and 2) determine impact of PHE on clinical outcomes in a predominantly African American hypertensive ICH population. Methods: Subjects with spontaneous non-traumatic ICH who were prospectively enrolled in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project were included in the analysis. Baseline MRIs were performed in subjects at median of 2 days from onset. Hematoma volume as well as PHE were calculated from GRE and FLAIR sequences, respectively, employing a semiautomated volumetric analysis. PHE volume was expressed as a percent of the hematoma volume (PHEv/ICHv x 100). Outcome measures included year 1 NIHSS score using a log-linear model and dichotomized (0-2 vs. 3-6) modified Rankin Scale (mRS) using a logistic regression model. Results: A total of 140 subjects were included in the analysis. Mean age was 59, 58% were male, 75% were black, and 85% had a history of hypertension. Baseline NIHSS score was mean 9 (median 6), mean ICH volume was 25 cc (range 0.5-136 cc), and mean relative PHE percent was 115% (range 0-559%). Independent predictors of PHE on multivariate analysis included ICH volume (p=0.004) and antiplatelet use on admission (p=0.02). At the year 1 timepoint, there was no significant association between the severity of PHE percent and good or poor outcome based on dichotomized mRS (p=0.67); however there was a modest trend towards an association between increased edema and lower NIHSS scores (p=0.15). Conclusions: In this large MRI-based cohort of patients with primary ICH, acute perihematomal edema measured on FLAIR sequences was not an independent predictor of poor functional outcome at year 1 employing the mRS. However, there was a modest trend towards an association between increased relative edema volume and lower year 1 NIHSS scores, which may suggest a protective effect of edema on outcome. Further studies in a larger cohort are needed to clarify the impact of both acute and peak perihematomal edema on outcome following primary ICH.

Acute Ischemic Stroke in Children versus Young Adults: Bigi S, Fischer U, Wehrli E, et al. Ann Neurol 2011;70:245–54.

This study from Switzerland compared 128 children (ages 1 month to 16 years) to 199 young adults (ages 16-45 years) who suffered an acute ischemic stroke from January 2000 to December 2008. Data for children were collected from the Swiss Neuro Pediatric Stroke Registry (a Swiss national registry) and data for young adults were collected from the Bernese stroke registry (a hospital-based registry). Children were more likely to be male (62% vs. 49%, p = 0.023) and had fewer risk factors such as hypertension (p = 0.001), hypercholesterolemia (p = 0.003), or a family history of stroke (p = 0.048). Stroke etiology in children was more likely to be “other determined cause” (51% vs. 29%, p < 0.001), steno-occlusive arteriopathy (18% vs. 0%, p < 0.001), and moyamoya syndrome (5% vs. 0.2%, p = 0.007). Stroke etiology in young adults was more likely to be cervicocerebral artery dissections (23% vs. 13%, p = 0.005) or cardioembolic (37% vs. 17%, p < 0.001). Initial stroke severity graded using the pediatric version of the National Institutes of Health Stroke Scale (PedNIHSS) for children and NIHSS for young adults was similar in both groups. There was also no difference in outcome at 3 and 6 months as determined by a modified Rankin scale score. Mortality rates were similar as well (4% in children and 6% in young adults, p = 0.436). Whereas 6 of 8 young adults died due to their stroke, 3 of 8 children died due to the underlying disease that provoked the stroke. A low PedNIHSS or NIHSS score was the most important predictor of favorable outcome in both groups (p < 0.001).

The impact of smoking on the severity of acute ischemic stroke

This study investigated the impact of smoking on the initial severity of acute ischemic stroke and examined its subsequent outcome. Patient data was collected from the Stroke Registry in the Chang Gung Healthcare System (SRICHS). A total of 2650 patients admitted for acute ischemic stroke from January to December 2009 were included. Baseline characteristics were compared between smokers and non-smokers. Factors affecting the initial severity and the recovery from neurological deficit were examined by logistic regression analysis. The patients were further divided according to stroke mechanism for subgroup analysis. The total number of smokers and non-smokers was 817 (31.9%) and 1833 (69.1%), respectively. Univariate analysis showed that smokers had lower NIHSS scores on admission than did non-smokers (P<0.001). In subgroup analysis, smokers with small-vessel occlusions frequently had higher NIHSS scores on admission than did non-smokers (P=0.001). However, smokers with cardioembolic stroke had lower NIHSS scores on admission as compared to non-smokers (P=0.024). No subgroup had smoking as a significant factor for neurological recovery during hospitalization. Smoking correlated with higher NIHSS scores on admission for small-vessel occlusion. Conversely, it was associated with lower NIHSS scores on admission for cardioembolism.

A large screening of angiogenesis biomarkers and their association with neurological outcome after ischemic stroke

BackgroundThe induction of angiogenesis after stroke may enhance neurorestorative processes. Our aim was to examine the endogenous angiogenesis balance and their association with long-term clinical outcome in ischemic stroke patients. MethodsA total of 109 stroke subjects were included in the study. Firstly, plasma samples were obtained from control subjects (n=26) and tPA-treated stroke patients (n=29) at baseline (within 3h of symptoms onset), 1, 2, 12, 24h after tPA treatment, at discharge and 3 months after the ischemic event. Angiogenic promoters (PDGF-AA, PDGF-BB, HGF, FGF, KGF, HB-EGF, TPO, VEGF, VEGFR-1, VEGFR-2 and SDF-1α) and inhibitors (endostatin, angiostatin, thrombospondin-1 and thrombospondin-2) were analyzed by Searchlight® technology or ELISA. Additionally, baseline and 24h endostatin plasma level was determined in a new set of stroke patients (n=80). Clinical parameters (NIHSS, mRS, mortality and hemorrhagic transformation events) were assessed to evaluate outcome. ResultsBaseline PDGF-BB, endostatin and thrombospondin-2 levels were higher in stroke patients than in controls (p<0.05). A pro-angiogenic balance was associated with lower NIHSS scores and less intracranial hemorrhagic complications. Interestingly, a high baseline endostatin level was associated to long-term functional dependency (mRS>2; p=0.004). Finally, a baseline endostatin cut-off point of 184ng/mL was an independent predictor of functional dependency at three months in the multiple logistic regression with an odds ratio of 8.9 (95% CI: 2.7–28.8; p=0.0002). ConclusionsOur results indicate that an early pro-angiogenic balance is associated with mild short-term neurological deficit, while an acute anti-angiogenesis status determined by high endostatin plasma level predicts a worse long-term functional outcome.

Expérience de la thrombolyse intraveineuse des infarctus cérébraux à l’hôpital d’instruction des armées Sainte-Anne de Toulon de septembre 2003 à juin 2009

Since 2003, intravenous thrombolysis with rt-PA for stroke victims has been largely developed in the military hospital of Toulon. We report the results of our practice and compare them with the literature. Wealso sought to identify predictive factors of favorable outcome after thrombolysis. All patients treated with rt-PA for a stroke in the carotid territory between September 2003 and June 2009 were prospectively included. Disability was assessed at 3 months with the modified Rankin Scale (m-RS); outcome was considered unfavorable if m-RS score was above 2. Multivariate analysis was then performed to identify parameters correlating with poor and favorable outcome at 3 months follow-up. One hundred and one patients were included in this study (mean initial National Institute of Health Stroke Scale [NIHSS]: 15.2). 53.4% had a Rankin score higher than 2 at 3 months follow-up. The absence of diabetes mellitus, low NIHSS score on admission, short time from stroke onset to treatment, and prior statin use were identified as independent predictive factors of favorable functional outcome. After 6 years of activity, our stroke unit has results that appear similar to those of the French and international trials in terms of safety and efficacy. Efficacy of rt-PA in our series is poor for strokes caused by large-vessel atherothrombotic changes and cervical artery dissection due to high incidence of internal carotid thrombosis in these cases. Our studies also suggest that prior statin use may be an independent predictive factor of favorable outcome after thrombolysis.

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