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VBCN - July 2015 Volume 2, No 2 - Stroke
Chase Doyle

A new retrospective review of patients presenting with acute ischemic stroke has shown additional predictors of outcome independent of traditional assessment tools. According to a recent study, these factors are not assessed by the National Institutes of Health Stroke Scale (NIHSS) but are already part of the standard intake assessment (Kenmuir CL, et al. J Stroke Cerebrovasc Dis. 2015;24:1685-1689).

In patients with mild stroke, “several factors including age, ambulatory status on admission, and ability to swallow on admission may be independent predictors of functional outcome and discharge home,” noted Cynthia L. Kenmuir, MD, PhD, Department of Neurology, University of Pittsburgh Medical Center (UPMC), PA, and colleagues. “These data support the development of a modified grading system for assessing functional outcome in mild stroke that considers these factors.”

According to the researchers, despite the widespread adoption of the NIHSS as a triage tool, controversy remains over its effectiveness in assessing patients with mild stroke symptoms. Evidence has shown, for example, that 29% to 43% of patients eligible for recombinant tissue plasminogen activator (rt-PA) did not receive the treatment (Barber PA, et al. Neurology. 2001;56:1015-1020).

“There is…little agreement as to what constitutes a ‘mild stroke’ or ‘too good to treat,’” Dr Kenmuir and colleagues wrote. “For instance, a stroke scale score of 3 could be significantly disabling if the points were given for language or homonymous hemianopsia, but perhaps nondisabling if the symptoms were a mild facial asymmetry with dysarthria and a mild arm drift.”

Although several other systems have been proposed for predicting outcomes, Dr Kenmuir and colleagues noted that many of these involve complicated algorithms that are not readily assessed. The focus of this retrospective study, therefore, was on standard intake assessment screenings that are easily obtainable at all stroke centers.

Retrospective Review of Discharge Outcomes

Dr Kenmuir and colleagues reviewed discharge outcomes of patients who presented to the UPMC Stroke Institute with acute ischemic stroke between 2005 and 2013. Of 7189 patients reviewed, 881 had an initial NIHSS score of <5 and complete information on outcome measures. The outcome measures included the modified Rankin Scale score 0-1 and discharge to home.

Of the 881 patients, 570 (65%) were discharged home, and 311 (35%) were discharged to a nursing facility, inpatient rehabilitation center, or died. Only 12 (1.4%) patients received intravenous rt-PA, regardless of discharged status.

“Patients not discharged directly home were older, had higher NIHSS scores, were unable to ambulate independently, and did not pass their initial dysphagia screen,” the team wrote.

Only 26% of patients who were discharged home had failed their initial ambulation or their initial dysphagia screening, whereas 68% of patients who were discharged to postacute care facilities or died had failed both screenings.

Only 1% of patients discharged home had failed their initial ambulation and the dysphagia screenings.

“This study has identified 2 baseline screening factors collected by nurses as part of their standard intake examination for patients with stroke that are predictive of outcome in patients with mild strokes. Both the dysphagia and ambulation screens are sensitive independent predictors of outcome while the combination of failing both screens was also a specific predictor of poor outcome,” the researchers noted.

These results “could be useful to help guide treatment,” the researchers concluded. “Stroke trials with thrombolysis for low NIHSS should include the admission ambulation and swallowing status as important modifiers of outcome.”

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Last modified: August 5, 2015
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