What Change in the National Institutes of Health Stroke Scale Should Define Neurologic Deterioration in Acute Ischemic Stroke?

doi:10.1016/j.jstrokecerebrovasdis.2012.04.012

Journal of Stroke and Cerebrovascular Diseases

Volume 22, Issue 5, July 2013, Pages 675-682

https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.04.012 Get rights and content

Background

Neurologic deterioration (ND) occurs in one-third of patients with stroke. However, the true incidence of ND and risk for adverse outcomes remains unknown because no standardized definition of ND exists. Our study compared the prognostic value of a range of definitions for ND in patients with acute ischemic stroke (AIS).

Methods

All patients who presented to our center with AIS within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) scores, etiologies of ND, and outcome measures were compared between patients according to a range of ND definitions using receiver operating characteristic analyses.

Results

Three hundred forty-seven patients were included. The 2 definitions of ND with the highest sensitivity and specificity for several outcome measures were tested against each other: an increase in the NIHSS score by ≥2 or ≥4 points in a 24-hour period. More than one third (36.9%) of patients experienced ≥2-point ND versus 17.3% with ≥4-point ND. Patients who experienced ND by either definition had prolonged hospitalization (P < .001), poorer functional outcome (discharge modified Rankin Scale score >2; P < .001), and higher discharge NIHSS score (P < .001) compared to patients without ND. Compared to patients without ND, a ≥2-point ND was associated with a 3-fold risk of death (odds ratio 3.120; 95% confidence interval 1.231-7.905; P < .0165) after adjusting for admission NIHSS score, serum glucose, and age.

Conclusions

A ≥2-point ND is a sensitive indicator of poor outcome and in-hospital mortality. An accepted definition of ND is needed to systematically study and compare results across trials for ND in patients with stroke.

Section snippets

Definitions of ND

We conducted a single-center retrospective analysis of all consecutive patients who presented with acute ischemic stroke between July 2008 and June 2010. Patients were excluded if they presented >48 hours after last seen normal (LSN) or had an unknown time of LSN, because studies have shown that a significant number of patients with acute stroke will clinically worsen during the first several days of the cerebrovascular event, and that this period is the target for neuroprotection.13, 22, 23

Demographics

Of the 438 patients screened at our center, 347 met the inclusion criteria. The mean age was 64.6 years old, with 44.4% of the patients being female and 64.6% black. ND occurred in 128 patients using the ≥2-point definition (36.9% of included patients) versus 60 patients using the ≥4-point definition (17.3% of included patients). Baseline demographic information, pertinent medical history, and percentage of patients treated with either intravenous tissue plasminogen activator or intra-arterial

Discussion

Among all thresholds for a change in NIHSS, a ≥2-point change is a highly sensitive predictor of poor functional outcome, unfavorable discharge position, and in-hospital death, while a ≥4-point threshold for ND was found to be less sensitive although highly specific for these outcome measures (except for in-hospital mortality, for which the ≥4-point threshold was both highly sensitive and specific). More than one-third of the patients in our study experienced ND according to the ≥2-point

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The rate of early neurological deterioration (END) differs in different subtypes of ischaemic stroke. Previous studies showed PLCL2 gene is a novel susceptibility locus for the occurrence of atherosclerosis and thrombotic events. The objective of this research is to examine the efficacy that PLCL2 may have on the risk of END in large artery atherosclerotic (LAA) stroke. Tagged single nucleotide polymorphisms (SNPs) were identified by a strategy of fine-mapping. The genotyping of the selected SNPs was performed by SNPscan. The impact of PLCL2 on indicating the susceptibility of END in LAA patients was evaluated by binary logistic regression. The SNP–SNP interactions of PLCL2 for END was assessed by generalized multifactor dimensionality reduction (GMDR). A total of 1527 LAA stroke patients were recruited, 582 patients (38 %) experienced END. Compared to participants without END, participants experienced END were much older (P = 0.018), more likely to suffer pre-existing diabetes mellitus (P = 0.036), higher frequent in active tobacco users (P = 0.022) and had much higher median NIHSS on admission (P < 0.001). Rs4685423 was identified to be a predictor to the risk of END: the frequency of END in AA genotype patients is lower than that in AC or CC genotype patients (multivariate-adjusted, OR 0.63; 95 % CI 0.49–0.80; P < 0.001). The SNP-SNP interactions analysis indicates rs4685423 has the greatest impact on the risk of END for LAA patients. The time from admission diagnosis to END onset in AA genotype patients is much later than that in CA or CC genotype patients (log-rank, P = 0.005). In summary, the PLCL2 rs4685423 SNP is probably associated with the END risk in LAA stroke patients.
Cilostazol addition to aspirin may worsen the short-term outcome in patients with large artery disease: ADS subanalysis
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Our previous acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of neurological deterioration in non-cardioembolic stroke patients. In this post-hoc analysis, we investigated whether the impact of dual antiplatelet therapy (DAPT) may depend on neurological severity, as represented by large artery disease.
Neurological deterioration was defined as neurological progression with an increment of the National Institutes of Health Stroke Scale (NIHSS) score of ≥2. NIHSS score subgroups were divided into that of 0–1, 2–4, 5–10, and >10.
Among 1014 patients, 203 (20%) had the large artery disease, and 811 (80%) did not. In the total cohort, the rate of neurological deterioration was 10.8% in the DAPT group and 8.3% in the aspirin group (P = 0.197). When we focused on the large artery disease group, DAPT group had a higher rate of neurological deterioration as 18.3% compared to 8.2% in the aspirin group (P = 0.036). Among patients with NIHSS score of 0–1 and 2–4, the rates of neurological deterioration were not different between the two group (both, P = 1.000). However, when NIHSS score elevated to 5–10, 45% in the DAPT group and 9.1% in the aspirin group deteriorated (P = 0.013). Among the patients with NIHSS score of >10, 60% in the DAPT group and none (0%) in the aspirin group had the neurological deterioration (P = 0.045).
DAPT with aspirin and cilostazol was associated with higher rate of neurological deterioration when patients have large artery disease and not mild neurological deficits.
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Early neurological deterioration (END) after ischemic stroke is a severe clinical event and can be caused by hemorrhagic and ischemic injury. We studied the difference between the risk factors of END occurs with or without hemorrhagic transformation after intravenous thrombolysis.
Consecutive cerebral infarction patients who underwent intravenous thrombolysis from 2017 to 2020 in our hospital were retrospectively recruited. END was defined as a ≥2 points increase on 24-h National Institutes of Health Stroke Scale (NIHSS) score after therapy compared with the best neurological status after thrombolysis and divided into two types based on the computed tomography (CT): symptomatic intracranial hemorrhage (ENDh) and non-hemorrhagic factors (ENDn). Potential risk factors of ENDh and ENDn were assessed by multiple logistic regression and applied to establish the prediction model.
A total of 195 patients were included. In multivariate analysis, the previous history of cerebral infarction (odds ratio [OR],15.19; 95% confidence interval [CI],1.43–161.17; P = 0.025), previous history of atrial fibrillation (OR,8.43; 95%CI,1.09–65.44; P = 0.043), higher baseline NIHSS score (OR,1.19; 95%CI,1.03–1.39; P = 0.022) and higher alanine transferase level (OR,1.05; 95%CI, 1.01–1.10; P = 0.016) were independently associated with ENDh. While higher systolic blood pressure (OR,1.03; 95%CI,1.01–1.05; P = 0.004), higher baseline NIHSS score (OR,1.13; 95%CI,2.86–27.43; P < 0.000) and large artery occlusion (OR,8.85, 95%CI,2.86–27.43; P < 0.000) were independent risk factors of ENDn. The prediction model showed good specificity and sensitivity in predicting the risk of ENDn.
There are differences between the major contributors to ENDh and ENDn, while a severe stroke can increase the occurrence of both sides.
Early neurological deterioration in acute ischemic stroke
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Safety, feasibility, and acceptability of a novel device to monitor ischaemic stroke patients
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Original ArticleWhat Change in the National Institutes of Health Stroke Scale Should Define Neurologic Deterioration in Acute Ischemic Stroke?

Background

Methods

Results

Conclusions

Section snippets

Definitions of ND

Demographics

Discussion

Measurements of acute cerebral infarction: Lesion size by computed tomography

Stroke

Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group

J Neurosci Nurs

Measurements of acute cerebral infarction: A clinical examination scale

Stroke

Comparison of neurological scales and scoring systems for acute stroke prognosis

Stroke

Reliability of the National Institutes of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial

Stroke

Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group

Stroke

Ensuring reliability of outcome measures in multicenter clinical trials of treatments for acute ischemic stroke. The program developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST)

Stroke

Training as a prerequisite for reliable use of NIH Stroke Scale

Stroke

NIHSS training and certification using a new digital video disk is reliable

Stroke

Deteriorating ischemic stroke: Risk factors and prognosis

Neurology

Progression of stroke after arrival at hospital

Stroke

Early Neurological Deterioration (END) after stroke: The END depends on the definition

Int J Stroke

Early neurological deterioration in acute stroke: Clinical characteristics and impact on outcome

QJM

Original Article
What Change in the National Institutes of Health Stroke Scale Should Define Neurologic Deterioration in Acute Ischemic Stroke?