Early Trajectory of Stroke Severity Predicts Long-Term Functional Outcomes in Ischemic Stroke Subjects

Abstract

Background and Purpose— The trajectory of neurological improvement after stroke treatment is clinically likely to be an important prognostic signal. We compared the accuracy of early longitudinal National Institutes of Health Stroke Scale (NIHSS) measurement versus other early markers of stroke severity post treatment in predicting subjects’ 90-day stroke outcome. Methods— Data are from the Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times). Stroke severity was assessed at baseline, 1, 2, 5, 30, and 90 days. Subjects’ functional outcome was assessed using the modified Rankin Scale at baseline, 30 days, and 90 days. Group-based trajectory model was used to identify distinct subgroups of longitudinal trajectories of NIHSS measured over the first 2, 5, and 30 days. The accuracy of baseline NIHSS, infarct volume, 24-hour change in NIHSS, infarct volume, and disease severity trajectory subgroups in predicting 90-day stroke outcome were assessed using logistic regression analysis. Results— Group-based trajectory model of the 2-day longitudinal NIHSS data revealed 3 distinct subgroups of NIHSS trajectories—large improvement (41.6%), minimal improvement (31.1%), and no improvement (27.3%) subgroups. Individuals in the large improvement group were more likely were more likely to exhibit good outcomes after 90 days than those in the minimal improvement or no improvement subgroup. Among candidate predictors, the 2-day trajectory subgroup variable was the most accurate in predicting 90-day modified Rankin Scale at 84.5%. Conclusions— Early trajectory of neurological improvement defined by 2-day longitudinal NIHSS data predicts functional outcomes with greater accuracy than other common variables. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01778335.

Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 h

“…A study on follow-up of 154 patients revealed an initial NIHSS < 5 and an improvement in neurological symptoms in the first 2 h after stroke to have predictive value for GFO ( 6 ). In patients with large vessel occlusion included in the ESCAPE trial and endovascularly treated, improvement in NIHSS within 48 h was a better predictor of outcome than baseline NIHSS ( 21 ). The predictive value of change in NIHSS in the early time-interval after stroke might be a reflection of reperfusion (spontaneously or by an intervention), but this could not be analyzed in this cohort since we did not collect data on reperfusion status.…”

Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke

“…Recent results from the ESCAPE investigators showed that a neurological improvement in the first 2 days following a stroke predicted functional outcome with greater accuracy than other common variables [35]. Also, follow-up imaging was demonstrated to be a good predictor and possibly superior to mTICI scores [36, 37].…”

Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke

“…Early improvement in NIHSS score may function as a surrogate marker of outcome in situations in which an mRS score cannot be obtained. 126,127 Although it is ideal to assess the patient in person, this may not always be possible, and telephone assessment of mRS score is a reasonable alternative that is well validated. 128 We understand that some patients may be lost to follow-up by 90 days.…”