Stroke Prognostication using Age and NIH Stroke Scale

Abstract

Objectives: Age and stroke severity are major determinants of stroke outcomes, but systematically incorporating these prognosticators in the routine practice of acute ischemic stroke can be challenging. We evaluated the effect of an index combining age and stroke severity on response to IV tissue plasminogen activator (tPA) among patients in the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke trials. Methods:We created the Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index by combining age in years plus NIH Stroke Scale (NIHSS) $100. We applied the SPAN-100 index to patients in the NINDS tPA stroke trials (parts I and II) to evaluate its ability to predict clinical response and risk of intracerebral hemorrhage (ICH) after thrombolysis. The main outcome measures included ICH (any type) and a composite favorable outcome (defined as a modified Rankin Scale score of 0 or 1, NIHSS #1, Barthel index $95, and Glasgow Outcome Scale score of 1) at 3 months. Bivariate and multivariable logistic regression analyses were used to determine the association between SPAN-100 and outcomes of interest.Results: Among 624 patients in the NINDS trials, 62 (9.9%) participants were SPAN-100 positive.Among those receiving tPA, ICH rates were higher for SPAN-100-positive patients (42% vs 12% in SPAN-100-negative patients; p , 0.001); similarly, ICH rates were higher in SPAN-100-positive patients (19% vs 5%; p 5 0.005) among those not receiving tPA. SPAN-100 was associated with worse outcomes. The benefit of tPA, defined as favorable composite outcome at 3 months, was present in SPAN-100-negative patients (55.4% vs 40.2%; p , 0.001), but not in SPAN-100-positive patients (5.6% tPA vs 3.9%; p 5 0.76). Similar trends were found for secondary outcomes (e.g., symptomatic ICH, catastrophic outcome, discharge home). Conclusion:The SPAN-100 index could be a simple method for estimating the clinical response and risk of hemorrhagic complications after tPA for acute ischemic stroke. These results need further confirmation in larger contemporary datasets. Neurology â 2013;80:21-28 GLOSSARY AR 5 attributable risk; AUC 5 area under the curve; CI 5 confidence interval; ECASS 5 European Cooperative Acute Stroke Study; HAT 5 Hemorrhage after Thrombolysis; ICH 5 intracerebral hemorrhage; mRS 5 modified Rankin Scale; NIHSS 5 NIH Stroke Scale; NINDS 5 National Institute of Neurological Disorders and Stroke; NNH 5 number needed to harm; NNT 5 number needed to treat; OR 5 odds ratio; PAR 5 population attributable risk; ROC 5 receiver operating characteristic; sICH 5 symptomatic ICH; SPAN 5 Stroke Prognostication using Age and NIH Stroke Scale; tPA 5 tissue plasminogen activator; UCSD 5 University of California, San Diego.Age and stroke severity are the 2 most important determinants of stroke outcomes.

Hemorrhagic Transformation after Ischemic Stroke in Animals and Humans

“…[140][141][142] Clinical Factors: Age, Hypertension, Hyperglycemia, and Hemorrhagic Transformation Increasing age has frequently been associated with an increased risk of HT in patients with stroke. 8,26,50,[143][144][145][146][147][148] The mechanisms by which age may contribute to HT are unclear. Age may enhance the production of ROS which promotes BBB disruption.…”

“…Clinical scores to predict HT that have been developed include the Multicenter Stroke Survey, 143 the Hemorrhage After Thrombolysis score, 170 and the Safe Implementation of Thrombolysis in Stroke Symptomatic Intracerebral Hemorrhage score, 144 the blood Sugar, Early infarct signs and hyperDense cerebral artery sign, Age, and NIHSS score, 145 the Glucose Race Age Sex Pressure Stroke Severity score, 146 the Stroke Prognostication using Age and NIHSS-100 index, 147 and the iScore 148 (Table 1). Though each score is able to identify patients at increased risk of HT, they do not achieve sufficient sensitivity or specificity to withhold tPA in otherwise tPA eligible patients.…”

Impact of Age and Baseline NIHSS Scores on Clinical Outcomes in the Mechanical Thrombectomy Using Solitaire FR in Acute Ischemic Stroke Study

“…8 Scores were dichotomized as SPAN-100-positive if the index score was Ն100 and SPAN-100-negative if the index score was Ͻ100.…”

“…Investigators reported that patients in the National Institute of Neurological Disorders and Stroke trial with a score of Ն100 (SPAN-100) did not benefit from IV-tPA therapy, with a higher rate of symptomatic intracranial hemorrhage and poor functional outcome compared with SPAN-100-negative patients. 8 However, these findings do not take into account the rate of successful recanalization that has been consistently shown to be one of the strongest predictors of favorable stroke outcome. 9 The National Institute of Neurological Disorders and Stroke trial, 10 conducted between 1991 and 1994, does not reflect contemporary stroke care; this feature limits its generalizability.…”

Iodinated Contrast Prior to Thrombolysis Was Not Associated With Worse Intracranial Hemorrhage

“…[14][15][16][17][18][19] The groups in our study were well balanced for these prognostic variables, excepting CT findings of early infarct and old stroke were more prevalent in the cohort selected for CTA. These early infarct findings may have contributed to the increased incidence of hemorrhagic transformation in the cohort, although it is not clear how this contributed to the distribution of bleed types and severity, nor eventual inhospital mortality.…”