The relationship between neurological function trajectory, assessed by repeated NIHSS measurement, and long-term cardiovascular events, recurrent stroke, and mortality after ischemic stroke

Abstract

Background: Clinically significant changes in neurological deficits frequently occur after stroke onset, reflecting further neurological injury, or neurological improvement. However, the NIH stroke scale (NIHSS) score is only evaluated once in most studies only, usually at stroke onset. Utilizing repeated measures of NIHSS scores to identify different trajectories of neurological function may be more informative, and provide more useful predictive information. We determined the association of neurological function trajectories with long-term clinical outcomes after ischemic stroke. Methods: A total of 4025 participants with ischemic stroke from the China Antihypertensive Trial in Acute Ischemic Stroke were included. Patients were recruited from 26 hospitals across China between August 2009 and May 2013. A group-based trajectory model was used to identify distinct neurological function trajectories, as measured by NIHSS at admission, 14 days or hospital discharge, and 3 months. Study outcomes were cardiovascular events, recurrent stroke, and all-cause mortality during 3–24 months after ischemic stroke onset. Cox proportional hazards models were used to examine associations of neurological function trajectories with outcomes. Results: We identified 3 distinct subgroups of NIHSS trajectories: persistent severe (persistent high NIHSS scores during the 3-month follow-up), moderate (NIHSS scores started at around 5 and gradually reduced), and mild (NIHSS scores always below 2). The three trajectory groups had different clinical profiles, and different risk of stroke outcomes at 24-month follow-up. Compared to the mild trajectory group, patients in the persistent severe trajectory group had a higher risk of cardiovascular events (multivariable-adjusted hazard ratios (95% CIs) 1.77 (1.10–2.86)), recurrent stroke (1.82 (1.10–3.00)) and all-cause mortality (5.64 (3.37–9.43)) Those with moderate trajectory had an intermediate risk; 1.45 (1.03–2.04) for cardiovascular events and 1.52 (1.06–2.19) for recurrent stroke. Conclusions: Longitudinal neurological function trajectories derived from repeated NIHSS measurements during the first 3 months after stroke, provide additional predictive information and are associated with long-term clinical outcomes. The trajectories characterized by persistent severe and moderate neurological impairment were associated with increased risk of subsequent cardiovascular events.

One‐Year Disability Trajectories and Long‐Term Cardiovascular Events, Recurrent Stroke, and Mortality After Ischemic Stroke

“…The strength of the group‐based trajectory modeling over traditional analysis is its ability to map the similar developmental course and to divide patients into different trajectories. 23 This trajectory analysis simultaneously estimates the average, variability, and the direction of variability to investigate the heterogeneity in functional disability trajectories after stroke onset. This study depicted the recovery trajectory of patients with ischemic stroke and showed distinct prognostic significance of functional disability trajectories.…”

Short-Term and Long-Term Risk of Recurrent Vascular Event by Cause After Ischemic Stroke in Young Adults

“…Second, we excluded patients who died within 30 days of the index event, and the median NIHSS score at admission was low; this indicates that we included mostly patients with less severe stroke, and, thus, these results are not generalizable to severely affected young patients. A large Chinese study 31 found that patient with mild NIHSS scores had a lower risk of recurrent vascular events compared with patients with severe or moderate NIHSS scores. Third, if diagnostic work-up was incomplete, the cause of the stroke was classified as cryptogenic, which could have led to misclassification, and, thus, an overestimation of cryptogenic strokes.…”