Developing predictive models of excellent and devastating outcome after stroke.

BACKGROUND: models to predict functional status post-stroke have utility in balancing groups in randomised trials, for outcome comparison between stroke centres and may assist in outcome prediction. This study aimed to develop models of both excellent [modified Rankin score (mRS) 0-1] and devastating outcomes (mRS of 5-6). METHODS: patients admitted with ischaemic or haemorrhagic stroke in 2001-02 to the Halifax Infirmary, Canada, were enrolled. Sixteen clinical variables from the first neurological assessment and six radiological variables from the acute CT scan were used to the model outcome at 6 months. RESULTS: five hundred and thirty-eight stroke patients were enrolled. Thirty per cent had an excellent outcome and 30% had a devastating outcome. Three models of the excellent outcome were developed [area under the receiver operator curve (AUC) 0.866-882] including the variables age, pre-stroke functional status, stroke severity, ability to lift both arms, walk independently, normal verbal Glasgow Coma Scale and leukoaraiosis. Predictive models of the devastating outcome (AUC of 0.859-0.874) included additional variables living alone pre-stroke and total anterior circulation stroke. The simplest models of both outcomes were externally validated (AUC of 0.856-0.885). CONCLUSION: this study demonstrates new externally validated predictive models of both excellent and devastating outcomes. Leukoaraiosis was the only independent radiological predictor of both outcomes. Living alone pre-stroke predicted devastating outcome post-stroke.

Fatigue impact scale demonstrates greater fatigue in younger stroke survivors.

BACKGROUND: Fatigue affects 33-77% of stroke survivors. There is no consensus concerning risk factors for fatigue post-stroke, perhaps reflecting the multifaceted nature of fatigue. We characterized post-stroke fatigue using the Fatigue Impact Scale (FIS), a validated questionnaire capturing physical, cognitive, and psychosocial aspects of fatigue. METHODS: The Stroke Outcomes Study (SOS) prospectively enrolled ischemic stroke patients from 2001-2002. Measures collected included basic demographics, pre-morbid function (Oxford Handicap Scale, OHS), stroke severity (Stroke Severity Scale, SSS), stroke subtype (Oxfordshire Community Stroke Project Classification, OCSP), and discharge function (OHS; Barthel Index, BI). An interview was performed at 12 months evaluating function (BI; Modified Rankin Score, mRS), quality of life (Reintegration into Normal living Scale, RNL), depression (Geriatric Depression Scale, GDS), and fatigue (FIS). RESULTS: We enrolled 522 ischemic stroke patients and 228 (57.6%) survivors completed one-year follow-up. In total, 36.8% endorsed fatigue (59.5% rated one of worst post-stroke symptoms). Linear regression demonstrated younger age was associated with increased fatigue frequency (ß=-0.20;p=0.01), duration (ß=-0.22;p<0.01), and disability (ß=-0.24;p<0.01). Younger patients were more likely to describe fatigue as one of the worst symptoms post-stroke (ß=-0.24;p=0.001). Younger patients experienced greater impact on cognitive (ß=-0.27;p<0.05) and psychosocial (ß=-0.27;p<0.05) function due to fatigue. Fatigue was correlated with depressive symptoms and diminished quality of life. Fatigue occurred without depression as 49.0% of respondents with fatigue as one of their worst symptoms did not have an elevated GDS. CONCLUSIONS: Age was the only consistent predictor of fatigue severity at one year. Younger participants experienced increased cognitive and psychosocial fatigue.

Predicting functional outcome after stroke by modelling baseline clinical and CT variables.

BACKGROUND: we aimed to assess whether the performance of stroke outcome models comprising simple clinical variables could be improved by the addition of more complex clinical variables and information from the first computed tomography (CT) scan. METHODS: 538 consecutive acute ischaemic and haemorrhagic stroke patients were enrolled in a Stroke Outcome Study between 2001 and 2002. Independent survival (modified Rankin scale

Clock Drawing Test in acute stroke and its relationship with long-term functional and cognitive outcomes.

Objective: The Clock Drawing Test (CDT) is commonly used as a screening tool for the assessment of dementia. The association between the CDT in acute stroke and long-term functional and cognitive outcomes in this population is unknown. The present prospective study is the first to examine if CDT scores in the acute stage after stroke are related to long-term outcomes and to compare the predictive ability of two scoring systems in a large sample of stroke patients. Method: A total of 340 patients admitted to an acute stroke unit were included in the present study. Separate stepwise multiple linear regression analyses were performed with eight independent variables (demographic/pre-stroke variables - age, sex, premorbid functioning; stroke-related variables - stroke severity, localization; cognitive variables - Orientation Test, CDT [2 scoring systems]), and four dependent variables administered one year post-stroke (Barthel Index, modified Rankin Scale, Reintegration to Normal Living index, Global Deterioration Scale). Results: Although both CDT scoring methods were related to all long-term outcome measures, the more comprehensive scoring system was the only baseline variable that significantly explained the variance in outcome measures in all four multiple regression models. Conclusion: Performance on the CDT in acute stroke is related to long-term outcomes including patients' degree of independence in performing activities of daily living, the degree to which they achieved reintegration into daily occupations, and the degree of cognitive decline observed one-year post-stroke. Future studies are needed to clarify the nature of the relationship between different CDT scoring systems and post-stroke outcomes.

Differences in wake-up and unknown onset stroke examined in a stroke registry.

INTRODUCTION: Debate exists as to whether wake-up stroke (WUS) (i.e. symptoms first noted on waking) differs from stroke developing while awake [awake onset stroke (AOS)]. Unknown onset stroke (UOS) with unclear symptom onset time is infrequently studied. AIMS: This study aimed to examine differences in stroke characteristics and outcomes in these three groups. METHODS: The stroke registry database from Halifax Infirmary, Canada, was interrogated for hospitalised stroke patients between 1999-2011. Information was available on demographics, stroke characteristics, and functional status at discharge and six months (modified Rankin score [mRS]). RESULTS: Of 3890 patients, 65% had AOS, 21% WUS and 14% UOS. UOS patients were significantly older, more commonly female and living alone than AOS patients, with no difference between AOS and WUS. UOS rates increased from 10 to 16% of patients during the study period (P < 0.0001). UOS but not WUS had a higher stroke severity than AOS. Intracerebral hemorrhage was less common (9 vs. 13%) and lacunar stroke more common (23 vs. 19%) in WUS compared to AOS. In UOS left hemisphere location was more likely, and lacunar stroke less common. Excellent outcomes were slightly lower for WUS. UOS had significantly higher rates of in-hospital mortality (23 vs. 16%, P < 0.0001) and poorer functional outcome six months after stroke (mRS < 3 in 26% of UOS and 46% of AOS, P = 0.02). CONCLUSION: WUS has lower rates of ICH but similar stroke severity and outcomes to AOS. UOS prevalence appears to be increasing, with higher stroke severity and worse prognosis.