The TWIST Tool Predicts When Patients Will Recover Independent Walking After Stroke: An Observational Study.

BACKGROUND: The likelihood of regaining independent walking after stroke influences rehabilitation and hospital discharge planning. OBJECTIVE: This study aimed to develop and internally validate a tool to predict whether and when a patient will walk independently in the first 6 months post-stroke. METHODS: Adults with stroke were recruited if they had new lower limb weakness and were unable to walk independently. Clinical assessments were completed one week post-stroke. The primary outcome was time post-stroke by which independent walking (Functional Ambulation Category score ≥ 4) was achieved. Cox hazard regression identified predictors for achieving independent walking by 4, 6, 9, 16, or 26 weeks post-stroke. The cut-off and weighting for each predictor was determined using ß-coefficients. Predictors were assigned a score and summed for a final TWIST score. The probability of achieving independent walking at each time point for each TWIST score was calculated. RESULTS: We included 93 participants (36 women, median age 71 years). Age < 80 years, knee extension strength Medical Research Council grade ≥ 3/5, and Berg Balance Test < 6, 6 to 15, or ≥ 16/56, predicted independent walking and were combined to form the TWIST prediction tool. The TWIST prediction tool was at least 83% accurate for all time points. CONCLUSIONS: The TWIST tool combines routine bedside tests at one week post-stroke to accurately predict the probability of an individual patient achieving independent walking by 4, 6, 9, 16, or 26 weeks post-stroke. If externally validated, the TWIST prediction tool may benefit patients and clinicians by informing rehabilitation decisions and discharge planning.

A multicentre, randomized, double-blinded, placebo-controlled Phase III study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND).

BACKGROUND AND HYPOTHESIS: Thrombolytic therapy with tissue plasminogen activator is effective for acute ischaemic stroke within 4·5 h of onset. Patients who wake up with stroke are generally ineligible for stroke thrombolysis. We hypothesized that ischaemic stroke patients with significant penumbral mismatch on either magnetic resonance imaging or computer tomography at three- (or 4·5 depending on local guidelines) to nine-hours from stroke onset, or patients with wake-up stroke within nine-hours from midpoint of sleep duration, would have improved clinical outcomes when given tissue plasminogen activator compared to placebo. STUDY DESIGN: EXtending the time for Thrombolysis in Emergency Neurological Deficits is an investigator-driven, Phase III, randomized, multicentre, double-blind, placebo-controlled study. Ischaemic stroke patients presenting after the three- or 4·5-h treatment window for tissue plasminogen activator and within nine-hours of stroke onset or with wake-up stroke within nine-hours from the midpoint of sleep duration, who fulfil clinical (National Institutes of Health Stroke Score ≥4-26 and prestroke modified Rankin Scale <2) will undergo magnetic resonance imaging or computer tomography. Patients who also meet imaging criteria (infarct core volume <70 ml, perfusion lesion : infarct core mismatch ratio >1·2, and absolute mismatch >10 ml) will be randomized to either tissue plasminogen activator or placebo. STUDY OUTCOME: The primary outcome measure will be modified Rankin Scale 0-1 at day 90. Clinical secondary outcomes include categorical shift in modified Rankin Scale at 90 days, reduction in the National Institutes of Health Stroke Score by 8 or more points or reaching 0-1 at day 90, recurrent stroke, or death. Imaging secondary outcomes will include symptomatic intracranial haemorrhage, reperfusion and or recanalization at 24 h and infarct growth at day 90.