Evaluation of stroke prognostication using age and NIH Stroke Scale index (SPAN-100 index) in delayed intravenous thrombolysis patients (beyond 4.5 hours).

OBJECTIVES: the efficacy of delayed intravenous tissue plasminogen activator (tPA), beyond the 4.5 h window, is evolving. Advanced age and high admission National Institutes of Health Stroke Scale (NIHSS) score are proposed to adversely affect the outcome of delayed thrombolysis and limit the inclusion criteria. The summation of patient age and admission NIHSS score was introduced as the SPAN-100 index as a tool of prediction of the clinical outcome after acute ischemic stroke (AIS). We aimed to assess the SPAN-100 index in AIS thrombolysed patients after 4.5 h. MATERIALS AND METHODS: The SPAN-100 index was applied to AIS patients receiving delayed IV thrombolysis (IVT) after 4.5 h. Patients demographics, risk factors, clinical, laboratory and radiological data, mismatch evidence, treatment onset and modality, NIHSS score at baseline and at discharge, and 3 months follow-up modified Rankin Scale (mRS) were reviewed. SPAN-100 score ≥ 100 is classified as SPAN-100 positive while score < 100 is SPAN-100 negative. Clinical outcomes, death and intracerebral hemorrhage (ICH) incidences were compared between SPAN-100 positive and negative groups. RESULTS: SPAN-100-positive delayed IVT-patients (11/136) had a 6-fold increased risk for unfavorable outcome compared to SPAN-negative patients (OR 6.34; 95% CI 1.59-25.24 p=0.004), however there was no relation between the SPAN-100 positivity and mortality or ICH. CONCLUSION: SPAN-100-positive patients are more likely to achieve non-favorable outcome with delayed IVT in comparison to the SPAN-100-negative patients. SPAN-100 index may influence the eligibility criteria of delayed thrombolysis.

Re-evaluation of the stroke prognostication using age and NIH Stroke Scale index (SPAN-100 index) in IVT patients - the-SPAN 10065 index.

BACKGROUND: The SPAN-100 index adds patient age and baseline NIHSS-score and was introduced to predict clinical outcome after acute ischemic stroke (AIS). Even with high NIHSS-scores younger patients cannot reach a SPAN-100-positive status (index ≥100). We aimed to evaluate the SPAN-100 index among a large, contemporary cohort of i.v.-thrombolysed AIS-patients and exclusively among older patients who can at least theoretically achieve SPAN-100-positivity. METHODS: The SPAN-100 index was applied to AIS-patients receiving i.v.-thrombolysis (IVT) in our institution between 01/2006 and 01/2013. Clinical outcome and symptomatic intracerebral hemorrhage rates were compared between SPAN-100-positive and -negative patients. Furthermore we excluded patients < 65 years, without any theoretical chance to achieve SPAN-100-positivity, and re-evaluated the index (SPAN65-100 index). RESULTS: SPAN-100-positive IVT-patients (124/1002) had a 9-fold increased risk for unfavorable outcome compared to SPAN-negative patients (OR 9.39; 95% CI 5.87-15.02; p <  0.001). The odds ratio for mortality was 7.48 (95% CI 4.90-11.43; p <  0.001). No association was found between SPAN-100-positivity and sICH-incidence (OR 0.88; 95% CI 0.31-2.53; p = 0.810). SPAN65-100-positivity (124/741) was associated with an 8-fold increased risk for unfavorable outcome (OR 7.6; 95% CI 4.71-12.22; p <  0.001) but not associated with higher sICH-rates (OR 0.86; 95% CI 0.29-2.53; p <  0.001). CONCLUSIONS: Also for patients ≥65 years the SPAN-100 index can be a fast, easy method to predict clinical outcome of IVT-patients in everyday practice. However, it should not be used to determine the risk of sICH after IVT. Based on a SPAN-positive status IVT should not be withheld from AIS-patients merely because of feared sICH-complications.

Poor performance of stroke prognostication using Age and National Institutes of Health Stroke Scale-100 to predict 3- and 12-month outcomes of ischemic stroke in China National Stroke Registry.

BACKGROUND: Stroke Prognostication using Age and NIH (National Institutes of Health) Stroke Scale (SPAN)-100 is a simple and easy-to-use tool for assessing the outcomes of ischemic stroke after thrombolysis. To explore its application, we evaluated SPAN-100's prognostic value in predicting 3- and 12-month outcomes in general ischemic stroke patients. METHODS: We applied the SPAN-100 to ischemic stroke patients from the China National Stroke Registry. Poor outcome was defined as a modified Rankin Scale of 2-6. Discrimination of SPAN-100 was assessed by the area under the receiver-operator curves (AUC) and 95% confidence intervals (CI). We also performed an exploratory post hoc analysis of the performance of the SPAN index score using 80 as the cutoff point. RESULTS: Among 11,894 ischemic stroke patients, 479 (4.0%) patients were SPAN-100 positive. The AUC of SPAN-100 for poor outcome was .54 (95% CI, .54-.54) at 3 months and .54 (95% CI, .54-.55) at 12 months, respectively. In the exploratory analysis, when 80 was used as the cutoff point of SPAN index score, the AUC for poor outcome was .66 (95% CI, .66-.67) at 3 months and .68 (95% CI, .67-.68) at 12 months, respectively. CONCLUSIONS: SPAN-100 suffered from low prediction power for 3- and 12-month outcomes of ischemic stroke in Chinese population. A cutoff point of 80 may improve the performance, but none of them had an AUC above the threshold of .8 required for use in individuals.

Validation and comparison of prognostic scales in Chinese patients with ischemic stroke: a prospective study from CATIS.

BACKGROUND: : Various tools are currently available to quantify the risks of adverse clinical outcomes after an ischemic stroke. This study aimed to validate and compare prognostic scales among Chinese patients with ischemic stroke. METHODS: : We compared three stroke prognostic scales (Stroke Prognostication using Age and the National Institutes of Health Stroke Scale-100 [SPAN-100], Totaled Health Risks in Vascular Events [THRIVE], and Acute Stroke Registry and Analysis of Lausanne [ASTRAL]) in 3870 Chinese patients with ischemic stroke from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS). The 2-year primary outcome was a combination of death and major disability (modified Rankin Scale score ≥3). RESULTS: : Among all the scales, the ASTRAL score had the best accuracy for predicting 2-year prognosis in Chinese patients with ischemic stroke. The C-statistic of the ASTRAL score for the 2-year primary outcome was 0.79 (95% confidence interval [CI]: 0.78-0.80), and the Hosmer-Lemeshow goodness-of-fit test showed that the ASTRAL score fitted Chinese patients with ischemic stroke well (χ2 = 9.83, P = 0.277). The incidences of the primary outcome in the <5%, 5%-9.9%, 10%-19.9%, and ≥20% risk groups based on the ASTRAL scores were 3.93%, 7.55%, 14.29%, and 41.81%, respectively (odds ratio: 1.23; 95% CI: 1.21-1.26; P < 0.001). CONCLUSION: : The ASTRAL score had higher efficacy than the SPAN-100 and THRIVE scores in predicting 2-year adverse outcomes among Chinese patients with ischemic stroke, suggesting that it could be a valuable risk assessment tool for the 2-year prognosis of such patients.

A Case Report of Recombinant Tissue Plasminogen Activator Use in a SPAN-100-Positive Geriatric Patient with Thrombocytopenia.

Thrombocytopenia (platelet count: < 100,000/mm3) is considered a contraindication in the use of intravenous thrombolysis for acute ischemic stroke. Little literature exists regarding tissue plasminogen activator (tPA) usage in thrombocytopenic patients, especially in older patients. Age and stroke severity are major prognostic indicators of the risk of hemorrhagic transformation. The Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index estimates a patient's risk of intracerebral hemorrhage (ICH) and clinical response to thrombolysis by combining age in years with the National Institutes of Health Stroke Scale (NIHSS) scores. If the total numeric sum is 100 or more, these individuals are considered SPAN-100-positive, while those with a sum less than 100 are considered SPAN-100-negative patients. SPAN-100-positive patients are found to have a greater risk of ICH and poorer long-term outcomes than SPAN-100-negative patients both with and without thrombolysis treatment. SPAN-100-positive patients are found to have a greater risk of ICH and poorer long-term outcomes than SPAN-100-negative patients both with and without thrombolysis treatment. Nonetheless, SPAN-100-positive patients treated with tPA have a reduced relative likelihood of severe disability or death than SPAN-100-positive patients not treated with tPA. We report a case of a SPAN-100-positive, 90-year-old community-dwelling patient who presented with an acute ischemic stroke, an NIHSS score of 14 with near complete left-sided plegia, and a platelet count of 85,000/mm3. Our patient was at increased risk of ICH and poor outcome regardless of tPA administration. However, due to the patient's high functional capacity prior to hospitalization and probable severe morbidity with poor recovery potential at his age, he was treated with tPA and showed a rapid improvement in neurological symptoms with no thrombolytic-associated morbidity. Thrombolytic therapy requires a case-by-case approach. Taking into account the patient's baseline and recovery potential is critical. Even absolute and relative contraindications, as they stand now, may need reconsideration, particularly those with little empiric evidence. More research is indicated to establish if thrombocytopenia should be reclassified as a relative rather than absolute contraindication to tPA.