National Institutes of Health Stroke Scale Correlates Well with Initial Intracerebral Hemorrhage Volume.

OBJECTIVES: The US Centers for Medicare and Medicaid Services (CMS) currently publicly reports hospital-quality, risk-adjusted mortality measure for ischemic stroke but not intracerebral hemorrhage (ICH). The NIHSS, which is captured in CMS administrative claims data, is a candidate metric for use in ICH risk adjustment and has been shown to predict clinical outcome with accuracy similar to the ICH Score. Correlation between early NIHSS and initial ICH volume would further support use of the NIHSS for ICH risk adjustment. MATERIALS AND METHODS: Among 372 ICH patients enrolled in a large multicenter trial (FAST-MAG), the relation between early NIHSS and early ICH volume was assessed with correlation and linear trend analysis. RESULTS: Overall, there was strong correlation between NIHSS and ICH volume, r = 0.77 (p < 0.001), and for every 10cc increase in ICH the NIHSS increased by 4.5 points. Correlation coefficients were comparable in all subgroups, but magnitude of NIHSS increase with ICH unit volume increase was greater with left than right hemispheric ICH, with presence rather than absence of IVH, with imaging done within the first hour than second hour after last known well, with men than women, and with younger than older patients. CONCLUSION: Early NIHSS neurologic deficit severity values correlate strongly with initial ICH hematoma volume. As with ischemic stroke, lesion volume increases produce greater NIHSS change in the left than right hemisphere, reflecting greater NIHSS sensitivity to left hemisphere function. These findings provide further support for the use of NIHSS in risk-adjusted mortality measures for intracerebral hemorrhage.

Beyond Functional Impairment: Redefining Favorable Outcome in Patients with Subarachnoid Hemorrhage.

BACKGROUND: For outcome assessment in patients surviving subarachnoid hemorrhage (SAH), the modified Rankin scale (mRS) represents the mostly established outcome tool, whereas other dimensions of outcome such as mood disorders and impairments in social life remain unattended so far. OBJECTIVE: The aim of our study was to correlate 12-month functional and subjective health outcomes in SAH survivors. METHODS: All SAH patients treated over a 5-year period received outcome assessment at 12 months, including functional scores (mRS and Barthel Index [BI]), subjective health measurement (EQ-5D), and whether they returned to work. Analyses - including utility-weighted mRS - were conducted to detect associations and correlations among different outcome measures, especially in patients achieving good functional outcome (i.e., mRS 0-2) at 12 months. RESULTS: Of 351 SAH survivors, 287 (81.2%) achieved favorable functional outcome at 12 months. Contrary to the BI, the EQ-5D visual analog scale (VAS) showed a strong association with different mRS grades, accentuated in patients with favorable functional outcome. Despite favorable functional outcome, patients reported a high rate of impairments in activities (24.0%), pain (33.4%), and anxiety/depression (42.5%). Further, multivariable analysis revealed (i) impairments in activities (odds ratio [OR] [95% confidence interval {CI}]: 0.872 [0.817-0.930]), (ii) presence of depression or anxiety (OR [95% CI]: 0.836 [0.760-0.920]), and (iii) return to work (OR [95% CI]: 1.102 [0.1.013-1.198]) to be independently associated with self-reported subjective health. CONCLUSION: Established stroke scores mainly focusing on functional outcomes do poorly reflect the high rate of subjective impairments reported in SAH survivors, specifically in those achieving good functional outcome. Further studies are needed to investigate whether psychoeducational approaches aiming at improving coping mechanisms and perceived self-efficacy may result in higher subjective health in these patients.

Health-Related Quality of Life and Fatigue After Transient Ischemic Attack and Minor Stroke.

BACKGROUND: Studies suggest that fatigue and cognitive impairment may be present after transient ischemic attack (TIA) or minor stroke, but little is known about consequences in daily life. The main aim was to explore the presence of fatigue, cognitive impairment, and consequences in daily life after minor stroke-TIA. METHODS: Patients (n = 92) were consecutively recruited from the Stroke Unit and were assessed within 2 weeks of hospital admission for first-ever and 3 months later. Control participants (n = 89) were recruited from the same population as the patients. Measures included the Fatigue Assessment Scale (FAS), Montreal Cognitive Assessment (MoCA), and The European Quality of Life index (EQ-5D-5L). RESULTS: The prevalence of substantial fatigue was 65.2% (confidence interval [CI] 95%: 54.6%-74.8%) and extreme fatigue was 20.7% (CI 95%: 12.9%-30.4%) in minor stroke-TIA patients. The prevalence of substantial fatigue in controls was 23.5% (CI95%: 15.0%-34.0%) and extreme fatigue was 4.5% (CI 95%: 1.8%-11.0%). The mean (SD) score on the MoCA was 24.1 (3.2) for the patients group and 27.3 (2.4) for controls (P < .001). FAS showed the strongest negative correlation score with the EQ-5D-5L index (r = -0.480; P < .0001), higher levels of mental and physical fatigue are associated with lower EQ-5D-5L index (r = -0.376; P < .001 and r = -0.497; P <.001, respectively). The correlations between the FAS and the MoCA measures were no significant. MoCA was not significantly correlated with EQ-5D-5L. CONCLUSIONS: Fatigue was a very common symptom in TIA/minor stroke patients. The fatigue had a significant impact on the health-related quality of life construct in its entirety, even after accounting for the influence of several factors.

Comparison of ABC Methods with Computerized Estimates of Intracerebral Hemorrhage Volume: The INTERACT2 Study.

BACKGROUND AND PURPOSE: Hematoma volume is a key determinant of outcome in acute intracerebral hemorrhage (ICH). We aimed to compare estimates of ICH volume between simple (ABC/2, length, width, and height) and gold standard planimetric software approaches. METHODS: Data are from the second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Multivariable linear regression was used to compare ICH volumes on baseline CT scans using the ABC/2, modified ABC/2 (mABC/2), and MIStar software. Other aspects of ICH morphology examined included location, irregularity, heterogeneity, intraventricular and subarachnoid hemorrhage extension (SAH) of hematoma, and associated white matter lesions and brain atrophy. RESULTS: In 2,084 patients with manual and semiautomated measurements, median (IQR) ICH volumes for each approach were: ABC/2 11.1 (5.11-20.88 mL), mABC/2 7.8 (3.88-14.11 mL), and MIStar 10.7 (5.59-18.66 mL). Median differences between ABC/2 and MIStar, and mABC/2 and MIStar were 0.34 (-1.01 to 2.96) and -2.4 (-4.95 to -0.7416), respectively. Hematoma volumes differed significantly with irregular shape (ABC/2 and MIStar, p < 0.001; mABC/2 and MIStar, p = 0.007) and larger volumes (mABC/2 and MIStar, p < 0.001; ABC/2 and MIStar, p = 0.07). ICH with SAH showed a significant discrepancy between ABC/2 and MIStar (p < 0.001). CONCLUSIONS: Overall, ABC/2 performs better than mABC/2 in estimating ICH volume. The largest discrepancies were evidenced against automated software for irregular-shaped and large ICH with SAH, but the clinical significance of this is uncertain.

Community mobility after stroke: a systematic review.

Background Stroke is the leading cause of severe disability and many survivors report long-term physical or cognitive impairments that may impact their ability to achieve community mobility (CM). PURPOSE: To determine the extent to which people with chronic stroke achieve CM compared to age-matched norms or non-neurologically impaired controls. Methods The StrokEDGE outcome measures were searched to identify validated tools that included >25% of items addressing CM. MEDLINE, CINAHL, Google Scholar, PubMed, PEDro and the Cochrane databases were searched from 2001 to 2015 with the identified outcome measures cross-referenced against search terms related to stroke and CM. INCLUSION CRITERIA: utilized a validated CM outcome measure, chronic (>3 months post) stroke survivors, and randomized controlled trial, observational or cohort study design. One reviewer screened the studies and performed data extraction and three performed quality appraisal. Fourteen studies met all inclusion criteria. Results Stroke survivors have impaired CM as demonstrated by 30-83% of normative or non-stroke subject CM scores. As time post-stroke increased, CM improved only slightly. Factors found to correlate with the CM were age, education, general well-being, emotional state, motor function and coordination, independence in activities of daily living, balance, endurance and driving status. Limitations of this review include a relatively high functioning cohort, no meta-analysis and reliance on outcome measures not specifically designed to measure CM. Conclusion Survivors of stroke may experience a significant decrease in CM compared to people without neurological injury. Rehabilitation addressing motor function, coordination, independence in activities of daily living, balance and endurance may be important for achieving higher levels of CM. Outcome measures directly addressing CM are needed.

Ischemic Stroke: Risk Stratification, Warfarin Teatment and Outcome Measure.

Stroke is a focal neurological syndrome of vascular basis, which may be due to ischemic thrombo-embolism or intra-cerebral haemorrhage. This condition has to be treated on emergency basis as it may cause an irreversible neurological damage. Warfarin has been a widely used oral anti-coagulant in treating ischemic stroke patients. This review highlights the benefits and challenges of warfarin treatment in stroke patients and discusses about the importance of risk stratification scores and bleeding scores in estimating the bleeding risk associated with warfarin treatment. This review also highlights the use of stroke outcome measures in identifying the patients with post-stroke disabilities to provide patient specific treatment.