Derivation and Validation of a Novel Prognostic Scale (Modified–Stroke Subtype, Oxfordshire Community Stroke Project Classification, Age, and Prestroke Modified Rankin) to Predict Early Mortality in Acute Stroke

Temporal Trends and Racial Disparities in Long-Term Survival After Stroke

BACKGROUND AND OBJECTIVES

Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality.

METHODS

All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression.

RESULTS

We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32).

DISCUSSION

Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Development of a Predictive Nomogram for Intra-Hospital Mortality in Acute Ischemic Stroke Patients Using LASSO Regression

Background and Purpose

Ischemic stroke is a leading cause of mortality and disability globally, necessitating accurate prediction of intra-hospital mortality (IHM) for improved patient care. This study aimed to develop a practical nomogram for personalized IHM risk prediction in ischemic stroke patients.

Methods

A retrospective study of 422 ischemic stroke patients (April 2020 - December 2021) from Chongqing Medical University's First Affiliated Hospital was conducted, with patients divided into training (n=295) and validation (n=127) groups. Data on demographics, comorbidities, stroke risk factors, and lab results were collected. Stroke severity was assessed using NIHSS, and stroke types were classified by TOAST criteria. Least absolute shrinkage and selection operator (LASSO) regression was employed for predictor selection and nomogram construction, with evaluation through ROC curves, calibration curves, and decision curve analysis.

Results

LASSO regression and multivariate logistic regression identified four independent IHM predictors: age, admission NIHSS score, chronic obstructive pulmonary disease (COPD) diagnosis, and white blood cell count (WBC). A highly accurate nomogram based on these variables exhibited excellent predictive performance, with AUCs of 0.958 (training) and 0.962 (validation), sensitivities of 93.2% and 95.7%, and specificities of 93.1% and 90.9%, respectively. Calibration curves and decision curve analysis validated its clinical applicability.

Conclusion

Age, admission NIHSS score, COPD history, and WBC were identified as independent IHM predictors in ischemic stroke patients. The developed nomogram demonstrated high predictive accuracy and practical utility for mortality risk estimation. External validation and prospective studies are warranted for further confirmation of its clinical efficacy.

Technical Risk Stratification Nomogram Model for 90-Day Mortality Prediction in Patients With Acute Basilar Artery Occlusion Undergoing Endovascular Thrombectomy: A Multicenter Cohort Study

BACKGROUND

This study aimed to establish and validate a nomogram model for predicting 90-day mortality in patients with acute basilar artery occlusion receiving endovascular thrombectomy.

METHODS AND RESULTS

A total of 242 patients with basilar artery occlusion undergoing endovascular thrombectomy were enrolled in our study, in which 172 patients from 3 stroke centers were assigned to the training cohort, and 70 patients from another center were assigned to the validation cohort. Univariate and multivariate logistic regression analyses were adopted to screen prognostic predictors, and those with significance were subjected to establish a nomogram model in the training cohort. The discriminative accuracy, calibration, and clinical usefulness of the nomogram model was verified in the internal and external cohorts. Six variables, including age, baseline National Institutes of Health Stroke Scale score, Posterior Circulation-Alberta Stroke Program Early CT (Computed Tomography) score, Basilar Artery on Computed Tomography Angiography score, recanalization failure, and symptomatic intracranial hemorrhage, were identified as independent predictors of 90-day mortality of patients with basilar artery occlusion and were subjected to develop a nomogram model. The nomogram model exhibited good discrimination, calibration, and clinical usefulness in both the internal and the external cohorts. Additionally, patients were divided into low-, moderate-, and high-risk groups based on the risk-stratified nomogram model.

CONCLUSIONS

Our study proposed a novel nomogram model that could effectively predict 90-day mortality of patients with basilar artery occlusion after endovascular thrombectomy and stratify patients with high, moderate, or low risk, which has a potential to facilitate prognostic judgment and clinical management of stroke.

Clinico-topographic evaluation of anterior versus posterior acute ischemic stroke and correlation with early mortality-based scale prediction

Objective

Posterior circulation ischaemic strokes (PCIs) are a clinical syndrome associated with ischemia related to stenosis, in situ thrombosis, or embolic occlusion of the posterior circulation and differ from anterior circulation ischaemic strokes (ACIs) in many aspects. In this study, ACIs and PCIs were evaluated in terms of clinico-radiological and demographic aspects, and the relevance of objective scales to early disability and mortality was investigated.

Methods

The definition of ACIS or PCIS was classified according to the Oxfordshire Community Stroke Project (OCSP). There are mainly two groups divided into ACIs and PCIs. ACIs were included as total anterior circulation syndrome (TACS), partial anterior circulation syndrome (PACS) (right and left), and lacunar syndrome (LACS) (right and left), and PCIs were posterior circulation syndrome (POCS) (right and left). Arrival NIH Stroke Scale/Score (NIHSS) and Glasgow Coma Scale (GCS) scores were evaluated in clinical assessment and modified SOAR Score for Stroke (mSOAR) was for early mortality-based scale prediction. All data were compared, and mean, IQR (if applicable) values and ROC curve analysis were determined.

Results

A total of 100 AIS patients, 50 of whom were ACIs and 50 were PCIs, were included in the study and were evaluated within the first 24 h. Hypertension was the most common disease for both groups. The second most common was hyperlipidemia (82%) in the ACIs and diabetes mellitus (40%) in the PCIs. The frequency of right hemisphere ischemia was higher in ACIs (63.6%) and PCIs (48%). The mean NIHSS and GCS score (also median IQR) was higher in the right ACIs and the highest NIHSS mean was in the right partial anterior circulation syndrome (PACS) (respectively median (IQR): 9.5 (13) and median (IQR):14.5 (3)). The mean NIHSS and GCS score of bilateral posterior circulation syndrome (POCS) were the highest in PCIs (median (IQR):3 (17), (IQR):15 (4) respectively). The mSOAR mean was the highest in the right PACS in ACIs (median (IQR):2.5 (2)) and in bilateral POCs among PCIs (median(IQR):2(2)).

Conclusion

The association of PCIs with hyperlipidemia and the male gender was interpreted, and anterior infarcts were found to cause higher early clinical disability scores. The NIHSS scale was effective and reliable, especially in anterior acute strokes, but also emphasized the necessity of using the GCS assessment together in the first 24 h in the assessment of PCIs. mSOAR scale is a helpful predictor in estimating early mortality not only in ACIs but also in PCIs, similar to GCS.

Prediction of acute cerebrovascular stroke disability using mSOAR score (Stroke subtype, Oxfordshire Community Stroke Project, age, mRS and NIHSS)

Background

Stroke is among the most prevalent causes of disability. An easy reliable tool to predict stroke outcomes will help manage neurological and non-neurological events and rehabilitation. The modified SOAR (mSOAR) score, which includes stroke subtype, Oxfordshire Community Stroke Project (OCSP) classification, age, pre-stroke modified Rankin score (mRS), and National Institutes of Health Stroke Scale (NIHSS) is simple and easily calculated prognostic tool. The objective of this research was to test the ability of the mSOAR score to predict post-stroke disability as measured by mRS at discharge and 1 month after stroke onset.

Results

One hundred stroke patients (aged ≥ 18 years) were included. All subjects underwent complete neurologic examination, non-contrast head computed tomography. OCSP classification, Stroke subtype, NIHSS, and mRS score on discharge and 1 month after stroke onset were assessed for all patients. The mSOAR score was significantly correlated with mRS on discharge, after 1 month of stroke, and with the length of hospital stay. mSOAR score had high sensitivity and specificity for predicting moderate-to-severe disability on discharge and after 1 month of stroke onset.

Conclusion

The mSOAR is an excellent and accurate tool for predicting the severity of disability on discharge and 1-month post-stroke.

Genetics in aphasia recovery

Considerable research efforts have been exerted toward understanding the mechanisms underlying recovery in aphasia. However, predictive models of spontaneous and treatment-induced recovery remain imprecise. Some of the hitherto unexplained variability in recovery may be accounted for with genetic data. A few studies have examined the effects of the BDNF val66met polymorphism on aphasia recovery, yielding mixed results. Advances in the study of stroke genetics and genetics of stroke recovery, including identification of several susceptibility genes through candidate-gene or genome-wide association studies, may have implications for the recovery of language function. The current chapter discusses both the direct and indirect evidence for a genetic basis of aphasia recovery, the implications of recent findings within the field, and potential future directions to advance understanding of the genetics-recovery associations.

Outcomes of Endovascular Therapy in Patients With Prestroke Mobility Impairment

[Figure: see text].

Modified early warning score and risk of mortality after acute stroke

OBJECTIVE

An accurate prediction tool may facilitate optimal management of patients with acute stroke from an early stage. We evaluated the association between admission modified early warning score (MEWS) and mortality in patients with acute stroke.

METHOD

Data from the Anglia Stroke Clinical Network Evaluation Study (ASCNES) were analysed. We evaluated the association between admission MEWS and four outcomes; in-patient, 7-day, 30-day and 1-year mortality. Logistic regression models were used to calculate the odds of all mortality timeframes, whereas Cox proportional hazards models were used to calculate mortality at 1 year. Five univariate and multivariate models were constructed, adjusting for confounders. Patients with a moderate (2-3) or high (≥4) scores were compared to patients with a low score (0-1).

RESULTS

The study population consisted of 2006 patients. A total of 1196 patients had low MEWS, 666 had moderate MEWS and 144 had a high MEWS. A high MEWS was associated with increased mortality as an in-patient (OR 4.93, 95 % CI: 2.88-8.42), at 7 days (OR 7.53, 95 % CI: 4.24-13.38), at 30 days (OR 5.74, 95 % CI: 3.38-9.76) and 1-year (HR 2.52, 95 % CI 1.88-3.39). At 1 year, model 5 had a 1.02 OR (95 % CI 0.83-1.24) with moderate MEWS and 2.52 (95 % CI 1.88-3.39) with high MEWS.

CONCLUSION

Elevated MEWS on admission is a potential marker for acute-stroke mortality and may therefore be a useful risk prediction tool, able to guide clinicians attempting to prognosticate outcomes for patients with acute-stroke.

Influence of Including Patients with Premorbid Disability in Acute Stroke Trials: The HeadPoST Experience

BACKGROUND

Patients with premorbid functional impairment are generally excluded from acute stroke trials. We aimed to determine the impact of including such patients in the Head Positioning in acute Stroke Trial (HeadPoST) and early additional impairment on outcomes.

METHODS

Post hoc analyses of HeadPoST, an international, cluster-randomized crossover trial of lying-flat versus sitting-up head positioning in acute stroke. Associations of early additional impairment, defined as change in modified Rankin scale (mRS) scores from premorbid levels (estimated at baseline) to Day 7 ("early ΔmRS"), and poor outcome (mRS score 3-6) at Day 90 were determined with generalized linear mixed model. Heterogeneity of the trial treatment effect was tested according to premorbid mRS scores 0-1 versus 2-5.

RESULTS

Of 8,285 patients (38.9% female, mean age 68 ± 13 years) with complete data, there were 1,984 (23.9%) with premorbid functional impairment (mRS 2-5). A significant linear association was evident for early ∆mRS and poor outcome (per 1-point increase in ΔmRS, adjusted odds ratio 1.20, 95% confidence interval 1.14-1.27; p < 0.0001). Patients with greater premorbid functional impairment were less likely to develop additional impairment, but their risk of poor 90-day outcome significantly increased with increasing (worse) premorbid mRS scores (linear trend p < 0.0001). There was no heterogeneity of the trial treatment effect by level of premorbid function.

CONCLUSIONS

Early poststroke functional impairment that exceeded premorbid levels was associated with worse 90-day outcome, and this association increased with greater premorbid functional impairment. Yet, including premorbid impaired patients in the HeadPoST did not materially affect the subsequent treatment effect.

CLINICAL TRIAL REGISTRATION

HeadPoST is registered at http://www.ClinicalTrials.gov (NCT02162017).

Stroke-Specific Quality of Life one-year post-stroke in two Scandinavian country-regions with different organisation of rehabilitation services: a prospective study

Purpose: To compare stroke-specific health related quality of life in two country-regions with organisational differences in subacute rehabilitation services, and to reveal whether organisational factors or individual factors impact outcome.Materials and methods: A prospective multicentre study with one-year follow-up of 369 first-ever stroke survivors with ischaemic or haemorrhagic stroke, recruited from stroke units in North Norway (n = 208) and Central Denmark (n = 161). The 12-domain Stroke-Specific Quality of Life scale was the primary outcome-measure.Results: The Norwegian participants were older than the Danish (M_age= 69.8 vs. 66.7 years, respectively), had higher initial stroke severity, and longer stroke unit stays. Both cohorts reported more problems with cognitive, social, and emotional functioning compared to physical functioning. Two scale components were revealed. Between-country differences in the cognitive-social-mental component showed slightly better function in the Norwegian participants. Depression, anxiety, pre-stroke dependency, initial stroke severity, and older age were substantially associated to scale scores.Conclusions: Successful improvements in one-year functioning in both country-regions may result from optimising long-term rehabilitation services to address cognitive, emotional, and social functioning. Stroke-Specific Quality of Life one-year post-stroke could be explained by individual factors, such as pre-stroke dependency and mental health, rather than differences in the organisation of subacute rehabilitation services.IMPLICATIONS FOR REHABILITATIONThe stroke-specific health related quality of life (SS-QOL) assessment tool captures multidimensional effects of a stroke from the perspective of the patient, which is clinically important information for the rehabilitation services.The cognitive-social-mental component and the physical health component, indicate specific functional problems which may vary across and within countries and regions with different organisation of rehabilitation services.For persons with mild to moderate stroke, longer-term functional improvements may be better optimised if the rehabilitation services particularly address cognitive, emotional, and social functioning.

Predicting Functional Outcome Based on Linked Data After Acute Ischemic Stroke: S-SMART Score

Prediction of outcome after stroke may help clinicians provide effective management and plan long-term care. We aimed to develop and validate a score for predicting good functional outcome available for hospitals after ischemic stroke using linked data. A total of 22,005 patients with acute ischemic stroke from the Clinical Research Center for Stroke Registry between July 2007 and December 2014 were included in the derivation group. We assessed functional outcomes using a modified Rankin scale (mRS) score at 3 months after ischemic stroke. We identified predictors related to good 3-month outcome (mRS score ≤ 2) and developed a score. External validations (geographic and temporal validations) of the developed model were performed. The prediction model performance was assessed using the area under the receiver operating characteristic curve (AUC) and the calibration test. Stroke severity, sex, stroke mechanism, age, pre-stroke mRS, and thrombolysis/thrombectomy treatment were identified as predictors for 3-month good functional outcomes in the S-SMART score (total 34 points). Patients with higher S-SMART scores had an increased likelihood of a good outcome. The AUC of the prediction score was 0.805 (0.798-0.811) in the derivation group and 0.812 (0.795-0.830) in the geographic validation group for good functional outcome. The AUC of the model was 0.812 (0.771-0.854) for the temporal validation group. Moreover, they had good calibration. The S-SMART score is a valid and useful tool to predict good functional outcome following ischemic stroke. This prediction model may assist in the estimation of outcomes to determine care plans after stroke.

Shock Index Predicts Patient-Related Clinical Outcomes in Stroke

Background

The prognostic value of shock index (SI), heart rate divided by systolic blood pressure, in stroke for clinical outcomes other than mortality is not well understood.

Methods and Results

We examined the Get With The Guidelines–Stroke (GWTG‐Stroke) data to explore the usefulness of SI in predicting in‐hospital outcomes in 425 808 acute stroke cases (mean age: 71.0±14.5 years; 48.8% male; 89.7% ischemic stroke and 10.3% intracerebral hemorrhage) admitted between October 2012 and March 2015. Compared with patients with SI of 0.5 to 0.7, patients with SI >0.7 (13.6% of the sample) had worse outcomes, with adjusted odds ratios of 2.00 (95% confidence interval [CI], 1.92–2.08) for in‐hospital mortality, 1.46 (95% CI, 1.43–1.49) for longer length of hospital stay >4 days, 1.50 (95% CI, 1.47–1.54) for discharge destination other than home, 1.41 (95% CI, 1.38–1.45) for inability to ambulate independently at discharge, and 1.52 (95% CI, 1.47–1.57) for modified Rankin Scale score of 3 to 6 at discharge. Results were similar when analyses were confined to those with available National Institutes of Health Stroke Scale (NIHSS) or within individual stroke subtypes or when SI was additionally included in the models with or without blood pressure components. Every 0.1 increase in SI >0.5 was associated with significantly worse outcomes in linear spline models. The addition of SI to existing GWTG‐Stroke mortality prediction models without NIHSS demonstrated modest improvement, but little to no improvement was noted in models with NIHSS.

Conclusions

SI calculated at the point of care may be a useful prognostic indicator to identify those with high risk of poor outcomes in acute stroke, especially in hospitals with limited experience with NIHSS assessment.

Long-Term Consequences of Worsened Poststroke Status in Patients With Premorbid Disability

Supplemental Digital Content is available in the text.

Background and Purpose—

Patients with premorbid disability, generally defined as modified Rankin Scale (mRS) score ≥2, are often excluded from trials of acute stroke therapies. However, increased disability in such patients will adversely affect long-term outcomes if treatments are withheld in routine practice. We assessed the extent to which increased disability poststroke influences 5-year mortality, institutionalization, and costs in premorbidly disabled patients.

Methods—

In a population-based, prospective cohort of patients with ischemic stroke (OXVASC [Oxford Vascular Study], 2002–2014), we tracked mortality, institutionalization, and healthcare/social-care costs during follow-up. We compared 5-year mortality and poststroke institutionalization (Cox regressions) and 5-year healthcare/social-care costs (generalized linear model) in 3-month survivors with premorbid mRS of 2 to 4 (excluding extreme disability, mRS=5), based on the degree of change in mRS(ΔmRS) from prestroke to 3 months poststroke, adjusting analyses for age/sex/initial National Institutes of Health Stroke Scale.

Results—

Among 1607 patients, 530 (33.0%) had premorbid mRS of 2 to 4. Only 2 premorbidly disabled patients received thrombolysis, but 421 (79.4%) were alive at 3 months. ΔmRS was independently associated with 5-year mortality/institutionalization (adjusted hazard ratio for ΔmRS=1 versus 0: 1.59; 95% CI, 1.20–2.11; ΔmRS=2: 2.39; 95% CI, 1.62–3.53; ΔmRS=3: 4.12; 95% CI, 1.98–8.60; P<0.001) and costs (margin for ΔmRS ≥2 versus 0: $30 011, 95% CI, $4222–55 801; P=0.023). Results were similar on examining patients with premorbid mRS of 2, 3, and 4 separately (eg, 5-year mortality/institutionalization adjusted hazard ratio for premorbid mRS=3 with ΔmRS=1 versus 0: 1.60; 95% CI, 1.06–2.42; P=0.027; ΔmRS=2: 3.20; 95% CI, 1.85–5.54; P<0.001).

Conclusions—

Patients with stroke with premorbid disability have higher mortality, institutionalization, and costs if they accumulate additional disability because of the stroke. These findings highlight the long-term outcomes expected if acute interventions are routinely withheld in patients with mild-moderate premorbid disability and suggest that trials/registries should include such patients.

Thinking About the Future: A Review of Prognostic Scales Used in Acute Stroke

Background: There are many prognostic scales that aim to predict functional outcome following acute stroke. Despite considerable research interest, these scales have had limited impact in routine clinical practice. This may be due to perceived problems with internal validity (quality of research), as well as external validity (generalizability of results). We set out to collate information on exemplar stroke prognosis scales, giving particular attention to the scale content, derivation, and validation.

Methods: We performed a focused literature search, designed to return high profile scales that use baseline clinical data to predict mortality or disability. We described prognostic utility and collated information on the content, development and validation of the tools. We critically appraised chosen scales based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies (CHARMS).

Results: We chose 10 primary scales that met our inclusion criteria, six of which had revised/modified versions. Most primary scales used 5 input variables (range: 4–13), with substantial overlap in the variables included. All scales included age, eight included a measure of stroke severity, while five scales incorporated pre-stroke level of function (often using modified Rankin Scale), comorbidities and classification of stroke type. Through our critical appraisal, we found issues relating to excluding patients with missing data from derivation studies, and basing the selection of model variable on significance in univariable analysis (in both cases noted for six studies). We identified separate external validation studies for all primary scales but one, with a total of 60 validation studies.

Conclusions: Most acute stroke prognosis scales use similar variables to predict long-term outcomes and most have reasonable prognostic accuracy. While not all published scales followed best practice in development, most have been subsequently validated. Lack of clinical uptake may relate more to practical application of scales rather than validity. Impact studies are now necessary to investigate clinical usefulness of existing scales.

Impact of acute-phase complications and interventions on 6-month survival after stroke. A prospective observational study

The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome.

As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included.

A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14–2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44–3.15), hyperthermia (HR, 1.70; 95% CI, 1.18–2.45), pneumonia (HR, 1.76; 95% CI, 1.18–2.61), heart failure (HR, 2.87; 95% CI, 1.34–6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53–3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39–0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36–0.84) significantly increased 6-month survival.

In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.

Impact of anaemia on acute stroke outcomes depends on the type of anaemia: Evidence from a UK stroke register

BACKGROUND

Previous research has demonstrated an association between anaemia and poor outcomes in acute stroke. This study aimed to assess the impact of anaemia on stroke by anaemia subtype.

METHODS

Data from a prospective UK Regional Stroke Register were used to assess the association between hypochromic microcytic and normochromic normocytic anaemia on inpatient-mortality, length of stay (LOS) and discharge modified Rankin scale (mRS). Analysis was stratified by stroke subtypes and multivariable logistic regression, adjusting for potential confounders, was used to quantify this association. Patients who were not anaemic were the reference category.

RESULTS

A total of 8167 stroke patients (admitted between 2003 and 2015) were included, mean age (SD) 77.39±11.90years. Of these, 3.4% (n=281) had hypochromic microcytic anaemia and 15.5% (n=1262) had normochromic normocytic anaemia on admission. Normochromic normocytic anaemia was associated with increased odds of in-patient mortality OR 1.48 (1.24-1.77), 90-day mortality OR 1.63 (1.38-1.92), longer LOS OR 1.21 (1.06-1.40), defined as >7days, and severe disability defined as discharge mRS≥3 OR 1.31 (1.06-1.63), in patients with ischaemic stroke. Hypochromic microcytic anaemia was associated with 90-day mortality OR 1.90 (1.40-2.58) and a longer LOS OR 1.57 (1.20-2.05) in patients with ischaemic stroke.

CONCLUSIONS

Hypochromic microcytic and normochromic normocytic anaemia are associated with differing outcomes in terms of inpatient mortality and post stroke disability. While it is unclear if anaemia per se or another underlying cause is responsible for adverse outcomes, subtype of anaemia appears to be relevant in stroke prognosis.

Validating and comparing stroke prognosis scales

Objective:

To compare the prognostic accuracy of various acute stroke prognostic scales using a large, independent, clinical trials dataset.

Methods:

We directly compared 8 stroke prognostic scales, chosen based on focused literature review (Acute Stroke Registry and Analysis of Lausanne [ASTRAL]; iSCORE; iSCORE-revised; preadmission comorbidities, level of consciousness, age, and neurologic deficit [PLAN]; stroke subtype, Oxfordshire Community Stroke Project, age, and prestroke modified Rankin Scale [mRS] [SOAR]; modified SOAR; Stroke Prognosis Instrument 2 [SPI2]; and Totaled Health Risks in Vascular Events [THRIVE]) using individual patient-level data from a clinical trials archive (Virtual International Stroke Trials Archive [VISTA]). We calculated area under receiver operating characteristic curves (AUROC) for each scale against 90-day outcomes of mRS (dichotomized at mRS >2), Barthel Index (>85), and mortality. We performed 2 complementary analyses: the first limited to patients with complete data for all components of all scales (simultaneous) and the second using as many patients as possible for each individual scale (separate). We compared AUROCs and performed sensitivity analyses substituting extreme outcome values for missing data.

Results:

In total, 10,777 patients contributed to the analyses. Our simultaneous analyses suggested that ASTRAL had greatest prognostic accuracy for mRS, AUROC 0.78 (95% confidence interval [CI] 0.75–0.82), and SPI2 had poorest AUROC, 0.61 (95% CI 0.57–0.66). Our separate analyses confirmed these results: ASTRAL AUROC 0.79 (95% CI 0.78–0.80 and SPI2 AUROC 0.60 (95% CI 0.59–0.61). On formal comparative testing, there was a significant difference in modified Rankin Scale AUROC between ASTRAL and all other scales. Sensitivity analysis identified no evidence of systematic bias from missing data.

Conclusions:

Our comparative analyses confirm differences in the prognostic accuracy of stroke scales. However, even the best performing scale had prognostic accuracy that may not be sufficient as a basis for clinical decision-making.

Validation of the mSOAR and SOAR scores to predict early mortality in Chinese acute stroke patients

BACKGROUND

It is unclear in Chinese patients with acute stroke how the SOAR (stroke subtype, Oxfordshire Community Stroke Project classification, age, and prestrike modified Rankin) and mSOAR (modified-SOAR) scores performed in predicting discharge mortality and 3-month mortality. We aimed to validate the predictability of these scores in this cohort.

METHODS

Data from the China National Stroke Registry (CNSR) study was used to perform the mSOAR and SOAR scores for predicting the discharge and 3-month mortality in acute stroke patients.

RESULTS

A total of 11073 acute stroke patients were included in present study. The increased mSOAR and SOAR scores were closely related to higher death risk in acute stroke patients. For discharge mortality, the area under the receiver-operator curve (AUC) of the mSOAR and SOAR scores were 0.784 (95% CI 0.761-0.807) and 0.722 (95% CI: 0.698-0.746). For 3-month mortality, they were 0.787 (95% CI: 0.771-0.803) and 0.704 (95% CI: 0.687-0.721), respectively. The mSOAR and SOAR scores showed significant correlation between the predicted and observed probabilities of discharge mortality (mSOAR: r = 0.945, P = 0.001; SOAR: r = 0.994, P<0.001) and 3-month mortality (mSOAR: r = 0.984, P<0.001; SOAR: r = 0.999; P<0.001).

CONCLUSIONS

The mSOAR score predicted reliably the risk of death in Chinese acute stroke patients.

Pre-Stroke Modified Rankin Scale: Evaluation of Validity, Prognostic Accuracy, and Association with Treatment

Background and purpose

The modified Rankin Scale (mRS) was designed to measure poststroke recovery but is often used to describe pre-stroke disability. We sought to evaluate three aspects of pre-stroke mRS: validity as a measure of pre-stroke disability; prognostic accuracy and association of pre-stroke mRS scores, and process of care.

Methods

We used data from a large, UK clinical registry. For analysis of validity, we compared pre-stroke mRS against other markers of pre-stroke function (age, comorbidity index, care needs). For analysis of prognostic accuracy, we described univariable and multivariable models comparing pre-stroke mRS and other prognostic variables against a variety of outcomes (early and late mortality, length of stay, institutionalization, incident complications). Finally, we described association of pre-stroke mRS and components of evidence-based stroke care (early neuroimaging, admission to stroke unit, assessment of swallow).

Results

We analyzed data of 2,491 stroke patients. Concurrent validity analyses suggested statistically significant, but modest correlations between pre-stroke mRS and chosen variables (rho >0.40; p < 0.0001 for all). Every point increase of pre-stroke mRS was associated with poorer outcomes for our prognostic variables (unadjusted p < 0.001). This association held when corrected for other covariates. For example, pre-stroke mRS 4–5 odds ratio (OR): 6.84 (95% CI: 4.24–11.03) for 1 year mortality compared to mRS 0 in adjusted model. There was a difference between pre-stroke mRS and treatment, with higher pre-stroke mRS more likely to receive evidence-based care.

Conclusion

Results suggest that pre-stroke mRS has some concurrent validity and is a robust predictor of prognosis. This association is not explained by the influence of pre-stroke mRS on care pathways.

mSOAR: an effective bedside stroke prognosis tool

The modified-SOAR (mSOAR) score is composed of the stroke subtype, Oxfordshire Community Stroke Project classification, age, pre-stroke modified Rankin score (mRS) and the National Institutes of Health Stroke Scale score. It has previously been shown to be a reliable predictor of mortality and length of -hospital stay. This study sought to identify whether the mSOAR can also be used to predict patient disability on discharge. A post-hoc calculation of mSOAR using Sentinel Stroke National Audit Programme (SSNAP) data and electronic discharge -summaries was performed on all stroke admissions to Bridgend Hospital over an 11-month period. This study included 230 patients, of which 88% had suffered infarcts and 23% had experienced a previous cerebrovascular episode or transient ischaemic attack; 52% were female. The mortality rate was 13% and 57% had slight disability or less (mRS≤2) on discharge. Each increase in mSOAR score was associated with significantly worse discharge disability (p<0.05). We conclude that the mSOAR score is an excellent tool for predicting both discharge disability and mortality. As such, it's useful for admission prognosis discussions with patients, their relatives and the multidisciplinary team and for early supported discharge decision making.

GISCOME - Genetics of Ischaemic Stroke Functional Outcome network: A protocol for an international multicentre genetic association study

Introduction

Genome-wide association studies have identified several novel genetic loci associated with stroke risk, but how genetic factors influence stroke outcome is less studied. The Genetics of Ischaemic Stroke Functional outcome network aims at performing genetic studies of stroke outcome. We here describe the study protocol and methods basis of Genetics of Ischaemic Stroke Functional outcome.

Methods

The Genetics of Ischaemic Stroke Functional outcome network has assembled patients from 12 ischaemic stroke projects with genome-wide genotypic and outcome data from the International Stroke Genetics Consortium and the National Institute of Neurological Diseases Stroke Genetics Network initiatives. We have assessed the availability of baseline variables, outcome metrics and time-points for collection of outcome data.

Results

We have collected 8831 ischaemic stroke cases with genotypic and outcome data. Modified Rankin score was the outcome metric most readily available. We detected heterogeneity between cohorts for age and initial stroke severity (according to the NIH Stroke Scale), and will take this into account in analyses. We intend to conduct a first phase genome-wide association outcome study on ischaemic stroke cases with data on initial stroke severity and modified Rankin score within 60-190 days. To date, we have assembled 5762 such cases and are currently seeking additional cases meeting these criteria for second phase analyses.

Conclusion

Genetics of Ischaemic Stroke Functional outcome is a unique collection of ischaemic stroke cases with detailed genetic and outcome data providing an opportunity for discovery of genetic loci influencing functional outcome. Genetics of Ischaemic Stroke Functional outcome will serve as an exploratory study where the results as well as the methodological observations will provide a basis for future studies on functional outcome. Genetics of Ischaemic Stroke Functional outcome can also be used for candidate gene replication or assessing stroke outcome non-genetic association hypotheses.

External Validation of a Case-Mix Adjustment Model for the Standardized Reporting of 30-Day Stroke Mortality Rates in China

BACKGROUND AND PURPOSE

A case-mix adjustment model has been developed and externally validated, demonstrating promise. However, the model has not been thoroughly tested among populations in China. In our study, we evaluated the performance of the model in Chinese patients with acute stroke.

METHODS

The case-mix adjustment model A includes items on age, presence of atrial fibrillation on admission, National Institutes of Health Stroke Severity Scale (NIHSS) score on admission, and stroke type. Model B is similar to Model A but includes only the consciousness component of the NIHSS score. Both model A and B were evaluated to predict 30-day mortality rates in 13,948 patients with acute stroke from the China National Stroke Registry. The discrimination of the models was quantified by c-statistic. Calibration was assessed using Pearson's correlation coefficient.

RESULTS

The c-statistic of model A in our external validation cohort was 0.80 (95% confidence interval, 0.79-0.82), and the c-statistic of model B was 0.82 (95% confidence interval, 0.81-0.84). Excellent calibration was reported in the two models with Pearson's correlation coefficient (0.892 for model A, p<0.001; 0.927 for model B, p = 0.008).

CONCLUSIONS

The case-mix adjustment model could be used to effectively predict 30-day mortality rates in Chinese patients with acute stroke.