Spanish cross-cultural adaptation and validation of the National Institutes of Health Stroke Scale

Heterogeneity in measurement of NIHSS: a systematic review and meta-analysis

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) is a pivotal clinical tool used to assess patients with acute stroke. However, substantial heterogeneity in the application and interpretation of stroke scale items can occur. This systematic review aimed to elucidate heterogeneity in measuring the NIHSS.

MATERIAL AND METHODS

A literature search was performed on PubMed/OVID/Cochran's CENTRAL from inception to 2023. The references of the included papers were reviewed for further eligible articles. Clinical characteristic, NIHSS values, and sources of heterogeneity were recorded. Non-human and non-English language articles were excluded. The study quality was assessed using MINORS and GRADE. Meta-analysis and meta-regression were performed using a random-effects model to explore the sources of heterogeneity.

RESULTS

Twenty-one papers for a total of 818 patients (mean per study: 39 ± 37) and 9696 NIHSS examinations (median per study: 8 [CI95% 2 to 42]) were included. Motor function had a higher ICC agreement (ranging from 0.85 ["Right Leg"] to 0.90 ["Right Arm"]) compared to the remaining items (ranging from 0.58 ["Facial Palsy"] to 0.85 ["Level of consciousness commands"]. The meta-regression showed a low effect size of covariates such as language version, remote evaluation, and retrospective analysis on NIHSS items (e.g., for "Level of consciousness commands," language effect was 0.30 [CI95% 0.20 to 0.48] and for "Visual", the retrospective assessment effect was -0.27 [CI95% -0.51 to -0.03]).

CONCLUSION

The NIHSS scores showed moderate to excellent inter-rater agreement, with the highest heterogeneity in non-motor function evaluation. Using a non-English version, remote evaluation and retrospective analysis had small effects in terms of heterogeneity in the NIHSS scores.

Hydroxytyrosol, a Promising Supplement in the Management of Human Stroke: An Exploratory Study

Hydroxytyrosol (HT) is a bioactive olive oil phenol with beneficial effects in a number of pathological situations. We have previously demonstrated that an HT-enriched diet could serve as a beneficial therapeutic approach to attenuate ischemic-stroke-associated damage in mice. Our exploratory pilot study examined this effect in humans. Particularly, a nutritional supplement containing 15 mg of HT/day was administered to patients 24 h after the onset of stroke, for 45 days. Biochemical and oxidative-stress-related parameters, blood pressure levels, serum proteome, and neurological and functional outcomes were evaluated at 45 and 90 days and compared to a control group. The main findings were that the daily administration of HT after stroke could: (i) favor the decrease in the percentage of glycated hemoglobin and diastolic blood pressure, (ii) control the increase in nitric oxide and exert a plausible protective effect in oxidative stress, (iii) modulate the evolution of the serum proteome and, particularly, the expression of apolipoproteins, and (iv) be beneficial for certain neurological and functional outcomes. Although a larger trial is necessary, this study suggests that HT could be a beneficial nutritional complement in the management of human stroke.

New Picture Stimuli for the NIH Stroke Scale: A Validation Study

BACKGROUND

The National Institutes of Health Stroke Scale is a widely accepted tool for structured graded neurological examination of stroke or suspected stroke in the hyperacute setting. Concerns have arisen about the use of its picture stimuli in a contemporary and global health context. Here, we present new stimuli prepared to serve the needs of stroke providers worldwide: the precarious painter image description and updated objects for naming.

METHODS

This was a validation study of 101 healthy fluent English speakers. Participants were reached by the Johns Hopkins Outpatient Center, the University of South Carolina, and Prisma Health from 2022 to 2023 and included residents of the United States, Germany, Canada, the United Kingdom, Australia, and Zambia. Participants were recorded in person or via video conferencing when asked to describe the new picture, while a subset named seven illustrations. Multivariate analyses of variance were used for primary analyses. In a complementary investigation, 299 attendees of the 2023 International Stroke Conference were asked about their preference for the existing or new stimuli and why.

RESULTS

Each of the 44 content units from the picture description was included by at least 5% of respondents in the demographically representative subsample. Performance was similar across healthy participants irrespective of age, sex, race, ethnicity, or education. Typical descriptions were characterized by an average of 23 content units (SD=5) conveyed with 167 syllables (SD=79). The new naming stimuli were recognized by 100% of participants from many countries as being familiar and identifiable, and names provided in response to the task were highly convergent. The majority of stroke health care providers preferred both the precarious painter and naming stimuli.

CONCLUSIONS

The description of the new National Institutes of Health Stroke Scale picture, the precarious painter, results in rich samples among healthy speakers that will provide an appropriate basis for the detection of language deficits.

National Institutes of Health Stroke Scale: comparison of original and modified versions for Singapore culture

Introduction

The National Institutes of Health Stroke Scale (NIHSS), originally designed in the United States of America, contains items on dysphasia and dysarthria that are deemed culturally unsuitable for the Singapore context. We compared the error rates of dysphasia objects, dysphasia phrases and dysarthria words between the original and alternative items in a cohort of Singaporean subjects without dysphasia or dysarthria.

Methods

In this prospective study, 140 English-speaking Singaporean subjects without impairments of dysphasia or dysarthria had an assessment of NIHSS items 9 and 10 using the original and alternative items. Paired analyses were conducted for comparison of error rates.

Results

The error rates were high for four original dysphasia objects (Hammock: 62.9%, Cactus: 38.6%, Feather: 23.6%, Glove: 20.7%) and significantly lower for alternative items (Snail: 5%, Horse: 1.4%, Hanger: 1.4%, Car: 0%) (P < 0.001). For dysphasia phrases and dysarthria words, the error rates were low and there were no differences in error rates between the original and alternative items.

Conclusion

There are cultural issues with several dysphasia objects in the original NIHSS as evidenced by the high error rates, which were lowered with more culturally suitable alternatives. This study formed a basis to derive a more suitable version of the NIHSS for English-speaking subjects in Singapore.

NIHSS is deficient in acute stroke presenting with cortical deafness; clinical skills remain the backbone: a case report

Background

National institutes of health stroke scale (NIHSS) is used, since its appearance in analysis of stroke in any national or international single center or multicenter study. It is also the golden standard assessment scale for stroke patients whether by emergency medical services on the way to hospital or by emergency room staff and by neurologists whether juniors or senior consultants. Yet, it is not capable of identifying all stroke cases. Along the current case report a relatively rare case of cortical deafness is presented highlighting its rarity and its vascular mechanism as well as how defective is NIHSS in recognizing it.

Case presentation

72-year-old female patient presented with sudden episodic less than 60 min duration of bilateral deafness; initial imaging showed right hemispheric encephalomalacia of old stroke. Patient was initially managed as psychogenic case especially that her NIHSS was zero. On returning again to emergency room she was administered thrombolysis and regained full hearing power. Follow-up imaging revealed a new ischemic stroke along her left auditory cortex explaining her cortical deafness.

Conclusion

Cortical deafness might be missed especially that NIHSS does not detect it. NIHSS role as the only golden standard scale for diagnosing and following up stroke cases ought to be revised.

Bias in Stroke Evaluation: Rethinking the Cookie Theft Picture

Despite a current emphasis on equity in stroke care, one of the most common stroke assessment tools that is used both nationally and internationally, includes an anachronistic image that projects cultural, linguistic, and socioeconomic bias. This image, titled The Cookie Theft picture, is included in the National Institutes of Health Stroke Scale and was originally developed in 1972. Now, 50 years later, it does not reflect our current diverse, linguistically rich, and multicultural patient population.

Validation of a Polish version of the National Institutes of Health Stroke Scale: Do moderate psychometric properties affect its clinical utility?

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) is a validated tool for assessing the severity of stroke. It has been adapted into several languages; however, a Polish version with large-scale psychometric validation, including repeatability and separate assessments of anterior and posterior stroke, has not been developed. We aimed to adapt and validate a Polish version of the NIHSS (PL-NIHSS) while focusing on the psychometric properties and site of stroke.

METHODS

The study included 225 patients with ischemic stroke (102 anterior and 123 posterior circulation stroke). Four NIHSS-certified researchers estimated stroke severity using the most appropriate scales to assess the psychometric properties (including internal consistency, homogeneity, scalability, and discriminatory power of individual items) and ultimately determine the reliability, repeatability, and validity of the PL-NIHSS.

RESULTS

The PL-NIHSS achieved Cronbach's alpha coefficient of 0.6885, which indicates moderate internal consistency and homogeneity. Slightly more than half of the individual items provided sufficient discriminatory power (r > 0.3). A favorable coefficient of repeatability (0.6267; 95% confidence interval: 0.5737-0.6904), narrow limits of inter-rater agreement, and excellent intraclass correlation coefficients or weighted kappa values (> 0.90), demonstrated high reliability of PL-NIHSS. Highly significant correlations with other tools confirmed the validity and predictive value of the PL-NIHSS. In posterior stroke, the PL-NIHSS achieved the required Cronbach's alpha coefficient (0.71070). Additionally, stroke location did not affect other psychometric features or instrument reliability and validity.

CONCLUSIONS

We developed a valid and reliable tool for assessing stroke severity in Polish-speaking participants. Moderate psychometric features were emphasized without limiting its clinical applications.

Effectiveness of a Functional Rehabilitation Program for Upper Limb Apraxia in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

To analyze the effectiveness of a home-based restorative and compensatory upper limb apraxia (ULA) rehabilitation program.

DESIGN

Randomized controlled trial.

SETTING

Neurology Unit of San Cecilio Hospital and 2 private and specialized health care centers.

PARTICIPANTS

Community dwelling participants (N=38) between the ages of 25 and 95 years old (sex ratio, 1:1) with unilateral mild-to-moderate poststroke lesions (time of evolution since stroke, 12.03±8.98mo) and secondary ULA.

INTERVENTIONS

Participants were randomly assigned to an 8-week combined ULA functional rehabilitation group (n=19) 3 days per week for 30 minutes or to a traditional health care education protocol group (n=19) once a month for 8 weeks. Both interventions were conducted at home.

MAIN OUTCOME MEASURES

Sociodemographic and clinical data, Barthel Index (primary outcome), Lawton and Brody Scale, observation and scoring activities of daily living, the De Renzi tests for ideational and ideomotor apraxia and imitating gestures test, recognition of gestures, test for upper limb apraxia , and stroke-specific quality of life scale were assessed at 3 time points: baseline, posttreatment (8wk), and follow-up (8wk).

RESULTS

There were statistically significant differences among the groups regarding ideomotor apraxia, imitating gestures, global recognition of gestures, intransitive gestures, and comprehension of gesture production (P<.05) in favor of the experimental group. However, no statistically significant differences were found between the groups regarding functionality or quality of life (P>.05). Regarding the within-group effect, statistically significant differences were found in all neuropsychological outcomes at posttreatment and follow-up (P<.05).

CONCLUSION

A functional rehabilitation program was found to be superior to a traditional health care education program and resulted in improvements in neuropsychological functioning in ULA poststroke. Conventional education showed an insufficient effect on apraxia recovery. Further studies with larger sample sizes are needed to determine the effect of rehabilitation strategies on functionality and quality of life of poststroke ULA patients.

Validity and Reliability of the Persian Versions of National Institute of Health Stroke Scale and Modified National Institute of Health Stroke Scale in Hospitalized Patients

Background

National Institute of Health Stroke Scale (NIHSS) and Modified National Institute of Health Stroke Scale (mNIHSS) are two valid and reliable questionnaires that assess stroke severity. This study aimed to examine and compare the validity and reliability of Persian versions of NIHSS and mNIHSS in hospitalized patients.

Materials and Methods

The English versions of NIHSS and mNIHSS were translated to Persian (forward and backward), and three neurologists examined the face and content validity of both questionnaires. The Persian versions of NIHSS and mNIHSS were used in 75 hospitalized stroke patients (hemorrhagic and obstructive) admitted to Namazi teaching hospital, Shiraz, Iran. The reliability and validity of the Persian versions were examined by Cronbach's alpha coefficient and convergent validity.

Results

The values of Cronbach's alpha for Persian versions of NIHSS and mNIHSS were 0.81 and 0.86, respectively. The scaling success of convergent validity in NIHSS and mNIHSS were 80% and 100%, respectively.

Conclusion

The Persian versions of NIHSS and mNIHSS were reliable and valid. However, mNIHSS was more valid and reliable than NIHSS. Persian version of mNIHSS can be suggested to be used for assessing stroke severity in hospitalized stroke patients by neurologists and researchers.

Stroke Epidemiology in Argentina. Design of a Population-Based Study in General Villegas (EstEPA)

BACKGROUND

Epidemiological data on stroke is scarce in Latin America. Estudio Epidemiológico Poblacional sobre Accidente Cerebrovascular (EstEPA) is a population-based program planned to assess prevalence, incidence, mortality, and burden of disease for stroke in the Department of General Villegas, province of Buenos Aires, Argentina.

METHODS AND DESIGN

Prevalence study will consist of a two-phase survey approach in the urban area of General Villegas. First, trained social workers with a structured questionnaire will collect data in 2000 randomly selected housing units. Those subjects screened positive for possible strokes will be interviewed and examined by stroke neurologists to confirm diagnosis. The incidence study will be performed according to the methodology of WHO STEPS stroke surveillance manual and will detect all new strokes in the department during a 5-year period. General and disease-specific mortality rates will be assessed monthly during a 5-year period, using different sources of information. To assess the overall burden of cerebrovascular disease, disability adjusted life years will be calculated.

DISCUSSION

EstEPA will assess for the first time all aspects of stroke epidemiology in Argentina. Its results will help to implement population-based interventions and to properly allocate public health resources.

Short- and medium-term effect of kinesio taping or electrical stimulation in hemiplegic shoulder pain prevention: A randomized controlled pilot trial

OBJECTIVE

To compare the short and medium-term effectiveness of combining Kinesio Tape (KT) or neuromuscular electrical stimulation (NMES) with a conventional approach to prevent shoulder pain after stroke.

METHODS

Thirty-one first-time stroke survivors (58.06% females) were recruited and randomly assigned to one group; Control (n = 10), KT (n = 11), or NMES (n = 10). Ten of all participants were lost during follow-up because of death or a second stroke. The control group underwent conventional treatment (careful shoulder handling and daily mobilizations). This approach was combined with KT or NMES over deltoid muscles in the KT and NMES groups respectively. Measurements were taken at baseline, and at weeks 1, 2, 3, 4, 12, and 24 post-stroke. Data collected included self-perceived shoulder pain (Visual Analogue Scale), disability (Barthel Index and Berg scale), and upper limb function (Action Research Arm test).

RESULTS

In all groups, shoulder pain did not appear during the first month (p < 0.001), but increased afterwards. In the between-groups analysis, all groups similarly improved disability and function, and no significant differences were observed for any measure (p > 0.05).

CONCLUSION

The combination of KT or NMES with conventional treatment is no superior to conventional treatment alone to prevent hemiplegic shoulder pain.

The adaption and evaluation of a Latvian version of the National Institutes of Health Stroke Scale

Objectives To determine the validity and reliability of a Latvian version of the National Institutes of Health Stroke Scale (LV-NIHSS) for evaluating Latvian stroke patients. Methods The adaption of the LV-NIHSS followed standard methods used for the adaption and validation of clinical assessment tools. The scale validity was tested by comparison with the Glasgow Coma Scale (GCS) and the modified Rankin scale (mRs). The reliability of the LV-NIHSS was evaluated by intra-rater and inter-rater agreement using intra-class correlation coefficient (ICC) analysis. Results A total of 296 stroke patients and 101 control subjects were evaluated. The mean age of the overall study population was 73.6 years (range, 37 - 94 years; 227 [57.2%] were female). The mean LV-NIHSS score of the patients with stroke was 8.4 ± 6.2. In terms of construct validity of the LV-NIHSS, it correlated with the GCS ( r = -0.571) and mRs ( r = 0.755). In terms of the reliability of the LV-NIHSS, the inter-rater agreement had an ICC of 0.99 and the intra-rater agreement had an ICC of 0.99. Conclusion The adaption of LV-NIHSS was successful and the evaluation showed that the scale was valid and reliable for evaluating Latvian stroke patients.

Rehabilitation Profiles of Older Adult Stroke Survivors Admitted to Intermediate Care Units: A Multi-Centre Study

BACKGROUND

Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units.

METHODS

We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes).

RESULTS

Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles.

CONCLUSION

Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.

Functional rehabilitation of upper limb apraxia in poststroke patients: study protocol for a randomized controlled trial

Background

Upper limb apraxia is a common disorder associated with stroke that can reduce patients’ independence levels in activities of daily living and increase levels of disability. Traditional rehabilitation programs designed to promote the recovery of upper limb function have mainly focused on restorative or compensatory approaches. However, no previous studies have been completed that evaluate a combined intervention method approach, where patients concurrently receive cognitive training and learn compensatory strategies for enhancing daily living activities.

Methods/Design

This study will use a two-arm, assessor-blinded, parallel, randomized controlled trial design, involving 40 patients who present a left- or right-sided unilateral vascular lesion poststroke and a clinical diagnosis of upper limb apraxia. Participants will be randomized to either a combined functional rehabilitation or a traditional health education group. The experimental group will receive an 8-week combined functional program at home, including physical and occupational therapy focused on restorative and compensatory techniques for upper limb apraxia, 3 days per week in 30-min intervention periods. The control group will receive a conventional health education program once a month over 8 weeks, based on improving awareness of physical and functional limitations and facilitating the adaptation of patients to the home. Study outcomes will be assessed immediately postintervention and at the 2-month follow-up. The primary outcome measure will be basic activities of daily living skills as assessed with the Barthel Index. Secondary outcome measures will include the following: 1) the Lawton and Brody Instrumental Activities of Daily Living Scale, 2) the Observation and Scoring of ADL-Activities, 3) the De Renzi Test for Ideational Apraxia, 4) the De Renzi Test for Ideomotor Apraxia, 5) Recognition of Gestures, 6) the Test of Upper Limb Apraxia (TULIA), and 7) the Quality of Life Scale For Stroke (ECVI-38).

Discussion

This trial is expected to clarify the effectiveness of a combined functional rehabilitation approach compared to a conservative intervention for improving upper limb movement and function in poststroke patients.

Trial registration

Clinical Trial Gov number NCT02199093. The protocol registration was received 23 July 2014. Participant enrollment began on 1 May 2014. The trial is expected to be completed in March 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1034-1) contains supplementary material, which is available to authorized users.

Evaluation of the Stroke-Specific Quality-of-Life (SSQOL) Scale in Mexico: A Preliminary Approach

OBJECTIVES

The prevalence of stroke survivors with incomplete recovery in society has been estimated at 460/100,000 people, and one third of them require help in at least one daily activity. Two thirds of all deaths related to stroke in the world occur in low- and middle-income countries. The objective of the present work was to assess the reliability and validity of the previously translated Spanish Stroke-Specific Quality-of-Life (SSQOL) version 2.0 scales in Mexican stroke survivors.

METHODS

An observational and cross-sectional pilot study was conducted. Thirty-one patients who suffered stroke up to 1 year prior to the present study were included. Patients were interviewed twice in a 7-day period; other indexes and scales were applied. The reliability was assessed by using Cronbach's alpha (internal consistency) and test-retest by using Spearman's rho scores; the acceptability was evaluated by the floor and ceiling effects.

RESULTS

Ceiling and floor effects were observed for fewer than 20% of the patients. The overall internal consistency of the questionnaire was greater than 0.7 (Cronbach's α), with only two domains (family roles and personality) having lower internal consistency values. The results displayed high test-retest reliability: all domains had Spearman's rho scores of over 0.8. The questionnaire has adequate construct validity.

CONCLUSIONS

Our preliminary results showed that the psychometric properties (acceptability and reliability) of the Spanish SSQOL questionnaire are good, encouraging, and comparable to those of other similar studies. This study is the first approach to validate the Spanish version of the SSQOL questionnaire in Mexican stroke survivors.

Validity and reliability of a korean version of the national institutes of health stroke scale

Background and Purpose

The National Institutes of Health Stroke Scale (NIHSS) is a clinical assessment tool that is widely used in clinical trials and practice to evaluate stroke-related neurological deficits. The aim of this study was to determine the validity and reliability of the Korean version of the NIHSS (K-NIHSS) for evaluating Korean stroke patients.

Methods

The K-NIHSS was translated and adapted with regard to cultural and linguistic peculiarities. To examine its content validity, we quantified the Content Validity Index (CVI), which was rated by 11 stroke experts. The validity of the K-NIHSS was assessed by comparison with the Glasgow Coma Scale (GCS), the modified Rankin Scale (mRS), and the Barthel Index. The reliability of the K-NIHSS was evaluated using the unweighted kappa statistics for multiple raters and an intraclass correlation coefficient (ICC).

Results

The CVI of the K-NIHSS reached 0.91-1.00. The median K-NIHSS score at baseline was 3 (interquartile range, 2-7), and the mean±SD score was 6.0±6.6. The baseline K-NIHSS had a significantly negative correlation with the GCS at baseline and the Barthel Index after 90 days. The K-NIHSS also had a significantly positive correlation with the mRS after 90 days. Facial paresis and dysarthria had moderate interrater reliability (unweighted kappa, 0.41-0.60); kappa values were substantial to excellent (unweighted kappa, >0.60) for all the other items. The ICC for the overall K-NIHSS score was 0.998. The intrarater reliability was acceptable, with a median kappa range of 0.524-1.000.

Conclusions

The K-NIHSS is a valid and reliable tool for assessing neurological deficits in Korean acute stroke patients.

Door-to-door capture of incident and prevalent stroke cases in Durango, Mexico: the Brain Attack Surveillance in Durango Study

BACKGROUND AND PURPOSE

Stroke incidence and prevalence estimates in developing countries should include stroke cases not presenting to hospital. We performed door-to-door stroke case ascertainment in Durango Municipality, Mexico, to estimate stroke incidence and prevalence and to determine the error made by only ascertaining hospital cases.

METHODS

Between September 2008 and March 2009, 1996 housing units were randomly sampled to screen for stroke in Durango Municipality residents 35 years of age and older. Field workers utilized a validated screening tool. Those screening positive were referred to a neurologist for history and examination and a head CT scan. Prevalence and cumulative incidence from the door-to-door surveillance were calculated and compared with previously reported hospitalization rates during the same defined time.

RESULTS

Respondents included 2437 subjects from 1419 homes. The refusal rate was 3.8%. Twenty subjects had verified or probable stroke. The prevalence of probable or verified stroke was 7.7 per 1000 (95% CI, 4.3 per 1000-11.2 per 1000). Five patients had a stroke during the time of the hospital surveillance, yielding a cumulative incidence of 232.3 per 100 000 (95% CI, 27.8-436.9). Two of the 5 cases were captured by door-to-door surveillance but not by hospital surveillance.

CONCLUSIONS

This study provides the first community-based stroke prevalence and incidence estimates in Mexico. The wide confidence intervals, despite the large number of surveyed housing units, suggest the need for more advanced sampling strategies for stroke surveillance in the developing world.

Hyperacute ischemic stroke management: reperfusion and evolving therapies

Management of acute ischemic stroke patients is organized around several priorities aimed at ensuring optimal patient outcomes, the first of which is reperfusion therapy, followed by determination of pathogenic mechanism by provision of a comprehensive workup to determine probable cause of the ischemic stroke or transient ischemic attack, for the purpose of providing appropriate prophylaxis for subsequent events. Provision of secondary prevention measures along with therapies that prevent complications associated with neurologic disability, and evaluation for the most appropriate level of rehabilitation services are the final priorities during acute hospitalization. This article provides an overview of reperfusion therapies and emerging hemodynamic treatments for hyperacute ischemic strokes. Gaps in the scientific evidence that are driving current blood flow augmentation research are identified.

Validation of the Spanish, Portuguese and French versions of the Lupus Damage Index questionnaire: data from North and South America, Spain and Portugal

We have previously developed and validated a self-administered questionnaire, modelled after the Systemic Lupus International Collaborating Clinics Damage Index (SDI), the Lupus Damage Index Questionnaire (LDIQ), which may allow the ascertainment of this construct in systemic lupus erythematosus (SLE) patients followed in the community and thus expand observations made about damage. We have now translated, back-translated and adapted the LDIQ to Spanish, Portuguese and French and applied it to patients followed at academic and non-academic centres in North and South America, Portugal and Spain while their physicians scored the SDI. A total of 887 patients (659 Spanish-speaking, 140 Portuguese-speaking and 80 French-speaking patients) and 40 physicians participated. Overall, patients scored all LDIQ versions higher than their physicians (total score and all domains). Infrequent manifestations had less optimal clinimetric properties but overall agreement was more than 95% for the majority of items. Higher correlations were observed among the Spanish-speaking patients than the Portuguese-speaking and French-speaking patients; further adjustments may be needed before the Portuguese and French versions of the LDIQ are applied in community-based studies. The relationship between the LDIQ and other outcome parameters is currently being investigated in a different patient sample.

The modified National Institutes of Health Stroke Scale: its time has come

The National Institutes of Health Stroke Scale (NIHSS) is a well known, reliable and valid stroke deficit scale. The NIHSS is simple, quick, and has shown significant reliability in diverse groups, settings, and languages. The NIHSS also contains items with poor reliability and redundancy. Recent investigations (include assessing a new training DVD, analyzing webbased or videotape certifications, and testing foreign language versions) have further detailed reliability issues. Items recurrently shown to have poor reliability include Level of Consciousness, Facial Palsy, Limb Ataxia, and Dysarthria. The modified NIHSS (mNIHSS) minimizes redundancy and eliminates poorly reliable items. The mNIHSS shows greater reliability in multiple settings and cohorts, including scores abstracted from records, when used via telemedicine, and when used in clinical trials. In a validation of the mNIHSS against the NIHSS, the number of elements with excellent agreement increased from 54% to 71%, while poor agreement decreased from 12% to 5%. Overall, 45% of NIHSS items had less than excellent reliability vs. only 29% for the mNIHSS. The mNIHSS is not the ideal stroke scale, but it is a significant improvement over the NIHSS. The mNIHSS has shown reliability at bedside, with record abstraction, with telemedicine, and in clinical trials. Since the mNIHSS is more reliable, it may allow for improved practitioner communication, improved medical care, and refinement of trial enrollments. The mNIHSS should now serve as the primary stroke clinical deficit scale for clinical and research aims. When it comes to the mNIHSS, its time has come!