Initial NIHSS Predicts Poor Short-term Outcome After Minor Stroke ...

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Initial NIHSS Predicts Poor Short-term Outcome After Minor Stroke ...

Initial NIHSS Predicts Poor

Short-term Outcome After Minor

Stroke Even at Very Low Scores

Jonathan M. Raser, Arthur Z. Washington, Koto

Ishida, Christina A. Wilson, Swaroop A. Pawar,

Michael T. Mullen, Brett L. Cucchiara, Steven R

Messé, Scott E. Kasner


Disclosures

Initial NIHSS Predicts Poor Short-term Outcome

After Minor Stroke Even at Very Low Scores.

Presenter: Jonathan M. Raser

• No study funding source to be disclosed

• The authors have no relevant disclosures

• No discussion of off-label drug use


tPA for minor ischemic stroke

only 58 patients with minor stroke, with unclear benefit

Pooja Khatri et al. Stroke 2010, 41: 2581-2586.


Minor stroke outcomes

poor short-term outcome in 11-33%

Pooja Khatri et al. Stroke 2012, 43: 560-562.


Patients excluded for minor symptoms

Eric Smith et al. Stroke 2011, 42:3110-3115.

NIHSS predicts

poor outcome

NIHSS not available for

38.1%


Patients excluded for minor symptoms

Eric Smith et al. Stroke 2011, 42:3110-3115.

NIHSS predicts

poor outcome

NIHSS not available for

38.1%


Etiology of poor outcome?

It remains unclear why patients with minor

stroke do so poorly.


Primary hypothesis

After minor stroke, poor short-term outcome is

predicted by stroke severity, as measured by

the NIH Stroke Scale on presentation, even

when deficits are mild.


Secondary hypothesis

When deficits are mild, pre-existing medical

comorbidities and hospital complications

predict poor short-term outcome.


Definitions

minor stroke – NIHSS ≤ 6, including those

without persistent symptoms but imaging

evidence of acute cerebral infarction

poor short-term outcome – discharge

destination other than home


Methods

Retrospective cohort study of all patients

admitted with acute ischemic stroke over 30

month period at a single center

Initial cohort drawn from our hospital’s Get With

the Guidelines-Stroke database, including

NIHSS at presentation


Methods

Chart review:

- NIHSS at presentation for all patients

- neurologic deficits not captured by the NIHSS

- pre-existing comorbidities

- hospital course, including

- neurologic worsening

- medical complications

- rationale for discharge destination


all ischemic stroke

or TIA admissions

over 30 months

presentation

NIHSS ≤ 6,

excluding TIA

Results

471

minor stroke

admissions

chart review

461

(98%)

data available


Short-term outcome

poor outcome

good outcome

38% (95%CI 34-43%) had a poor short-term outcome,

defined as discharge to anywhere other than home


Short-term outcome

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

home

acute rehab (31%)

nursing facility (5%)

hospice/died (2%)

psychiatric facility (


Baseline prior to stroke

Impaired ambulation prior to new symptoms

was strongly associated with poor outcome

(OR 3.4, 95%CI 1.1-10, p=0.03)

but only present in 3% of patients

Advanced age also predicted poor short-term outcome

(OR 1.04 per year, 95% CI 1.03-1.06, p


NIHSS predicted poor outcome

% poor short-term outcome

70%

60%

50%

40%

30%

20%

10%

0%

Initial NIHSS predicts short-term outcome

0 1 2 3 4 5 6

NIHSS at presentation


NIHSS predicted poor outcome

% poor short-term outcome

70%

60%

50%

40%

30%

20%

10%

0%

Initial NIHSS predicts short-term outcome

0 1 2 3 4 5 6

NIHSS at presentation

In multivariate analysis, OR of poor outcome was

1.5 per NIHSS point (95%CI 1.3-1.7, p


NIHSS predicted poor outcome

% poor short-term outcome

70%

60%

50%

40%

30%

20%

10%

0%

Initial NIHSS predicts short-term outcome

0 1 2 3 4 5 6

NIHSS at presentation

For very mild stroke (NIHSS≤3), OR of poor outcome

was 1.8 per NIHSS point (95%CI 1.3-2.4, p


Use of IV tPA

too late

excluded due to minor/rapidly

improving

excluded for other reasons

received IV tPA

112 patients presented within 4.5 hours:

15% (17) received IV tPA

45% (50) were excluded solely for minor/rapidly improving symptoms


Outcome after IV tPA

After accounting for age, NIHSS, and baseline impaired

ambulation, there was no difference in outcome

between those treated with IV tPA

and those who were excluded

(OR for a poor outcome after tPA 1.9, 95%CI 0.4-9.5, p=0.43).

Treatment of minor/rapidly improving stroke is

at the discretion of the vascular neurologist,

with a policy favoring treatment of any disabling deficit.


Secondary hypothesis

When deficits are mild, pre-existing medical

comorbidities and hospital complications

predict poor short-term outcome.


Of 45 patients:

NIHSS 0 cohort

- 2 had recurrent ischemic events

- 2 had medical complications

- 6 had deficits not captured by NIHSS

- 4 were not discharged to home


NIHSS 0 cohort

Of 4 patients not returning home:

- 1 presented from rehab

without new deficit and returned

- 1 to rehab with new hand weakness

- 2 to nursing facility due to inability to

live alone safely, concern for dementia


NIHSS 0 cohort

Other putative risk factors are present:

- deficits not captured by NIHSS

- pre-existing comorbidities

- recurrent ischemic events

- medical complications

- multiple rationales for discharge destination


Limitations

• single center, retrospective study

• underpowered regarding tPA and outcome

• short-term outcome based on disposition

• differences between early and late patients


Conclusions

• poor short-term outcome was frequent after

minor stroke

• the NIHSS was predictive of poor outcome even

at very low scores

• further study is needed to determine the relative

impact of stroke-associated disability, pre-existing

comorbidities, and hospital complications

• a better understanding of why patients with

minor stroke have poor outcome could inform

design of trials of tPA in this population


Acknowledgments

• Hospital of the University of Pennsylvania

neurovascular team

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