Is the Association of National Institutes of Health Stroke Scale Scores and Acute Magnetic Resonance Imaging Stroke Volume Equal for Patients With Right- and Left-Hemisphere Ischemic Stroke? (original) (raw)
Related papers
2010
Background and Purpose-The National Institutes of Health Stroke Scale (NIHSS) is an established measure of neurological impairment; however, it can award more points for tests of presumed left-hemisphere function, such as language, than for tests of right-hemisphere function, such as neglect. This difference may be important if a low NIHSS score is used to exclude patients with right-hemisphere stroke from clinical trials or established treatments. The aim of this study was to investigate whether the relationship between acute NIHSS score and acute stroke volume as determined by acute diffusion-and perfusion-weighted MRI (DWI and PWI) differs between right-and left-sided stroke. Methods-This was a retrospective study of 153 patients with acute stroke seen at Beth Israel Deaconess Medical Center between January 1995 and March 2000 who underwent an MRI examination and NIHSS within 24 hours of stroke onset. NIHSS score was recorded prospectively by the admitting stroke fellow at the time of acute presentation, immediately preceding imaging. Computerized volumetric analysis of the MRI lesions was performed by investigators blinded to clinical data. Results-There were significant correlations between the acute NIHSS scores and acute DWI lesion volumes (rϭ0.48 right, rϭ0.58 left) and between acute NIHSS scores and perfusion-weight imaging hypoperfusion volumes (rϭ0.62 right, rϭ0.60 left). For patients with NIHSS scores of 0 to 5, the DWI volume of right cerebral lesions was greater than that of left-sided lesions (mean volume, 8.8 versus 3.2 cm 3 ; Pϭ0.04). Among patients with DWI lesions larger than the median volume (9 cm 3), 8 of 37 with right-sided stroke had an NIHSS score of 0 to 5 compared with 1 of 39 patients with left-sided stroke (Pϭ0.01). Multiple linear regression analysis revealed a significantly lower acute NIHSS on the right compared with the left side when adjusted for stroke volume on chronic T2 imaging (Pϭ0.03). Conclusions-Patients with right-sided stroke may have a low NIHSS score despite substantial DWI lesion volume. Acute imaging information, such as that available with multimodal MRI, may be useful to identify patients for inclusion in acute stroke protocols when there is clinical uncertainty about eligibility. Prospective evaluation of criteria incorporating acute imaging data is required.
Itemized NIHSS subsets predict positive MRI strokes in patients with mild deficits
Journal of the neurological sciences, 2015
While imaging is useful in confirming the diagnosis of ischemic stroke, negative diffusion weighted imaging (DWI) is reported in up to 25% of patients. Our aim was to identify predictors of MRI-positive stroke from the itemized NIHSS. Data were derived from the Stroke Warning Information and Faster Treatment study from February 2006 to February 2010 among patients with mild deficits (NIHSS 0-5) and a final diagnosis of stroke by a vascular neurologist. All MRI sequences were reviewed for the presence or absence of an acute infarct on DWI. Multivariate logistic regression assessed factors predicting DWI-positive strokes; p<0.05 was considered significant. 894 patients had a discharge diagnosis of stroke; 709 underwent MRI and 28.0% were DWI negative. All patients with visual field deficits or neglect were DWI positive. On multivariate analysis including total NIHSS (0-2 vs. 3-5) and itemized NIHSS score subsets, predictors of a positive DWI were NIHSS score of 3-5 (OR=3.3, 95% CI:...
Postthrombolysis hemorrhage risk is affected by stroke assessment bias between hemispheres
Neurology, 2011
Objective: Stroke symptoms in right hemispheric stroke tend to be underestimated in clinical assessment scales, resulting in greater infarct volumes in right as compared to left hemispheric strokes despite similar clinical stroke severity. We hypothesized that patients with right hemispheric nonlacunar stroke are at higher risk for secondary intracerebral hemorrhage after thrombolysis despite similar stroke severity. Methods: We analyzed data of 2 stroke cohorts with CT-based and MRI-based imaging before thrombolysis. Initial stroke severity was measured with the NIH Stroke Scale (NIHSS). Lacunar strokes were excluded through either the presence of cortical symptoms (CT cohort) or restriction to patients with prestroke diffusion-weighted imaging (DWI) lesion size Ͼ3.75 mL (MRI cohort). Probabilities of having a parenchymal hematoma were determined using multivariate logistic regression. Results: A total of 392 patients in the CT cohort and 400 patients in the MRI cohort were evaluated. Although NIHSS scores were similar in strokes of both hemispheres (median NIHSS: CT: 15 vs 13, MRI: 14 vs 16), the frequencies of parenchymal hematoma were higher in right hemispheric compared to left hemispheric strokes (CT: 12.4% vs 5.7%, MRI: 10.4% vs 6.8%). After adjustment for potential confounders (but not pretreatment lesion volume), the probability of parenchymal hematoma was higher in right hemispheric nonlacunar strokes (CT: odds ratio [OR] 2.3; 95% confidence interval [CI] 1.08-4.89; p ϭ 0.032) and showed a borderline significant effect in the MRI cohort (OR 2.1; 95% CI 0.98-4.49; p ϭ 0.057). Adjustment for pretreatment DWI lesion size eliminated hemispheric differences in hemorrhage risk. Conclusions: Higher hemorrhage rates in right hemispheric nonlacunar strokes despite similar stroke severity may be caused by clinical underestimation of the proportion of tissue at bleeding risk. Neurology ® 2011;76:629-636 GLOSSARY CI ϭ confidence interval; DWI ϭ diffusion-weighted imaging; ICH ϭ intracerebral hemorrhage; IQR ϭ interquartile range; MR ϭ magnetic resonance; NIHSS ϭ NIH Stroke Scale; OR ϭ odds ratio; TEMPiS ϭ Telemedical Project for Integrative Stroke Care; tPA ϭ tissue plasminogen activator.
The myth and truth of a comprehensive stroke scale
The Egyptian Journal of Neurology, Psychiatry and Neurosurgery
Background and purpose: The National Institutes of Health Stroke Scale (NIHSS) has been found to be biased toward the left hemispheric and motoric functions providing minimal assessment to the right hemispheric language and cognitive functions. The need to complement the role of the NIHSS is necessary in accurate and rapid assessment of AIS patients and better management. We hypothesized that combining the NIHSS with a quantitative analysis of Spoken Picture Description scale of Comprehensive Aphasia Test (SPD-CAT) could provide valuable data regarding side, site, and size of stroke. Subjects and methods: Eighty-six AIS patients presented within 48 h of onset of stroke were enrolled from Stroke Units of Ain-Shams University Hospitals (ASUHS). Clinical Assessment with NIHSS and SPD-CAT were correlated with the radiological MRI Brain lesions of stroke regarding (site, side, size/volume and lesion volume percent to the whole brain volume "LV% WBV"). Results: Total and subscale scores of NIHSS and SPD-CAT have a highly statistically significant correlation with the ischemic "LV% WBV." Quantitative analysis (content units) of SPD-CAT may help in prediction of the lobar site of the stroke with higher significance in the tempro-parietal and brainstem regions. Right hemispheric strokes have clinically and statistically significant scores on SPD-CAT in comparison to NIHSS scores. Also, the left to right ratio of content units of information carrying words (ICWs) in SPD-CAT gives a significant difference between right and left hemispheric strokes. Recording and analysis time of SPD-CAT makes it easy and rapidly applicable in emergency room (ER) and stroke units. Conclusion: Combining the quantitative analysis of NIHSS and SPD-CAT can better predict the side, size, and site of AIS within reasonable time table and without urgent MRI for AIS assessment and management.
Hemispheric differences in ischemic stroke: Is left-hemisphere stroke more common?
Journal of Clinical Neurology (Korea), 2013
Background and PurposezzUnderstanding the mechanisms underlying stroke can aid the development of therapies and improve the final outcome. The purposes of this study were to establish whether there are characteristic mechanistic differences in the frequency, severity, functional outcome, and mortality between left-and right-hemisphere ischemic stroke and, given the velocity differences in the carotid circulation and direct branching of the left common carotid artery from the aorta, whether large-vessel ischemia (including cardioembolism) is more common in the territory of the left middle cerebral artery. MethodszzTrial cohorts were combined into a data set of 476 samples. Using Trial of Org 10172 in Acute Stroke Treatment criteria, ischemic strokes in a total 317 patients were included in the analysis. Hemorrhagic stroke, stroke of undetermined etiology, cryptogenic stroke, and bilateral ischemic strokes were excluded. Laterality and vascular distribution were correlated with outcomes using a logistic regression model. The etiologies of the large-vessel strokes were atherosclerosis and cardioembolism. ResultszzThe overall event frequency, mortality, National Institutes of Health Stroke Scale (NIHSS) score, Glasgow Coma Scale score, and rate of mechanical thrombectomy interventions differed significantly between the hemispheres. Left-hemispheric strokes (54%) were more common than right-hemispheric strokes (46%; p=0.0073), and had higher admission NIHSS scores (p=0.011), increased mortality (p=0.0339), and higher endovascular intervention rates (p≤0.0001). ischemic strokes were more frequent in the distribution of the left middle cerebral artery (122 vs. 97; p=0.0003) due to the higher incidence of large-vessel ischemic stroke in this area (p=0.0011). ConclusionszzLeft-hemispheric ischemic strokes appear to be more frequent and often have a worse outcome than their right-hemispheric counterparts. The incidence of large-vessel ischemic strokes is higher in the left middle cerebral artery distribution, contributing to these hemispheric differences. The hemispheric differences exhibit a nonsignificant trend when strokes in the middle cerebral artery distribution are excluded from the analysis.
Journal of Neurology, Neurosurgery & Psychiatry, 2005
Background and objectives: Controversy exists about the optimal imaging technique in acute stroke. It was hypothesised that CT is comparable with DWI, when both are read systematically using quantitative scoring. Methods: Ischaemic stroke patients who had CT within six hours and DWI within seven hours of onset were included. Five readers used a quantitative scoring system (ASPECTS) to read the baseline (b) and follow up CT and DWI. Use of MRI in acute stroke was also assessed in patients treated with tissue plasminogen activator (tPA) by prospectively recording reasons for exclusion. Patients were followed clinically at three months. Results: bDWI and bCT were available for 100 consecutive patients (admission median NIHSS = 9). The mean bDWI and bCT ASPECTS were positively related (p,0.001). The level of interrater agreement ranged from good to excellent across all modalities and time periods. Bland-Altman plots showed more variability between bCT and bDWI than at 24 hours. The difference between bCT and bDWI was (2 ASPECTS points. Of bCT scans with ASPECTS 8-10, 81% had DWI ASPECTS 8-10. Patients with bCT ASPECTS of 8-10 were 1.9 times more likely to have a favourable outcome at 90 days than those with a score of 0-7 (95% CI 1.1 to 3.1, p = 0.002). The relative likelihood of favourable outcome with a bDWI ASPECTS 8-10 was 1.4 (95% CI 1.0 to 1.9, p = 0.10). Of patients receiving tPA 45% had contraindications to urgent MRI. Conclusion: The differences between CT and DWI in visualising early infarction are small when using ASPECTS. CT is faster and more accessible than MRI, and therefore is the better neuroimaging modality for the treatment of acute stroke.
Picturing the Size and Site of Stroke With an Expanded National Institutes of Health Stroke Scale
Stroke; a journal of cerebral circulation, 2016
The National Institutes of Health Stroke Scale (NIHSS) includes minimal assessment of cognitive function, particularly in right hemisphere (RH) stroke. Descriptions of the Cookie Theft picture from the NIHSS allow analyses that (1) correlate with aphasia severity and (2) identify communication deficits in RH stroke. We hypothesized that analysis of the picture description contributes valuable information about volume and location of acute stroke. We evaluated 67 patients with acute ischemic stroke (34 left hemisphere [LH]; 33 RH) with the NIHSS, analysis of the Cookie Theft picture, and magnetic resonance imaging, compared with 35 sex- and age-matched controls. We evaluated descriptions for total content units (CU), syllables, ratio of left:right CU, CU/minute, and percent interpretive CU, based on previous studies. Lesion volume and percent damage to regions of interest were measured on diffusion-weighted imaging. Multivariable linear regression identified variables associated with...
Stroke, 2004
Background and Purpose-Magnetic resonance imaging (MRI) methods such as diffusion-(DWI) and perfusion-weighted (PWI) imaging have been widely studied as surrogate markers to monitor stroke evolution and predict clinical outcome. The utility of quantitative electroencephalography (qEEG) as such a marker in acute stroke has not been intensively studied. The aim of the present study was to correlate ischemic cortical stroke patients' clinical outcomes with acute qEEG, DWI, and PWI data. Materials and Methods-DWI and PWI data were acquired from 11 patients within 7 and 16 hours after onset of symptoms. Sixty-four channel EEG data were obtained within 2 hours after the initial MRI scan and 1 hour before the second MRI scan. The acute delta change index (aDCI), a measure of the rate of change of average scalp delta power, was compared with the National Institutes of Health Stroke Scale scores (NIHSSS) at 30 days, as were MRI lesion volumes. Results-The aDCI was significantly correlated with the 30-day NIHSSS, as was the initial mean transit time (MTT) abnormality volume (ϭ0.80, PϽ0.01 and ϭ0.79, PϽ0.01, respectively). Modest correlations were obtained between the 15-hour DWI lesion volume and both the aDCI and 30-day NIHSSS (ϭ0.62, PϽ0.05 and ϭ0.73, PϽ0.05, respectively). Conclusions-In this small sample the significant correlation between 30-day NIHSSS and acute qEEG data (aDCI) was equivalent to that between the former and MTT abnormality volume. Both were greater than the modest correlation between acute DWI lesion volume and 30-day NIHSSS. These preliminary results indicate that acute qEEG data might be used to monitor and predict stroke evolution. (Stroke. 2004;35:899-903.)
Hospital topics, 2017
The National Institutes of Health Stroke Scale (NIHSS) is indispensable for both prognosis and treatment in patients with acute ischemic stroke. However, there is subtype of acute ischemic stroke (i.e., posterior circulation stroke) that is difficult to diagnose using the NIHSS. The authors report the limits of NIHSS in this stroke subtype, suggesting thereby the need to modify and render it more appropriate for the evaluation of the neurological signs occurring in posterior circulation stroke.