(Stroke. 1999;30:1208-1212.)
© 1999 American Heart Association, Inc.
Original Contributions |
Progression in Acute Stroke
Value of the Initial NIH Stroke Scale Score on Patient Stratification in Future Trials
From the National Institute of Neurological Disorders and Stroke, Stroke Branch (T.J.D., J.M.H.), National Institutes of Health; Naval Medical Center, Department of Neurology (T.J.D., A.J.D., B.J.K.); National Institute of Mental Health, National Institutes of Health (K.D.P.); and National Naval Medical Center, Department of Critical Care Medicine (B.J.K.), Bethesda, Md.
Correspondence to Thomas J DeGraba, MD, Clinical Stroke Research Unit, Stroke Branch, NINDS, NIH, 36 Convent Drive MSC 4128, Bldg 36 Rm 4A-03, Bethesda, MD 20892-4128. E-mail tjd{at}helix.nih.gov
Background and Purpose—The objective was to determine the occurrence of neurological changes during the first 48 hours after acute stroke as it relates to initial stroke severity.
Methods—The National Institutes of Health Stroke Scale (NIHSS)
was performed serially for the first 48 hours on 127 consecutive
ischemic stroke patients (129 strokes) admitted to the
neuroscience intensive care unit. Incidence of stroke
progression (a 
3-point increase on the NIHSS) was recorded and
analysis performed to determine its association with initial
stroke severity and other demographic and
physiological variables. Deficit resolution by
48 hours, defined as an NIHSS score of 0 or 1, measured the frequency
of functional recovery predicted by the initial deficit.
Results—Overall progression was noted in 31% of events (40/129).
Applying Bayes' solution to the observed frequency of worsening, the
greatest likelihood of predicting future patient progression occurs
with stratification at NIHSS scores of 
7 and >7. Patients with an
initial NIHSS of 7 experienced a 14.8% (13/88) worsening rate versus
a those with a score of >7 with a 65.9% (27/41) worsening rate
(P<0.000005). Forty-five percent (40/88) of those with
an initial score of 7 were functionally normal at 48 hours, whereas
only 2.4% (1/41) of those with scores of >7 returned to a normal
examination within this period (
2,
P<0.000005).
Conclusions—This study suggests that the early clinical course of the neurological deficit after acute stroke is dependent on the initial stroke severity and that a dichotomy in early outcome exists surrounding an initial NIHSS score of 7. These findings may have significant implications for the design and patient stratification in treatment protocols with respect to primary clinical outcome.
Key Words: outcome • stroke assessment • stroke, acute
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