(Stroke. 2000;31:858.)
© 2000 American Heart Association, Inc.
Original Contributions |
Retrospective Assessment of Initial Stroke Severity With the NIH Stroke Scale
From Roudebush Veterans Affairs Medical Center (L.S.W.) and the Department of Neurology, Indiana University School of Medicine (L.S.W., E.Y., A.M.L.-Y.), Indianapolis, Indiana.
Correspondence to Linda S. Williams, M, Roudebush VAMC, HSR&D 11-H, 1481 West 10th Street, Indianapolis, IN 46202. lwilliams@hsrd.va.iupui.edu
Background and Purpose—It is important to adjust stroke outcomes for differences in initial stroke severity. The NIH Stroke Scale (NIHSS) is a commonly used stroke severity measure but has been validated for retrospective scoring only in a subset of stroke clinical trial participants. The purpose of this research was to assess the validity and reliability of an algorithm for retrospective NIHSS scoring in a setting with usual chart documentation.
Methods—An algorithm for retrospective NIHSS scoring was developed with written history and physical admission notes. Missing physical examination data were scored as normal. One investigator prospectively scored the admission NIHSS in 32 consecutive stroke patients. Two raters retrospectively scored the NIHSS by applying the algorithm to photocopied admission notes. Linear regression was used to assess interrater reliability and agreement between prospective and retrospective NIHSS scores. The Wilcoxon signed rank test was used to assess systematic scoring bias. Weighted kappa statistics were calculated to assess the level of agreement of individual NIHSS items.
Results—Only 1 admission note was complete for all NIHSS elements. Interrater reliability was near perfect (r2=0.98, P<0.001). Agreement between prospective and retrospective NIHSS score was also excellent (r2=0.94, P<0.001) and there was no systematic bias in retrospective scores. Agreement for individual items was moderate to high for all items except level of consciousness.
Conclusions—Retrospective NIHSS scoring with the algorithm is reliable and unbiased even when physical examination elements are missing from the written record. Stroke research using retrospective review of charts or of administrative databases should adjust for differences in stroke severity using such an algorithm.
Key Words: outcome • prognosis • stroke assessment
This article has been cited by other articles:
 |
|
 |
|
  A. E. Hillis, L. Gold, V. Kannan, L. Cloutman, J. T. Kleinman, M. Newhart, J. Heidler-Gary, C. Davis, E. Aldrich, R. Llinas, et al. Site of the ischemic penumbra as a predictor of potential for recovery of functions Neurology, July 15, 2008; 71(3): 184 - 189. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Juhl Majersik, M. A. Smith, D. B. Zahuranec, B. N. Sanchez, and L. B. Morgenstern Population-Based Analysis of the Impact of Expanding the Time Window for Acute Stroke Treatment Stroke, December 1, 2007; 38(12): 3213 - 3217. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. S. Williams, T. Bakas, E. Brizendine, L. Plue, W. Tu, H. Hendrie, and K. Kroenke How Valid Are Family Proxy Assessments of Stroke Patients' Health-Related Quality of Life? Stroke, August 1, 2006; 37(8): 2081 - 2085. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. G. Stead, R. M. Gilmore, K. C. Vedula, A. L. Weaver, W. W. Decker, and R. D. Brown Jr Impact of acute blood pressure variability on ischemic stroke outcome Neurology, June 27, 2006; 66(12): 1878 - 1881. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. G. Stead, R. M. Gilmore, W. W. Decker, A. L. Weaver, and R. D. Brown Jr Initial emergency department blood pressure as predictor of survival after acute ischemic stroke Neurology, October 25, 2005; 65(8): 1179 - 1183. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
U. Fischer, M. Arnold, K. Nedeltchev, C. Brekenfeld, P. Ballinari, L. Remonda, G. Schroth, and H. P. Mattle NIHSS Score and Arteriographic Findings in Acute Ischemic Stroke Stroke, October 1, 2005; 36(10): 2121 - 2125. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. W. Duncan, R. Zorowitz, B. Bates, J. Y. Choi, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty, and D. Reker Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline Stroke, September 1, 2005; 36(9): e100 - e143. [Full Text] [PDF]
|
|
|
|
|
|
A. I. Qureshi, J. F. Kirmani, M. A. Sayed, A. Safdar, S. Ahmed, R. Ferguson, L. A. Hershey, K. J. Qazi, and for the Buffalo Metropolitan Area and Erie County Time to hospital arrival, use of thrombolytics, and in-hospital outcomes in ischemic stroke Neurology, June 28, 2005; 64(12): 2115 - 2120. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. K. Schiemanck, M. W.M. Post, Th. D. Witkamp, L. J. Kappelle, and A. J.H. Prevo Relationship between Ischemic Lesion Volume and Functional Status in the 2nd Week after Middle Cerebral Artery Stroke Neurorehabil Neural Repair, June 1, 2005; 19(2): 133 - 138. [Abstract] [PDF]
|
|
|
|
|
|
L. S. Williams, E. J. Brizendine, L. Plue, T. Bakas, W. Tu, H. Hendrie, and K. Kroenke Performance of the PHQ-9 as a Screening Tool for Depression After Stroke Stroke, March 1, 2005; 36(3): 635 - 638. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Brown, L. D. Lisabeth, N. M. Garcia, M. A. Smith, and L. B. Morgenstern Emergency department evaluation of ischemic stroke and TIA: The BASIC Project Neurology, December 28, 2004; 63(12): 2250 - 2254. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. B. Morgenstern, M. A. Smith, L. D. Lisabeth, J. M. H. Risser, K. Uchino, N. Garcia, P. J. Longwell, D. A. McFarling, O. Akuwumi, A. Al-Wabil, et al. Excess Stroke in Mexican Americans Compared with Non-Hispanic Whites: The Brain Attack Surveillance in Corpus Christi Project Am. J. Epidemiol., August 15, 2004; 160(4): 376 - 383. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Cestari, D. M. Weine, K. S. Panageas, A. Z. Segal, and L. M. DeAngelis Stroke in patients with cancer: Incidence and etiology Neurology, June 8, 2004; 62(11): 2025 - 2030. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. S. Williams, S. S. Ghose, and R. W. Swindle Depression and Other Mental Health Diagnoses Increase Mortality Risk After Ischemic Stroke Am J Psychiatry, June 1, 2004; 161(6): 1090 - 1095. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Morgenstern, L. D. Lisabeth, A. C. Mecozzi, M. A. Smith, P. J. Longwell, D. A. McFarling, and J. M.H. Risser A population-based study of acute stroke and TIA diagnosis Neurology, March 23, 2004; 62(6): 895 - 900. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. G. Merino and K. M. Heilman Editorial Comment--Measurement of Cognitive Deficits in Acute Stroke Stroke, October 1, 2003; 34(10): 2396 - 2398. [Full Text] [PDF]
|
|
|
|
 |
|
 N U Weir, C E Counsell, M McDowall, A Gunkel, and M S Dennis Reliability of the variables in a new set of models that predict outcome after stroke J. Neurol. Neurosurg. Psychiatry, April 1, 2003; 74(4): 447 - 451. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. E. Kasner, B. L. Cucchiara, M. L. McGarvey, J. M. Luciano, D. S. Liebeskind, and J. A. Chalela Modified National Institutes of Health Stroke Scale Can Be Estimated From Medical Records Stroke, February 1, 2003; 34(2): 568 - 570. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Semplicini, A. Maresca, G. Boscolo, M. Sartori, R. Rocchi, V. Giantin, P. L. Forte, and A. C. Pessina Hypertension in Acute Ischemic Stroke: A Compensatory Mechanism or an Additional Damaging Factor? Arch Intern Med, January 27, 2003; 163(2): 211 - 216. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Schlegel;, S. J. Kolb, J. M. Luciano, J. M. Tovar, B. L. Cucchiara, D. S. Liebeskind, and S. E. Kasner Utility of the NIH Stroke Scale as a Predictor of Hospital Disposition Stroke, January 1, 2003; 34(1): 134 - 137. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Appelros, I. Nydevik, A. Seiger, and A. Terent Predictors of Severe Stroke: Influence of Preexisting Dementia and Cardiac Disorders Stroke, October 1, 2002; 33(10): 2357 - 2362. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Bravata, N. Kim, J. Concato, H. M. Krumholz, and L. M. Brass Thrombolysis for Acute Stroke in Routine Clinical Practice Arch Intern Med, September 23, 2002; 162(17): 1994 - 2001. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. S. Williams, J. Rotich, R. Qi, N. Fineberg, A. Espay, A. Bruno, S. E. Fineberg, and W. R. Tierney Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke Neurology, July 9, 2002; 59(1): 67 - 71. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. C. Meyer, T. M. Hemmen, C. M. Jackson, and P. D. Lyden Modified National Institutes of Health Stroke Scale for Use in Stroke Clinical Trials: Prospective Reliability and Validity Stroke, May 1, 2002; 33(5): 1261 - 1266. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W.S. Burgin, L. Staub, W. Chan, PhD;, T.H. Wein, R.A. Felberg, J.C. Grotta, A.M. Demchuk, S.L. Hickenbottom, and L.B. Morgenstern Acute stroke care in non-urban emergency departments Neurology, December 11, 2001; 57(11): 2006 - 2012. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. C. Grotta, W. S. Burgin, A. El-Mitwalli, M. Long, M. Campbell, L. B. Morgenstern, M. Malkoff, and A. V. Alexandrov Intravenous Tissue-Type Plasminogen Activator Therapy for Ischemic Stroke: Houston Experience 1996 to 2000 Arch Neurol, December 1, 2001; 58(12): 2009 - 2013. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. E. Kasner, A. M. Demchuk, J. Berrouschot, E. Schmutzhard, L. Harms, P. Verro, J. A. Chalela, R. Abbur, H. McGrade, I. Christou, et al. Predictors of Fatal Brain Edema in Massive Hemispheric Ischemic Stroke Stroke, September 1, 2001; 32(9): 2117 - 2123. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. D. Bushnell, D. C.C. Johnston, and L. B. Goldstein Retrospective Assessment of Initial Stroke Severity : Comparison of the NIH Stroke Scale and the Canadian Neurological Scale Stroke, March 1, 2001; 32(3): 656 - 660. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. M. Lopez-Yunez, A. Bruno, L. S. Williams, E. Yilmaz, C. Zurru, and J. Biller Protocol Violations in Community-Based rTPA Stroke Treatment Are Associated With Symptomatic Intracerebral Hemorrhage Stroke, January 1, 2001; 32(1): 12 - 16. [Abstract] [Full Text] [PDF]
|
|