This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fink, J. N. Articles by Schlaug, G. Search for Related Content PubMed PubMed Citation Articles by Fink, J. N. Articles by Schlaug, G. Pubmed/NCBI databases Medline Plus Health Information MRI Scans Stroke Related Collections Acute Cerebral Infarction Acute Stroke Syndromes Emergency treatment of Stroke Computerized tomography and Magnetic Resonance Imaging

(Stroke. 2002;33:954.)
© 2002 American Heart Association, Inc.

Original Contributions

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?

John N. Fink, MB, ChB, FRACP; Magdy H. Selim, MD, PhD; Sandeep Kumar, MD; Brian Silver, MD; Italo Linfante, MD; Louis R. Caplan, MD Gottfried Schlaug, MD

From the Beth Israel Deaconess Medical Center (J.N.F., M.H.S., S.K., I.L., L.R.C., G.S.), Boston, Mass, and Henry Ford Hospital (B.S.), Detroit, Mich.

Correspondence to John N. Fink, MB ChB, FRACP, Department of Neurology, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand. E-mail john.fink{at}cdhb.govt.nz

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 (r=0.48 right, r=0.58 left) and between acute NIHSS scores and perfusion-weight imaging hypoperfusion volumes (r=0.62 right, r=0.60 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 cm³; P=0.04). Among patients with DWI lesions larger than the median volume (9 cm³), 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 (P=0.01). 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 (P=0.03).

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.

Key Words: cerebral infarction • magnetic resonance imaging

This article has been cited by other articles:

				S. Sato, K. Toyoda, T. Uehara, N. Toratani, C. Yokota, H. Moriwaki, H. Naritomi, and K. Minematsu Baseline NIH Stroke Scale Score predicting outcome in anterior and posterior circulation strokes Neurology, June 10, 2008; 70(24_Part_2): 2371 - 2377. [Abstract] [Full Text] [PDF]

				N. M. Menezes, H. Ay, M. Wang Zhu, C. J. Lopez, A. B. Singhal, J. O. Karonen, H. J. Aronen, Y. Liu, J. Nuutinen, W. J. Koroshetz, et al. The Real Estate Factor: Quantifying the Impact of Infarct Location on Stroke Severity Stroke, January 1, 2007; 38(1): 194 - 197. [Abstract] [Full Text] [PDF]

				O. C. Singer, M. C. Humpich, H. Laufs, H. Lanfermann, H. Steinmetz, and T. Neumann-Haefelin Conjugate Eye Deviation in Acute Stroke: Incidence, Hemispheric Asymmetry, and Lesion Pattern Stroke, November 1, 2006; 37(11): 2726 - 2732. [Abstract] [Full Text] [PDF]

				S. D. Legge, G. Saposnik, Y. Nilanont, and V. Hachinski Neglecting the Difference: Does Right or Left Matter in Stroke Outcome After Thrombolysis? Stroke, August 1, 2006; 37(8): 2066 - 2069. [Abstract] [Full Text] [PDF]

				S. Kumar, S. Savitz, G. Schlaug, L. Caplan, and M. Selim Antiplatelets, ACE inhibitors, and statins combination reduces stroke severity and tissue at risk Neurology, April 25, 2006; 66(8): 1153 - 1158. [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]

				D. M. Kent, M. D. Hill, R. Ruthazer, S. B. Coutts, A. M. Demchuk, I. Dzialowski, O. Wunderlich, and R. von Kummer "Clinical-CT Mismatch" and the Response to Systemic Thrombolytic Therapy in Acute Ischemic Stroke Stroke, August 1, 2005; 36(8): 1695 - 1699. [Abstract] [Full Text] [PDF]

				J. Prosser, K. Butcher, L. Allport, M. Parsons, L. MacGregor, P. Desmond, B. Tress, and S. Davis Clinical-Diffusion Mismatch Predicts the Putative Penumbra With High Specificity Stroke, August 1, 2005; 36(8): 1700 - 1704. [Abstract] [Full Text] [PDF]

				S. Di Legge, J. Fang, G. Saposnik, and V. Hachinski The impact of lesion side on acute stroke treatment Neurology, July 12, 2005; 65(1): 81 - 86. [Abstract] [Full Text] [PDF]

				O. C. Singer, F. Dvorak, R. du Mesnil de Rochemont, H. Lanfermann, M. Sitzer, and T. Neumann-Haefelin A Simple 3-Item Stroke Scale: Comparison With the National Institutes of Health Stroke Scale and Prediction of Middle Cerebral Artery Occlusion Stroke, April 1, 2005; 36(4): 773 - 776. [Abstract] [Full Text] [PDF]

				A. Davalos, M. Blanco, S. Pedraza, R. Leira, M. Castellanos, J. M. Pumar, Y. Silva, J. Serena, and J. Castillo The clinical-DWI mismatch: A new diagnostic approach to the brain tissue at risk of infarction Neurology, June 22, 2004; 62(12): 2187 - 2192. [Abstract] [Full Text] [PDF]

				S. Di Legge, V. Beletsky, V. Jain, V. Hachinski, J. E. Simon, S. C. Morgan, J. H.W. Pexman, M. D. Hill, and A. M. Buchan CT assessment of conjugate eye deviation in acute stroke Neurology, February 10, 2004; 62(3): 523 - 523. [Full Text] [PDF]

				M. Nakajima, K. Kimura, T. Ogata, T. Takada, M. Uchino, and K. Minematsu Relationships between Angiographic Findings and National Institutes of Health Stroke Scale Score in Cases of Hyperacute Carotid Ischemic Stroke AJNR Am. J. Neuroradiol., February 1, 2004; 25(2): 238 - 241. [Abstract] [Full Text] [PDF]

				M. D. Lindner, V. K. Gribkoff, N. A. Donlan, and T. A. Jones Long-Lasting Functional Disabilities in Middle-Aged Rats with Small Cerebral Infarcts J. Neurosci., November 26, 2003; 23(34): 10913 - 10922. [Abstract] [Full Text] [PDF]

				A. E. Hillis, R. J. Wityk, P. B. Barker, J. A. Ulatowski, and M. A. Jacobs Change in Perfusion in Acute Nondominant Hemisphere Stroke May Be Better Estimated by Tests of Hemispatial Neglect Than by the National Institutes of Health Stroke Scale Stroke, October 1, 2003; 34(10): 2392 - 2396. [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]

				B Cucchiara, S E Kasner, D A Wolk, P D Lyden, V A Knappertz, T Ashwood, T Odergren, and A Nordlund Lack of hemispheric dominance for consciousness in acute ischaemic stroke J. Neurol. Neurosurg. Psychiatry, July 1, 2003; 74(7): 889 - 892. [Abstract] [Full Text] [PDF]

				D. F. Hanley Review of Critical Care and Emergency Approaches to Stroke Stroke, February 1, 2003; 34(2): 362 - 364. [Full Text] [PDF]