Donate Help Contact The AHA Sign In Home
American Heart Association
Stroke
Search: search_blue_button Advanced Search
« Previous Article | Table of Contents | Next Article »
Stroke. 2007;38:1091-1096
Published online before print February 1, 2007, doi: 10.1161/01.STR.0000258355.23810.c6
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
38/3/1091    most recent
01.STR.0000258355.23810.c6v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Banks, J. L.
Right arrow Articles by Marotta, C. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Banks, J. L.
Right arrow Articles by Marotta, C. A.
Related Collections
Right arrow Health policy and outcome research
Right arrow Neuroprotectors
Right arrow Thrombolysis
Right arrow Cerebrovascular disease/stroke

(Stroke. 2007;38:1091.)
© 2007 American Heart Association, Inc.

Comments, Opinions, and Reviews

Outcomes Validity and Reliability of the Modified Rankin Scale: Implications for Stroke Clinical Trials

A Literature Review and Synthesis

Jamie L. Banks, MSc, PhD Charles A. Marotta, MD, PhD

From the Health Economics Research and Quality of Life Evaluation Services (J.L.B.), Abt Associates, Inc, Lexington, Mass; and Health Economics and Outcomes Research (C.A.M.), Division of Medical Sciences, AstraZeneca Pharmaceuticals LP, Wilmington, Del.

Correspondence to Charles A. Marotta, MD, PhD, AstraZeneca LP, 1800 Concord Pike, Wilmington, DE 19850. E-mail charles.marotta{at}astrazeneca.com


*    Abstract
up arrowTop
 *Abstract
down arrowIntroduction
 down arrowMethods
 down arrowResults
 down arrowSummary and Conclusions
 down arrowReferences
 
Background and Purpose— The modified Rankin scale (mRS), a clinician-reported measure of global disability, is widely applied for evaluating stroke patient outcomes and as an end point in randomized clinical trials. Extensive evidence on the validity of the mRS exists across a large but fragmented literature. As new treatments for acute ischemic stroke are submitted for agency approval, an appreciation of the mRS’s attributes, specifically its relationship to other stroke evaluation scales, would be valuable for decision-makers to properly assess the impact of a new drug on treatment paradigms. The purpose of this report is to assemble and systematically assess the properties of the mRS to provide decision-makers with pertinent evaluative information.

Methods— A Medline search was conducted to identify reports in the peer-reviewed medical literature (1957–2006) that provide information on the structure, validation, scoring, and psychometric properties of the mRS and its use in clinical trials. The selection of articles was based on defined criteria that included relevance, study design and use of appropriate statistical methods.

Results— Of 224 articles identified by the literature search, 50 were selected for detailed assessment. Inter-rater reliability with the mRS is moderate and improves with structured interviews ({kappa} 0.56 versus 0.78); strong test-re-test reliability ({kappa}=0.81 to 0.95) has been reported. Numerous studies demonstrate the construct validity of the mRS by its relationships to physiological indicators such as stroke type, lesion size, perfusion and neurological impairment. Convergent validity between the mRS and other disability scales is well documented. Patient comorbidities and socioeconomic factors should be considered in properly applying and interpreting the mRS. Recent analyses suggest that randomized clinical trials of acute stroke treatments may require a smaller sample size if the mRS is used as a primary end point rather than the Barthel Index.

Conclusions— Multiple types of evidence attest to the validity and reliability of the mRS. The reported data support the view that the mRS is a valuable instrument for assessing the impact of new stroke treatments.


Key Words: cerebrovascular accident • disability evaluation • randomized controlled trials • rankin scale • reproducibility of results


*    Introduction
up arrowTop
 up arrowAbstract
 *Introduction
down arrowMethods
 down arrowResults
 down arrowSummary and Conclusions
 down arrowReferences
 
The modified Rankin Scale (mRS) is a clinician-reported measure of global disability that has been widely applied for evaluating recovery from stroke1,2 and as a primary end point in randomized clinical trials (RCTs) of emerging acute stroke treatments.3 The value of the mRS as a RCT end point has been examined in several investigations wherein proponents emphasize the importance of the scale’s brevity, simplicity of use and interpretability in the context of stroke trials.4 Extensive evidence on the validity, reliability and sensitivity of the mRS exists across a broad but fragmented literature.5–8

As new stroke drugs are submitted for agency approval, an in-depth understanding of the mRS in terms of its relationship to other stroke evaluation scales and clinical outcomes would be useful for decision-makers to properly assess their impact. The purpose of this review is to assemble and systematically assess the properties of the mRS to provide decision-makers with pertinent evaluative information they need for decision-making.


*    Methods
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 *Methods
down arrowResults
 down arrowSummary and Conclusions
 down arrowReferences
 
An initial literature search was conducted in MEDLINE from 1957 (date of original Rankin Scale (RS) publication to December 2004, with updates through April 2006) to identify articles on (1) the structure, scoring, and psychometric properties of the mRS and (2) the effectiveness of the mRS as an end point in RCTs of acute stroke treatment. Search criteria included the term Rankin AND one or more of each of the following MeSH terms: psychometrics, reliability and validity, predictive value of tests, sensitivity and specificity, disability evaluation, statistics and randomized controlled trials. Other search terms including lesion volume, stroke type, end point and design, were used to search for additional articles. Two reviewers selected articles for assessment based on relevance to the study objectives and (1) the use of appropriate statistical methods in assessing validity, and (2) analysis of the mRS as a primary end point in RCTs of acute ischemic stroke treatments. The initial search identified 224 articles of which 50 were selected for a detailed assessment (40 relating mainly to validity/reliability, 2 to the original Rankin and related scales, 8 related to RCTs). Additional articles providing information on the limitations of the mRS, and others were identified from bibliographies of the retrieved articles.


*    Results
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 *Results
down arrowSummary and Conclusions
 down arrowReferences
 
Historical Development
The history of the mRS dates from publication of the original Rankin Scale in 1957.1 Developed by Dr John Rankin in Glasgow, Scotland, the RS comprises 5 grades of stroke severity ranging from "no significant disability" to "severe disability" (Table 1), and was intended as a descriptive categorization of functional recovery of cerebrovascular disease patients (>60 years) at the time of discharge or transfer from the index hospitalization.* The mRS was published in 1988 and consists of 6 categories (grades 0 to 5) rather than 5 for the RS; an additional category, grade "6" denoting death, is usually incorporated into the mRS for RCT purposes9 (Table 1). In the mRS: grade 1 of the original RS ("no significant disability") is replaced by 2 grades, 0 and 1, with grade 0 describing patients without symptoms and grade 1 describing patients without significant disability "despite symptoms." This finer discrimination of mild strokes increases the usefulness of the mRS in evaluating RCTs of acute stroke interventions. Additionally, grade 2 in the mRS ("unable to perform all previous activities") is more definitive compared with that grade of the RS ("unable to carry out some of previous activities").


View this table:
[in this window]
[in a new window]

  		TABLE 1. Original and Modified RSs

The mRS is heavily weighted toward global disability (in particular, physical disability) and the need for assistance.2,6,7 As a global disability measure, the broad categories of the mRS (Table 1) subsume instrumental activities of daily living (IADL; eg, meal preparation, shopping, handling money)4 and basic ADLs (BADL; eg, walking, dressing, grooming) with emphasis on compromised motor function.10 The global nature of the mRS thereby allows the clinician to consider nonphysical attributes essential to a person’s self-maintenance and well-being, such as cognition and language,4 social functioning,11 and poststroke mood disturbances, particularly depression, that may contribute to perceived disability.12 This allowance for consideration of IADLs and other nonphysical characteristics distinguishes the mRS from BADL-specific measures, such as the Barthel Index (BI).13{dagger}

Test-Retest Reliability
Reliability refers to the extent to which a scale consistently and reproducibly measures the attributes it was intended to measure. Test-retest reliability evaluates the consistency of results over time in the absence of changes in the subject population and the raters.14 The {kappa} statistic indicates the extent of agreement among different sets of results not occurring by chance; a weighted {kappa} adjusts for the extent of disagreement, eg, differences of 1 grade versus 2 grades of the scale.{ddagger}

Strong test-re-test reliability of the mRS was reported in 2 independent studies (Table 2). In 1 investigation, 2 raters each graded 48 patients on 2 separate occasions with excellent consistency.15


View this table:
[in this window]
[in a new window]

  		TABLE 2. Reliability of the mRS With and Without Structured Interviews

Inter-Rater Reliability
Inter-rater reliability evaluates the consistency of results among raters. Because mRS categories are broad and the assessments are subjective, variability may occur across clinical raters. In 3 separate studies, inter-rater reliability of the mRS ranged from moderate to nearly perfect, indicated by the weighted {kappa} (Table 2). In addition to those studies, strong inter-rater reliability has also been reported for a German version of the mRS ({kappa}=0.76).16 Structured interviews have been shown to improve inter-rater reliability of the mRS.5,15,17 When used in a RCT setting, training and certification of raters should be considered to reduce inter-rater variability.

Validity
Validity is the degree to which an instrument measures the concept it was intended to measure. Construct validity is applied when a gold standard does not exist. This type of validity assessment uses multiple sources of comparison to test how accurately a measure captures the outcome it claims to measure in different contexts. Convergent (criterion) validity, a fundamental aspect of construct validity, measures the degree of correlation between different measures of the same construct. Other forms of validity include predictive validity (ability to predict future events)6,14 and theoretical validity (degree to which results are consistent with a priori expectations).18 In this report we focus on construct and convergent validity, clinical sensitivity and limitations, and then consider the application of the mRS in clinical trials of acute ischemic stroke treatments.

Construct Validity: Relationship to Stroke Severity
Construct validity of the mRS has been affirmed by multiple studies in which it has been consistently observed that the location, type and extent of stroke injury are closely related to short and longer-term disability (Table 3; detail in supplemental Table I, available online at http://stroke.ahajournals.org). Numerous investigations have reported an increased risk of poor outcome (defined as mRS >2 or >3) from discharge to 6 months for more severe types of stroke.19–28 For example, a study of 198 younger ischemic stroke patients showed that total anterior circulation infarction was an independent predictor of mRS grade ≥2 or death at 3 months (P=0.011).22 Similar results have been reported for older stroke populations.27,28


View this table:
[in this window]
[in a new window]

  		TABLE 3. Summary of mRS Construct Validity


View this table:
[in this window]
[in a new window]

  		TABLE I. Summary of Evidence on the Construct Validity of the Original and Modified Rankin Scales(a)**

Studies in small patient series have consistently shown significant relationships between lesion volume (measured by diffusion-weighted and other imaging methods) and mRS grades (Table 3; detail in supplemental Table I), with larger lesions predicting more severe disability.20,29–34 As would be reasonably expected, improved brain perfusion and recanalization after thrombolytic therapy are also associated with improved mRS disability outcomes.21,33,35,36 For example, in a study of 177 acute ischemic stroke patients, recanalization within 5 hours post–recombinant tissue plasminogen activator treatment (in addition to National Institutes of Health Stroke Scale [NIHSS] baseline scores and other factors) independently predicted mRS grade ≤2 at 3 months poststroke (odds ratio=4.11, 95% CI=2.42 to 6.95; P<0.001).21

Multivariate regression analyses have demonstrated that acute impairment score (measured with the NIHSS,20–22,37 Canadian Neurological Scale,26,38 Mathew scale,31 Los Angeles Motor Scale,39 or European Stroke Scale40) independently predict mRS grade at 2 months to 1 year poststroke (detail in supplemental Table I). For example, Demchuk and coworkers observed that patients with the mildest strokes (NIHSS score 1 to 5) compared with those with more severe strokes (NIHSS scores 11 to 15, 16 to 20, >20) had improved chances of achieving a favorable outcome defined by mRS grade 0 to 1 (95% CI=0.02 to 0.16, P<0.001; 95% CI=0.13 to 0.56, P<0.001; 95% CI=0.20 to 0.79, P=0.008, respectively).41 Transitions in mRS grades have also been shown to correspond to transitions in NIHSS scores during stroke recovery.11 Consistent with these observations, moderate to strong correlations (Pearson r=0.60 to 0.86) between acute impairment and mRS grades at discharge or follow-up have also been reported.38,40,42,43 Specific impairments that appear to contribute significantly to the more severe mRS grades include those involving alertness, orientation, leg motor function, following commands, and arm and hand function (detail in supplemental Table I).23,44,45

Convergent Validity: Relationship to Other Disability Scales
Convergent validity of the mRS has been demonstrated by comparisons with other disability scales used to evaluate stroke patients, including the American Heart Association’s Stroke Outcomes Classification (AHA.SOC), the BI, the motor component of the Functional Independence Measure (m-FIM), the Short Form-36 (SF-36), and the Stroke Impact Scale (SIS; Table 4; detail in supplemental Table II, available online at http://stroke.ahajournals.org).8,11,43,46–48 For example, using stroke registry data, Kwon and coworkers quantified the frequency distribution of BI scores relative to mRS grades and showed that the highest BI scores (95 to 100, indicating excellent to complete recovery) correspond to mRS grades 0, 1 and 2.46


View this table:
[in this window]
[in a new window]

  		TABLE 4. Summary of Convergent Validity


View this table:
[in this window]
[in a new window]

  		TABLE II. Summary of Evidence on the Convergent Validity of the Original and Modified Rankin Scales(a)

The particular relationship between the BI and the mRS has been explored in detailed investigations,7,8,46,48 reflecting the common use of these scales as end points in acute stroke treatment RCTs. Post hoc and quantitative translations between mRS grades and BI scores have been derived to facilitate comparisons among trial results.7,48 Whereas the correlation between trial end points of both scales is strong (r=0.89, P<0.001),43 their different structures, domains and scoring methods provide distinctive information. As described previously, the BI measures dependence in 10 BADLs, whereas the mRS captures higher functioning in addition to aspects of self-care. Eight of the ten BI domains reflect voluntary motor functions (see footnote{dagger}). However, poststroke disability can also affect speech, language or cognitive function.49 For example, a patient with substantial communication problems may still score ≥90 on the BI. This "ceiling effect" is a major disadvantage of the BI relative to a global disability instrument.9,45,46,49–51 Data from a large prospective cohort study of stroke patients demonstrated the limitations of the BI in mild stroke patients.45 The mRS was also reported to be more sensitive for distinguishing between mild and moderate disability, which suggests it may also be more sensitive to acute stroke treatment effects.45

Clinical Sensitivity
The clinical sensitivity or responsiveness of an instrument refers to its ability to detect a clinically important change.52 Limited information is available regarding the sensitivity of the mRS to changes in disability levels after a stroke. In a rehabilitation setting the sensitivity of 2 global disability measures, the mRS and the International Stroke Trial Measure (ISTM),53 and 2 ADL measures, the BI and FIM,54 were tested and compared in a nonrandom sample of 95 moderately disabled stroke patients.52 A change of one mRS grade was considered to be clinically significant based on the range of severity covered by the scale grades. Although the mRS was shown to be more sensitive than the ISTM (P<0.001), it was less sensitive than either the BI (P<0.002) or the FIM (P<0.005), with the latter being the most sensitive of the 4 instruments under the conditions of the study. On this basis, the authors recommended the use of ADL scales for stroke intervention trials. However, other analyses (see below) based on treatment effects anticipated in the acute stroke setting suggest that those effects may be better detected using the mRS.

Limitations
A number of limitations apply to the mRS when used to measure disability outcome after stroke. A substantial literature documents the negative effect of patient comorbidities (including cardiovascular disease, diabetes, and arthritis),55–58 surgery,59 and socioeconomic factors60 on physical functioning, cognitive abilities,58 and overall health status, factors that may have a direct impact on the mRS.59 This is particularly important because comorbidities are common in stroke patients and the incidence of stroke in socioeconomically disadvantaged populations is especially high.61 It is essential for the clinician to take these various attributes into account to avoid misapplication and misinterpretation of the mRS.

End Point in Clinical Trials
The mRS has been used often as an end point in RCTs of acute ischemic stroke treatments based on its straightforward application, acceptable inter-rater reliability, and ability to discriminate levels of stroke disability.45,46 Studies have found that the sample size requirements of trials using mRS-based end points are smaller than BI-based end points without the loss of statistical power.50,62 For example, the sample required for a neuroprotectant RCT using a mRS end point (dichotomized at grade ≤1) was estimated to be 38% of that required for a BI end point (dichotomized at ≥60).50

Optimizing mRS end points for acute stroke treatment RCTs involves careful definition and appropriate statistical analyses. A "favorable" outcome defined as mRS grade ≤1 or ≤2 was estimated to be more powerful than dichotomization at higher grades.3,63,64 The importance of the cut-point for dichotomization was illustrated in a post hoc analysis of the ECASS II trial of alteplase. This study found that expanding the definition of "favorable" outcome from mRS grade ≤1 to grade ≤2 changed a statistically insignificant result to a significant one.3,64 Concerns over dichotomized end points center on the risk of failure to detect the impact of treatment. In a prospective study of 459 stroke patients, 116 subjects had transitioned from a baseline mRS score of 5 to a 3-month score of 4 or 3; or, from a baseline score of 4 to a 3-month score of 3.11 If those observations apply to RCTs, the reported shifts in mRS grades of more severe stroke patients toward reduced disability may not be captured by an end point defined as mRS ≤2,11 even though all mRS grade transitions are considered to be clinically meaningful.65

Transition across the entire mRS grade spectrum has been proposed as a more comprehensive measure of impact for acute stroke interventions.11,66 This type of analysis uses the entire data set and has the advantage of reflecting simultaneously the risk and benefit of an intervention compared with an analysis based on a dichotomized end point. The SAINT I trial of the neuroprotectant NXY-059 for acute ischemic stroke exemplifies this approach.65 In this trial, the primary end point was prespecified as the mRS grade at 90 days (or last rating) with the analysis based on the overall difference in grade distribution of the 2 treatment groups.


*    Summary and Conclusions
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 *Summary and Conclusions
down arrowReferences
 
A large and diverse literature supports the view that the mRS is a valid and clinically relevant instrument for assessing recovery from stroke and is a valuable end point for RCTs of acute ischemic stroke treatments. The scale consists of well-defined and easily understood grades that describe the range of global disability. When properly administered, the mRS exhibits a strong relationship with clinical measurements of stroke severity in addition to other disability and outcomes end points. However, clinicians should be aware that mRS grading may be affected by a variety of factors, including patient comorbidities and socioeconomic status. Use of the mRS in RCTs may benefit from a carefully defined end point as well as from a form of statistical analysis that is most likely to accurately reflect the effect of treatment.


*    Acknowledgments
 
The authors gratefully acknowledge the financial sponsorship of AstraZeneca LP. We greatly appreciate the contributions of Chris Pashos, PhD for his review and comments and of Yoko Komatsuzaki, MPH, Er Chen, MPP, Yu-Chen Yeh, MS and Cassie Cai, MS, MS for their administrative and editorial assistance.

Disclosures

None.


*    Footnotes
 
*The mRS was not developed for the acute assessment of stroke. For example, the scale would have limited value if it were used in the acute setting as illustrated by assigning a patient with a mild stroke mRS grade 4 or 5 on the basis of the need for nursing care and supervision. Back

{dagger}The Barthel Index ADL items are: feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfers, mobility, stairs.13 Back

{ddagger}Strength of agreement for the {kappa} statistic has been categorized as follows: <0=poor; 0–0.20=slight; 0.21–0.40=fair; 0.41–0.60=moderate; 0.61–0.80=substantial; 0.81–1.00=almost perfect.67 Back

Received August 29, 2006; revision received October 5, 2006; accepted October 6, 2006.


*    References
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 up arrowSummary and Conclusions
 *References
 

  1. Rankin L. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 1957; 2: 200–215.[Medline] [Order article via Infotrieve]
  2. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van GJ. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988; 19: 604–607.[Abstract/Free Full Text]
  3. Sulter G, Steen C, De KJ. Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke. 1999; 30: 1538–1541.[Abstract/Free Full Text]
  4. De Haan R, Limburg M, Bossuyt P, Van Der MJ, Aaronson N. The clinical meaning of Rankin ‘handicap’ grades after stroke. Stroke. 1995; 26: 2027–2030.[Abstract/Free Full Text]
  5. Wilson JT, Hareendran A, Grant M, Baird T, Schulz UG, Muir KW, Bone I. Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke. 2002; 33: 2243–2246.[Abstract/Free Full Text]
  6. Wade DT. Measurement in Neurological Rehabilitation. New York: Oxford University Press; 1992.
  7. Wolfe CD, Taub NA, Woodrow EJ, Burney PG. Assessment of scales of disability and handicap for stroke patients. Stroke. 1991; 22: 1242–1244.[Abstract/Free Full Text]
  8. Duncan PW, Wallace D, Lai SM, Johnson D, Embretson S, Laster LJ. The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change. Stroke. 1999; 30: 2131–2140.[Medline] [Order article via Infotrieve]
  9. Uyttenboogaart M, Stewart RE, Vroomen PC, De KJ, Luijckx GJ. Optimizing cutoff scores for the Barthel index and the modified Rankin scale for defining outcome in acute stroke trials. Stroke. 2005; 36: 1984–1987.[Abstract/Free Full Text]
  10. Bonita R, Beaglehole R. Recovery of motor function after stroke. Stroke. 1988; 19: 1497–1500.[Abstract/Free Full Text]
  11. Lai SM, Duncan PW. Stroke recovery profile and the Modified Rankin assessment. Neuroepidemiology. 2001; 20: 26–30.[CrossRef][Medline] [Order article via Infotrieve]
  12. Dennis M, O’Rourke S, Lewis S, Sharpe M, Warlow C. Emotional outcomes after stroke: factors associated with poor outcome. J Neurol Neurosurg Psychiatry. 2000; 68: 47–52.[Abstract/Free Full Text]
  13. Mahoney F, Barthel D. Functional evaluation: the Barthel Index. Md State Med J. 1965; 14: 61–65.[Medline] [Order article via Infotrieve]
  14. McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires (2nd edition). New York: Oxford University Press; 1996.
  15. Wilson JT, Hareendran A, Hendry A, Potter J, Bone I, Muir KW. Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview. Stroke. 2005; 36: 777–781.[Abstract/Free Full Text]
  16. Berger K, Weltermann B, Kolominsky-Rabas P, Meves S, Heuschmann P, Bohner J, Neundorfer B, Hense HW, Buttner T. The reliability of stroke scales: the German version of NIHSS, ESS and Rankin scales. Fortschr Neurol Psychiatr. 1999; 67: 81–93.[Medline] [Order article via Infotrieve]
  17. Newcommon NJ, Green TL, Haley E, Cooke T, Hill MD. Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke. 2003; 34: 377–378.[Free Full Text]
  18. Ryan M, Scott DA, Reeves C, Bate A, van Teijlingen ER, Russell EM, Napper M, Robb CM. Eliciting public preferences for healthcare: a systematic review of techniques. Health Technol Assess. 2001; 5: 1–186.[Medline] [Order article via Infotrieve]
  19. Dawson SL, Manktelow BN, Robinson TG, Panerai RB, Potter JF. Which parameters of beat-to-beat blood pressure and variability best predict early outcome after acute ischemic stroke? Stroke. 2000; 31: 463–468.[Abstract/Free Full Text]
  20. Derex L, Nighoghossian N, Hermier M, Adeleine P, Berthezene Y, Philippeau F, Honnorat J, Froment JC, Trouillas P. Influence of pretreatment MRI parameters on clinical outcome, recanalization and infarct size in 49 stroke patients treated by intravenous tissue plasminogen activator. J Neurol Sci. 2004; 225: 3–9.[CrossRef][Medline] [Order article via Infotrieve]
  21. Molina CA, Alexandrov AV, Demchuk AM, Saqqur M, Uchino K, varez-Sabin J. Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator. Stroke. 2004; 35: 151–156.[Abstract/Free Full Text]
  22. Nedeltchev K, der Maur TA, Georgiadis D, Arnold M, Caso V, Mattle HP, Schroth G, Remonda L, Sturzenegger M, Fischer U, Baumgartner RW. Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry. 2005; 76: 191–195.[Abstract/Free Full Text]
  23. Paciaroni M, Arnold P, Van MG, Bogousslavsky J. Severe disability at hospital discharge in ischemic stroke survivors. Eur Neurol. 2000; 43: 30–34.[CrossRef][Medline] [Order article via Infotrieve]
  24. Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Ischemic stroke subtypes: a population-based study of functional outcome, survival, and recurrence. Stroke. 2000; 31: 1062–1068.[Abstract/Free Full Text]
  25. Pinto AN, Melo TP, Lourenco ME, Leandro MJ, Brazio A, Carvalho L, Franco AS, Ferro JM. Can a clinical classification of stroke predict complications and treatments during hospitalization? Cerebrovasc Dis. 1998; 8: 204–209.[CrossRef][Medline] [Order article via Infotrieve]
  26. Sumer MM, Ozdemir I, Tascilar N. Predictors of outcome after acute ischemic stroke. Acta Neurol Scand. 2003; 107: 276–280.[CrossRef][Medline] [Order article via Infotrieve]
  27. Tei H, Uchiyama S, Ohara K, Kobayashi M, Uchiyama Y, Fukuzawa M. Deteriorating ischemic stroke in 4 clinical categories classified by the Oxfordshire Community Stroke Project. Stroke. 2000; 31: 2049–2054.[Abstract/Free Full Text]
  28. Ueda T, Sakaki S, Kumon Y, Ohta S. Multivariable analysis of predictive factors related to outcome at 6 months after intra-arterial thrombolysis for acute ischemic stroke. Stroke. 1999; 30: 2360–2365.[Medline] [Order article via Infotrieve]
  29. Kluytmans M, van Everdingen KJ, Kappelle LJ, Ramos LM, Viergever MA, van der GJ. Prognostic value of perfusion- and diffusion-weighted MR imaging in first 3 days of stroke. Eur Radiol. 2000; 10: 1434–1441.[CrossRef][Medline] [Order article via Infotrieve]
  30. Barber PA, Parsons MW, Desmond PM, Bennett DA, Donnan GA, Tress BM, Davis SM. The use of PWI and DWI measures in the design of "proof-of-concept" stroke trials. J Neuroimaging. 2004; 14: 123–132.[CrossRef][Medline] [Order article via Infotrieve]
  31. Vila N, Filella X, Deulofeu R, Ascaso C, Abellana R, Chamorro A. Cytokine-induced inflammation and long-term stroke functional outcome. J Neurol Sci. 1999; 162: 185–188.[CrossRef][Medline] [Order article via Infotrieve]
  32. Parsons MW, Li T, Barber PA, Yang Q, Darby DG, Desmond PM, Gerraty RP, Tress BM, Davis SM. Combined (1)H MR spectroscopy and diffusion-weighted MRI improves the prediction of stroke outcome. Neurology. 2000; 55: 498–505.[Abstract/Free Full Text]
  33. Lev MH, Segal AZ, Farkas J, Hossain ST, Putman C, Hunter GJ, Budzik R, Harris GJ, Buonanno FS, Ezzeddine MA, Chang Y, Koroshetz WJ, Gonzalez RG, Schwamm LH. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke. 2001; 32: 2021–2028.[Abstract/Free Full Text]
  34. van Everdingen KJ, van der GJ, Kappelle LJ, Ramos LM, Mali WP. Diffusion-weighted magnetic resonance imaging in acute stroke. Stroke. 1998; 29: 1783–1790.[Abstract/Free Full Text]
  35. Chalela JA, Kang DW, Luby M, Ezzeddine M, Latour LL, Todd JW, Dunn B, Warach S. Early magnetic resonance imaging findings in patients receiving tissue plasminogen activator predict outcome: insights into the pathophysiology of acute stroke in the thrombolysis era. Ann Neurol. 2004; 55: 105–112.[CrossRef][Medline] [Order article via Infotrieve]
  36. Liu Y, Karonen JO, Vanninen RL, Nuutinen J, Koskela A, Soimakallio S, Aronen HJ. Acute ischemic stroke: predictive value of 2D phase-contrast MR angiography–serial study with combined diffusion and perfusion MR imaging. Radiology. 2004; 231: 517–527.[Abstract/Free Full Text]
  37. Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17: 21–27.[Medline] [Order article via Infotrieve]
  38. Fiorelli M, Alperovitch A, Argentino C, Sacchetti ML, Toni D, Sette G, Cavalletti C, Gori MC, Fieschi C; Italian Acute Stroke Study Group. Prediction of long-term outcome in the early hours following acute ischemic stroke. Arch Neurol. 1995; 52: 250–255.[Abstract]
  39. Llanes JN, Kidwell CS, Starkman S, Leary MC, Eckstein M, Saver JL. The Los Angeles Motor Scale (LAMS): a new measure to characterize stroke severity in the field. Prehosp Emerg Care. 2004; 8: 46–50.[Medline] [Order article via Infotrieve]
  40. Hantson L, De Weerdt W, De Keyser J, Diener HC, Franke C, Palm R, Van Orshoven M, Schoonderwalt H, De Klippel N, Herroelen L. The European Stroke Scale. Stroke. 1994; 25: 2215–2219.[Abstract]
  41. Demchuk AM, Tanne D, Hill MD, Kasner SE, Hanson S, Grond M, Levine SR. Predictors of good outcome after intravenous tPA for acute ischemic stroke. Neurology. 2001; 57: 474–480.[Abstract/Free Full Text]
  42. De Haan R, Horn J, Limburg M, Van Der MJ, Bossuyt P. A comparison of five stroke scales with measures of disability, handicap, and quality of life. Stroke. 1993; 24: 1178–1181.[Abstract/Free Full Text]
  43. Lai SM, Duncan PW. Evaluation of the American Heart Association Stroke Outcome Classification. Stroke. 1999; 30: 1840–1843.[Abstract/Free Full Text]
  44. Appelros P, Nydevik I, Viitanen M. Poor outcome after first-ever stroke: predictors for death, dependency, and recurrent stroke within the first year. Stroke. 2003; 34: 122–126.[Abstract/Free Full Text]
  45. Weimar C, Kurth T, Kraywinkel K, Wagner M, Busse O, Haberl RL, Diener HC. Assessment of functioning and disability after ischemic stroke. Stroke. 2002; 33: 2053–2059.[Abstract/Free Full Text]
  46. Kwon S, Hartzema AG, Duncan PW, Min-Lai S. Disability measures in stroke: relationship among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale. Stroke. 2004; 35: 918–923.[Abstract/Free Full Text]
  47. Lai SM, Perera S, Duncan PW, Bode R. Physical and social functioning after stroke: comparison of the Stroke Impact Scale and Short Form-36. Stroke. 2003; 34: 488–493.[Abstract/Free Full Text]
  48. Parmigiani G, Ashih HW, Samsa GP, Duncan PW, Lai SM, Matchar DB. Cross-calibration of stroke disability measures: Bayesian analysis of longitudinal ordinal categorical data using negative dependence. J Am Stat Assoc. 2003; 98: 273–281.[CrossRef]
  49. Kelly-Hayes M, Robertson JT, Broderick JP, Duncan PW, Hershey LA, Roth EJ, Thies WH, Trombly CA. The American Heart Association Stroke Outcome Classification. Stroke. 1998; 29: 1274–1280.[Free Full Text]
  50. Young FB, Lees KR, Weir CJ. Strengthening acute stroke trials through optimal use of disability end points. Stroke. 2003; 34: 2676–2680.[Abstract/Free Full Text]
  51. Duncan PW, Lai SM, Bode RK, Perera S, DeRosa J. Stroke Impact Scale-16: A brief assessment of physical function. Neurology. 2003; 60: 291–296.[Abstract/Free Full Text]
  52. Dromerick AW, Edwards DF, Diringer MN. Sensitivity to changes in disability after stroke: a comparison of four scales useful in clinical trials. J Rehabil Res Dev. 2003; 40: 1–8.[CrossRef][Medline] [Order article via Infotrieve]
  53. Lindley R. Very simple methods of assessing outcome after stroke can be valid. Cerebrovasc Dis. 1992; 2: 209.
  54. Guide for the Uniform Data Set for Medical Rehabilitation. Uniform Data System for Medical Rehabilitation. 1993.
  55. Lai S, Studenski S, Duncan PW, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke. 2002; 249: 1160–1167.
  56. Lalonde L, O’Connor A, Joseph L, Growver SA, Group CCCA. Health-related quality of life in cardiac patients with dyslipidemia and hypertension. Qual Life Res. 2004; 13: 793–804.[CrossRef][Medline] [Order article via Infotrieve]
  57. MacKenzie AE, Chang AM. Predictors of quality of life following stroke. Disabil Rehabil. 2002; 24: 259–265.[CrossRef][Medline] [Order article via Infotrieve]
  58. Nichols-Larsen DS, Clark PC, Zeriongue A, Greenspan A, Blanton. Factors influencing stroke survivors’ quality of life during subacute recovery. Stroke. 2005; 36: 1480–1484.[Abstract/Free Full Text]
  59. Rojas M, Silver A, Llewellyn C, Rances L. A study of adverse occurrences and major functional impairment following surgery. Agency for Healthcare Research and Quality, Rockville, MD, US Department of Health and Human Services, May 2005.
  60. Horner RD, Swanson JW, Bosworth HB, Matchar DB. VA Acute Stroke Study Team (VAST). Effects of race and poverty on the process and outcome of inpatient rehabilitation services among stroke patients. Stroke. 2003; 34: 1027–1031.[Abstract/Free Full Text]
  61. Gresham GE, Phillips TF, Wolf PA, McNamara PM, Kannel WB, Dawber TR. Epidemiologic profile of long-term stroke disability: the Framingham Study. Arch Phys Med Rehabil. 1979; 60: 487–491.[Medline] [Order article via Infotrieve]
  62. Sacco RL, DeRosa JT, Haley EC Jr, Levin B, Ordronneau P, Phillips SJ, Rundek T, Snipes RG, Thompson JL. Glycine antagonist in neuroprotection for patients with acute stroke: GAIN Americas: a randomized controlled trial. JAMA. 2001; 285: 1719–1728.[Abstract/Free Full Text]
  63. Broderick JP, Lu M, Kothari R, Levine SR, Lyden PD, Haley EC, Brott TG, Grotta J, Tilley BC, Marler JR, Frankel M. Finding the most powerful measures of the effectiveness of tissue plasminogen activator in the NINDS tPA stroke trial. Stroke. 2000; 31: 2335–2341.[Abstract/Free Full Text]
  64. Hacke W, Kaste M, Fieschi C, von KR, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, ez-Tejedor E, Trouillas P. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998; 352: 1245–1251.[CrossRef][Medline] [Order article via Infotrieve]
  65. Lees KR, Zivin JA, Ashwood T, Davalos A, Davis SM, Diener HC, Grotta J, Lyden P, Shuaib A, Hardemark HG, Wasiewski WW. NXY-059 for acute ischemic stroke. N Engl J Med. 2006; 354: 588–600.[Abstract/Free Full Text]
  66. Saver JL. Number needed to treat estimates incorporating effects over the entire range of clinical outcomes: novel derivation method and application to thrombolytic therapy for acute stroke. Arch Neurol. 2004; 61: 1066–1070.[Abstract/Free Full Text]
  67. Feinstein AR. Clinimetrics. New Haven, Connecticut: Yale University Press; 1987.



This article has been cited by other articles:


Home page
 StrokeHome page
T. J. Quinn, J. Dawson, M. R. Walters, and K. R. Lees
Reliability of the Modified Rankin Scale
Stroke, November 1, 2007; 38(11): e144 - e144.
[Full Text] [PDF]

Home page
 StrokeHome page
J. L. Banks and C. A. Marotta
Response to Letter by Quinn et al
Stroke, November 1, 2007; 38(11): e145 - e145.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
38/3/1091    most recent
01.STR.0000258355.23810.c6v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Banks, J. L.
Right arrow Articles by Marotta, C. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Banks, J. L.
Right arrow Articles by Marotta, C. A.
Related Collections
Right arrow Health policy and outcome research
Right arrow Neuroprotectors
Right arrow Thrombolysis
Right arrow Cerebrovascular disease/stroke

Stroke Home | Subscriptions | Archives | Feedback | Authors | Help | AHA Journals Home | Search
Copyright © 2007 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.