Prediction of outcome after stroke

Plasma bioactive adrenomedullin predicts outcome after acute stroke in early rehabilitation

An early and reliable prediction of outcomes after stroke is important for early effective stroke management and the adequate optimal planning of post-stroke rehabilitation and long-term care. Bioactive adrenomedullin (bio-ADM) is a 52-amino acid peptide that is an important peptide hormone in nervous system diseases. The aim of this study was to investigate the prognostic value of bio-ADM on outcomes after rehabilitation in patients with stroke. A total of 557 consecutive patients with a primary diagnosis of ischemic or hemorrhagic stroke (age 69.6-12.9 years, male 51.3%, ischemic stroke 72.5%), who were admitted to an in-patient early rehabilitation center directly after discharge from acute stroke hospital care, were enrolled in this prospective observational study. Plasma concentrations of bio-ADM were determined by using a chemiluminescence immunoassay (functional assay sensitivity 8 pg/ml). The early rehabilitation barthel index (ERBI) was used for the neurological assessment of the patients. The plasma bio-ADM level was analyzed in association with 6-month all-cause mortality as well as a composite outcome of all-cause mortality, unscheduled re-hospitalization, or transfer to a long-term care facility in a vegetative or minimally conscious state. Bio-ADM levels significantly increased in patients with ischemic stroke who died compared to surviving patients (40.4 pg/ml vs. 23.8 pg/ml, p < 0.001) or in those with composite outcomes compared to those with no events (36.9 pg/ml vs. 23.5 pg/ml, p < 0.001). Six-month all-cause mortality was higher in all patients with bio-ADM levels > 70 pg/ml (HR 4.83 [CI 2.28-10.2]). Patients with bio-ADM levels > 70 pg/ml also had higher rates of 6-month composite outcomes (HR 3.82 [CI 2.08-7.01]). Bio-ADM was an independent predictor of all-cause mortality and 6-month composite outcomes after adjusting for age, gender, and ERBI (adjusted OR 1.5; 95% CI 1.0-2.1; p = 0.047 and adjusted OR 1.48; 95% CI 1.1-2.0; p = 0.01, respectively). Bio-ADM may be a suitable novel biomarker to assess the outcomes of patients in rehabilitation after acute stroke. Elevated bio-ADM concentrations may have prognostic value for fatal and nonfatal events in patients with ischemic stroke during early rehabilitation.

The crossed leg sign indicates a favorable outcome after severe stroke

OBJECTIVE

We investigated whether crossed legs are a prognostic marker in patients with severe stroke.

METHODS

In this controlled prospective observational study, we observed patients with severe stroke who crossed their legs during their hospital stay and matched them with randomly selected severe stroke patients who did not cross their legs. The patients were evaluated upon admission, on the day of leg crossing, upon discharge, and at 1 year after discharge. The Glasgow Coma Scale, the NIH Stroke Scale (NIHSS), the modified Rankin Scale (mRS), and the Barthel Index (BI) were obtained.

RESULTS

Patients who crossed their legs (n = 34) and matched controls (n = 34) did not differ in any scale upon admission. At the time of discharge, the GCS did not differ, but the NIHSS was better in crossed legs patients (6.5 vs 10.6; p = 0.0026), as was the mRS (3.4 vs 5.1, p < 0.001), and the BI (34.0 vs 21.1; p = 0.0073). At 1-year follow-up, mRS (2.9 vs 5.1, p < 0.001) and the BI (71.3 vs 49.2; p = 0.045) were also better in the crossed leg group. The mortality between the groups differed grossly; only 1 patient died in the crossing group compared to 18 in the noncrossing group (p < 0.001).

CONCLUSION

Leg crossing is an easily obtained clinical sign and is independent of additional technical examinations. Leg crossing within the first 15 days after severe stroke indicates a favorable outcome which includes less neurologic deficits, better independence in daily life, and lower rates of death.

Predicting long-term outcome after acute ischemic stroke: a simple index works in patients from controlled clinical trials

BACKGROUND AND PURPOSE

An early and reliable prognosis for recovery in stroke patients is important for initiation of individual treatment and for informing patients and relatives. We recently developed and validated models for predicting survival and functional independence within 3 months after acute stroke, based on age and the National Institutes of Health Stroke Scale score assessed within 6 hours after stroke. Herein we demonstrate the applicability of our models in an independent sample of patients from controlled clinical trials.

METHODS

The prognostic models were used to predict survival and functional recovery in 5419 patients from the Virtual International Stroke Trials Archive (VISTA). Furthermore, we tried to improve the accuracy by adapting intercepts and estimating new model parameters.

RESULTS

The original models were able to correctly classify 70.4% (survival) and 72.9% (functional recovery) of patients. Because the prediction was slightly pessimistic for patients in the controlled trials, adapting the intercept improved the accuracy to 74.8% (survival) and 74.0% (functional recovery). Novel estimation of parameters, however, yielded no relevant further improvement.

CONCLUSIONS

For acute ischemic stroke patients included in controlled trials, our easy-to-apply prognostic models based on age and National Institutes of Health Stroke Scale score correctly predicted survival and functional recovery after 3 months. Furthermore, a simple adaptation helps to adjust for a different prognosis and is recommended if a large data set is available.