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Gardener H, Romano LA, Smith EE, Campo-Bustillo I, Khan Y, Tai S, Riley N, Sacco RL, Khatri P, Alger HM, Mac Grory B, Gulati D, Sangha NS, Olds KE, Benesch CG, Kelly AG, Brehaut SS, Kansara AC, Schwamm LH, Romano JG. Functional status at 30 and 90 days after mild ischaemic stroke. Stroke Vasc Neurol 2022; 7:svn-2021-001333. [PMID: 35474180 PMCID: PMC9614160 DOI: 10.1136/svn-2021-001333] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/23/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/OBJECTIVE This study compares the global disability status of patients who had a mild ischaemic stroke at 30 and 90 days poststroke, as measured by the modified Rankin Scale (mRS), and identifies predictors of change in disability status between 30 and 90 days. METHODS The study population included 1339 patients who had a ischaemic stroke enrolled in the Mild and Rapidly Improving Stroke Study with National Institutes of Health (NIH) stroke score 0-5 and mRS measurements at 30 and 90 days. Outcomes were (1) Improvement defined as having mRS >1 at 30 days and mRS 0-1 at 90 days OR mRS >2 at 30 days and mRS 0-2 at 90 days and (2) Worsening defined as an increase of ≥2 points or a worsening from mRS of 1 at 30 days to 2 at 90 days. Demographic and clinical characteristics at hospital arrival were abstracted from medical records, and regression models were used to identify predictors of functional improvement and decline from 30 to 90 days post-stroke. Significant predictors were mutually adjusted in multivariable models that also included age and stroke severity. RESULTS Fifty-seven per cent of study participants had no change in mRS value from 30 to 90 days. Overall, there was moderate agreement in mRS between the two time points (weighted kappa=0.59 (95% CI 0.56 to 0.62)). However, worsening on the mRS was observed in 7.54% of the study population from 30 to 90 days, and 17.33% improved. Participants of older age (per year OR 1.02, 95% CI 1.00 to 1.03), greater stroke severity (per NIH Stroke Scale (NIHSS) point at admission OR 1.17, 95% CI 1.03 to 1.34), and those with no alteplase treatment (OR 1.72, 95% CI 1.11 to 2.69) were more likely to show functional decline after mutual adjustment. DISCUSSION A quarter of all mild ischaemic stroke participants exhibited functional changes between 30 and 90 days, suggesting that the 30-day outcome may insufficiently represent long-term recovery in mild stroke and longer follow-up may be clinically necessary. TRIAL REGISTRATION NUMBER NCT02072681.
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Affiliation(s)
- Hannah Gardener
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Leo A Romano
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric E Smith
- Hotchkiss Brain Institute, Univ Calgary, Calgary, Alberta, Canada
| | | | - Yosef Khan
- American Heart Association, American Heart Association, Dallas, Texas, USA
| | - Sofie Tai
- American Heart Association, American Heart Association, Dallas, Texas, USA
| | - Nikesha Riley
- American Heart Association, American Heart Association, Dallas, Texas, USA
| | - Ralph L Sacco
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pooja Khatri
- Neurology and Rehabilitation Medicine, Univ Cincinnati, Cincinnati, Ohio, USA
| | - Heather M Alger
- American Heart Association, American Heart Association, Dallas, Texas, USA
| | - Brian Mac Grory
- Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Deepak Gulati
- Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Neurology, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Navdeep S Sangha
- Neurology, Los Angeles Medical Center, Los Angeles, California, USA
| | - Karin E Olds
- Neurology, St Luke's Hospital, Kansas City, Missouri, USA
| | | | - Adam G Kelly
- Neurology, University of Rochester, Rochester, New York, USA
| | - Scott S Brehaut
- Stroke Center, Faxton St. Luke's Healthcare, Utica, New York, USA
| | - Amit C Kansara
- Neurology, Providence St Vincent Medical Center, Portland, Oregon, USA
| | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jose G Romano
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Romano JG, Gardener H, Smith EE, Campo-Bustillo I, Khan Y, Tai S, Riley N, Sacco RL, Khatri P, Alger HM, Mac Grory B, Gulati D, Sangha NS, Olds KE, Benesch CG, Kelly AG, Brehaut SS, Kansara AC, Schwamm LH. Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke. Stroke 2021; 53:482-487. [PMID: 34645285 DOI: 10.1161/strokeaha.121.034124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. METHODS A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines-Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. RESULTS Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. CONCLUSIONS Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02072681.
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Affiliation(s)
- Jose G Romano
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Hannah Gardener
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Iszet Campo-Bustillo
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Yosef Khan
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Sofie Tai
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Nikesha Riley
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Ralph L Sacco
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | | | - Heather M Alger
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | | | - Deepak Gulati
- Ohio State University Wexner Medical Center, Columbus (D.G.)
| | | | | | | | - Adam G Kelly
- University of Rochester Medical Center, NY (C.G.B., A.G.K.)
| | | | - Amit C Kansara
- Providence St. Vincent Medical Center, Portland, OR (A.C.K.)
| | - Lee H Schwamm
- Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
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Romano JG, Gardener H, Campo-Bustillo I, Khan Y, Tai S, Riley N, Smith EE, Sacco RL, Khatri P, Alger HM, Mac Grory B, Gulati D, Sangha NS, Craig JM, Olds KE, Benesch CG, Kelly AG, Brehaut SS, Kansara AC, Schwamm LH. Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS. Stroke 2021; 52:1995-2004. [PMID: 33947209 DOI: 10.1161/strokeaha.120.032809] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jose G Romano
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Hannah Gardener
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Iszet Campo-Bustillo
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Yosef Khan
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Sofie Tai
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Nikesha Riley
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K.)
| | - Heather M Alger
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC (B.M.G.)
| | - Deepak Gulati
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus (D.G.)
| | | | | | - Karin E Olds
- Department of Neurology, St. Luke's Hospital, Kansas City, MO (K.E.O.)
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, NY (C.G.B., A.G.K.)
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, NY (C.G.B., A.G.K.)
| | | | - Amit C Kansara
- Providence St. Vincent Medical Center, Portland, OR (A.C.K.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
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