Visual neglect as a predictor of functional outcome one year after stroke

OBJECTIVE: The aim was to study the role of visual neglect in acute right hemisphere brain infarct as a predictor of poor functional outcome during the first year after stroke. In particular, we were interested in the additional value of neglect measures besides hemiparesis, hemianopia, cognitive deficits and age. PATIENTS AND METHODS: A consecutive series of 57 patients with a neuroradiologically verified right hemisphere infarct was examined within 10 days of the stroke. Fifty patients were followed up for 1 year. Neglect was measured with the Conventional and the Behavioural subtests of the Behavioural Inattention Test (BITC and BITB, respectively). The predictors were determined at the 10-day examination. Functional outcome was assessed 3, 6 and 12 months after the onset with the Frenchay Activities Index. RESULTS: Neglect in BITB was the best single predictor, which together with high age formed the best combination of predictors for poor functional outcome at each follow-up. Hemiparesis was also included in this prediction model at the 3-month follow-up, but hemianopia, BITC, or visuoconstructional and memory deficits showed no additional predictive value. However, neglect usually recovered soon. When neurological and cognitive deficits were assessed at the same time as the outcome, hemiparesis rather than neglect was the strongest correlate of poor outcome. CONCLUSION: Neglect in acute stroke is an important predictor of poor functional recovery. Residual neglect, which could be compensated in the follow-up tests, may nevertheless restrict patients' real-life activities and hobbies.     

Age and functional outcome after stroke

The effect of age on functional outcome after stroke remains uncertain. Many studies have found that younger patients do better than older patients, whereas others have found minimal or no effect of age on rehabilitation outcomes. We examined the effect of advancing age on FIM trade mark gain, length of stay, length of stay efficiency, and home discharge in 979 stroke rehabilitation patients at a long-term acute care rehabilitation hospital. We found a strong relationship of increasing age to poorer outcome in all measures for patients with admission FIM (AFIM) score <40, a variable relationship in those with AFIM 40-80, and no relationship of age to the outcome measures in patients with AFIM >80.     

Visible infarction on computed tomography is an independent predictor of poor functional outcome after stroke,and not of haemorrhagic transformation

OBJECTIVES: To examine a very large dataset to provide a robust answer to the question of whether visible infarction on computed tomography was (a) an independent predictor of functional outcome at all times up to 48 hours after stroke, and (b) independently associated with haemorrhagic transformation, with or without antithrombotic treatment. METHODS: The study assessed associations between visible infarction, time to randomisation, baseline neurological deficit, stroke syndrome, allocated aspirin or heparin treatment, recurrent haemorrhagic stroke, early death and six month functional outcome in the International Stroke Trial. RESULTS: Of 12 550 patients, 6267 (50%) had visible infarction up to 48 hours after stroke. The prevalence of visible infarction increased with increasing time from onset and extent of the stroke syndrome. Visible infarction was independently associated with increased death within 14 days (odds ratio (OR) 1.17, 95% CI 1.02 to 1.35), and of death or dependency at six months (OR 1.42, 95% CI 1.31 to 1.55), an absolute increase of 13%, or 130 per 1000 more dead or dependent patients with visible infarction than without it. There was no significant independent relation between visible infarction and fatal or non-fatal haemorrhagic transformation, or interaction between visible infarction and aspirin or heparin treatment allocation with six month functional outcome. CONCLUSIONS: Visible infarction on computed tomography up to 48 hours after stroke is an independent adverse prognostic sign.     

Cardiac autonomic dysfunction and functional outcome after ischaemic stroke

ischaemic stroke has been associated with an impairment of cardiac autonomic balance. The aim of this study was to assess the impact of cardiac autonomic derangement on functional outcome after a rehabilitation program in patients with recent ischaemic stroke. The study population included 85 consecutive first-ever stroke survivors (46 men and 39 women; mean age 60.0 ± 12.4 years), who underwent 24-h Holter monitoring before the beginning of a 60-day rehabilitation program. Time-domain measures of heart-rate variability (HRV) were considered in all cases. By the end of the rehabilitation program an unfavorable functional outcome with dependency (Barthel Index score of <75) was found in 44.7% of patients. Multivariate analysis demonstrated that age [odds ratio (OR) 1.09, 95% CI 1.04–1.19, P  = 0.002], stroke severity (OR 1.12, 95% CI 1.01–1.34, P  = 0.004), Barthel Index score (OR 0.92, 95% CI 0.87–0.98, P  = 0.01) and Rankin Scale score (OR 3.88, 95% CI 2.13–7.56, P  = 0.02) on admission, as well as lower values of the standard deviation of normal-to-normal R wave to R wave (RR) intervals (OR 9.67, 95% CI 2.58–18.67, P  = 0.006) were independent predictors of an unfavorable functional outcome. Assessment of HRV before a rehabilitation program may provide additional information on the probability of a functional recovery in stroke survivors.     

Predicting functional outcome and survival after acute ischemic stroke

OBJECTIVE: Disability and mortality represent the most relevant clinical outcome after acute ischemic stroke. However, validated and comprehensive prognostic models for recovery have not been developed. An accurate model including all previously suggested independent outcome predictors could improve the design and analysis of clinical trials. We therefore developed prognostic models for functional dependence and death after 100 days in a large cohort of stroke patients. METHODS: From the German Stroke Database, 1754 prospectively collected records of patients with acute ischemic stroke were used for the development of prognostic models. Intubated patients and patients with low functional status before stroke were excluded. Functional independence was defined as a Barthel Index >/=95 after 100 days. Prognostic factors assessable within 72 hours after admission were identified by a systematic literature review. The final models of binary logistic regression analyses were internally validated and calibrated. RESULTS: The resulting cross-validated and calibrated models correctly classified more than 80 % of the patients and yielded the following prognostic factors for functional independence: Age, right and left arm paresis at admission, NIH-Stroke Scale at admission, Rankin Scale 48-72 hours later, gender, prior stroke, diabetes, fever, lenticulostriate infarction, neurological complications. The following variables were identified as prognostic factors for death: Age, NIH-Stroke Scale at admission, and fever. CONCLUSIONS: Our work gives an important insight into prognostic factors after acute ischemic stroke and presents predictive models with high prognostic accuracy. Together with a prospective validation study, currently underway, we hence hope to improve the prediction of functional outcome after ischemic stroke.     

Depression is an independent predictor of poor long-term functional outcome post-stroke

The influence of depression on the long-term outcome of stroke patients was examined among 390 of 486 consecutive patients aged 55-85 years. They completed, at 3 months after ischaemic stroke, a detailed medical, neurological, and radiological stroke evaluation, structured measures of emotion (Beck's Depression Inventory, BDI), handicap (Rankin scale, RS), and assessment of activities of daily living (Barthel Index, BI). Further RS and BI was evaluated at 15-month follow-up from these 390 patients and BDI in 276 patients. A group of 256 patients completed, in addition to the 15-month follow-up, a comprehensive psychiatric evaluation, including the Present State Examination 3 months after stroke. The DSM-III-R criteria were used for diagnosis of the depressive disorders. BDI identified depression (cut-off point > or = 10 for depression) in 171 (43.9%) of 390 and in 123 (44.6%) of 276 patients at 3- and 15-month follow-up. DSM-III-R major depression was diagnosed in 66 (25.8%), and minor depression in 32 (12.5%), of 256 patients 3 months after stroke. Patients with BDI > or = 10, or major, but not minor, depression more often had poor functional outcome (RS > II and BI < 17) at 15 months. Poor functional outcome at 3 months also correlated with depression at 15 months. In logistic regression analysis, depression at 3 months (Beck > or = 10) correlated with poor functional outcome at 15 months (RS > II) (OR 2.5, 95% CI 1.6-3.8). More careful examination and treatment of depression in stroke patients is emphasized.     

Contralateral cerebellar hypometabolism: a predictor for stroke outcome?

Contralateral cerebellar hypometabolism (CCH) is a well established remote functional effect of cerebral damage. Because CCH has been reported to be reversible in acute stroke in at least some patients, the value of cerebellar metabolic asymmetry (CbMA; a reflection of the degree of CCH) as a predictor of stroke outcome has been assessed. Measurements of cerebellar oxygen consumption were performed by positron emission tomography (PET) in 16 patients within 5-30 hours of onset of their first ever middle cerebral artery territory stroke, and again 13-56 days later in 12 survivors. The neurological state was quantified at the time of each PET study and at day 60, with both the Mathew and Orgogozo scales. In the early PET study, the CbMAs ranged from around 0% to nearly 50% (individually significant at p < 0.05 in 9/16 patients) but were neither strongly nor consistently correlated with neurological outcome or recovery at day 60. Similarly, the changes in CbMAs from the early to the late PET study were not correlated with the concomitant neurological evolution. At the late PET study, however, there were excellent positive correlations between CbMAs and both neurological status and size of infarction (assessed by CT in the chronic stage). The correlation with neurological status was explained by the correlation with size of infarction. The poor predictive value of CbMAs in the early PET study may be partly because the cerebral metabolic disturbance might still be evolving at this early stage in some cases. Despite this lack of a strong quantitative link between CbMAs at the early PET study and outcome, the outcome was good in all the patients who did not exhibit significant CCH, suggesting that lack of CCH may predict good outcome in acute middle cerebral artery stroke.     

Growth-differentiation factor-15 and functional outcome after acute ischemic stroke

Blood biomarkers may improve the performance in predicting early stroke outcome beyond well-established clinical factors. We investigated the value of growth-differentiation factor-15 (GDF-15) to predict functional outcome after 90 days in a prospectively collected patient cohort with symptoms of acute ischemic stroke. Two hundred eighty-one patients with symptoms of acute ischemic stroke were prospectively investigated. Serial blood samples for GDF-15 analysis were obtained after the admission of the patient, after 6 and 24 h. Primary outcome was the dichotomized modified ranking scale (MRS) 90 days after the initial clinical event. Within the final study population (264 patients, mean age 70.3 ± 12.7 years, 55.3% male), National Institutes of Health Stroke Scale (NIH-SS) [odds ratio (OR) 1.269, 95% confidence interval (CI) 1.141-1.412, p < 0.001] and initial GDF-15 levels (OR 1.029, 95% CI 1.007-1.053, p = 0.011) were independently associated with a MRS ≥ 2 after day 90 after multiple regression analysis. Growth-differentiation factor-15 levels increase with higher NIH-SS-tertiles (p = 0.005). Receiver-operator characteristic curves demonstrated a discriminatory accuracy to predict unfavourable stroke outcome of 0.629 (95% CI 0.558-0.699), 0.753 (95% CI 0.693-812) and 0.774 (95% CI 0.717-0.832) for GDF-15, NIH-SS and the combination of these variables. The additional use of GDF-15 to NIH-SS ameliorates the model with a net reclassification index of 0.044 (p = 0.541) and integrated discrimination improvement of 0.034 (p = 0.443). Growth-differentiation factor-15 as an acute stroke biomarker independently predicts unfavourable functional 90 day stroke outcome. Discriminatory value in addition to NIH-SS is only modestly distinct.