Neurologic Examination at 24 to 48 Hours Predicts Functional Outcomes in Basilar Artery Occlusion Stroke

• Type of Material: Article
• Authors: Srikant Rangaraju, Emory University; Tudor G. Jovin, University of Pittsburgh; Michael Frankel, Emory University; Wouter J. Schonewille, University Medical Center Utrecht; Ale Algra, University Medical Center Utrecht; L. Jaap Kappelle, University Medical Center Utrecht; Raul Nogueira, Emory University
• Language: English
• Date: 2016-10
• Publisher: American Heart Association
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2016 American Heart Association, Inc.
• Final Published Version (URL): http://dx.doi.org/10.1161/STROKEAHA.116.014567
• Title of Journal or Parent Work: Stroke
• ISSN: 0039-2499
• Volume: 47
• Issue: 10
• Start Page: 2534
• End Page: 2540
• Grant/Funding Information: This study was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number ULITR000454.; Dr. Rangaraju is a recipient of a clinical research training fellowship from the American Brain Foundation.
• Keywords: Vertebrobasilar disease; Thrombosis; Brain ischemia; Cerebrovascular disease/stroke; Ischemic stroke; Prognosis; Basilar artery ischemia; Clinical prediction rule; Critical care outcomes; Stroke; Mortality/survival; Neurologic examination
• Research Categories: Biology, Neuroscience

Abstract

Background and Purpose - Accurate long-term outcome prognostication in basilar artery occlusion strokes may guide clinical management in the subacute stage. We determine the prognostic value of the follow-up neurological examination using the National Institutes of Health stroke scale (NIHSS) and identify 24- to 48-hour NIHSS risk categories in basilar artery occlusion patients. Methods - Participants of an observational registry of radiologically confirmed acute basilar artery occlusion (BASICS [Basilar Artery International Cooperation Study]) with prospectively collected 24- to 48-hour NIHSS and 1-month modified Rankin scale scores were included. Uni- and multivariable modeling were performed to identify independent predictors of poor outcome. Predictive powers of baseline and 24- to 48-hour NIHSS for poor outcome (modified Rankin scale, 4-6) and 1-month mortality were determined by receiver operating characteristic analyses. Classification and regression tree analysis was performed to identify risk groups. Results - Three hundred seventy-six of 619 BASICS participants were included, of whom 65.4% had poor outcome. In multivariable analyses, 24- to 48-hour NIHSS (odds ratio=1.28 [1.21-1.35] ), history of minor stroke (odds ratio=2.64 [1.04-6.74], time to treatment > 6 hours (odds ratio=3.07 [1.35-6.99]), and age (odds ratio=1.02 [0.99-1.04] ) were retained in the final model as predictors of poor outcome. Prognostic power of 24- to 48-hour NIHSS was higher than baseline NIHSS for 1-month poor outcome (area under the curve, 0.92 versus 0.75) and mortality (area under the curve, 0.85 versus 0.72). Classification and regression tree analysis identified five 24- to 48-hour NIHSS risk categories with poor outcome rates of 9.4% (NIHSS 0-4), 36% (NIHSS 5-11), 84.3% (NIHSS 12-22), 96.1% (NIHSS 23-27), and 100% (NIHSS≥28). Conclusions - Twenty-four- to 48-hour NIHSS accurately predicts 1-month poor outcome and mortality and represents a clinically valuable prognostic tool for the care of basilar artery occlusion patients.