A Study of Factors Affecting Functional Outcomes in Patients With Successful Recanalization by Mechanical Thrombectomy
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Background and purpose: Reperfusion therapy is typically performed in cases with acute cerebral infarction. Mechanical thrombectomy (MT) achieves superior recanalization and favorable outcomes. However, some patients have poor functional prognosis despite successful recanalization. We investigated factors affecting functional prognosis after MT with good reperfusion. Methods: Among the 205 consecutive cases with ischemic stroke treated with MT at our center from January 1, 2019 to March 31, 2021, 168 with successful recanalization were included. Factors affecting early neurological improvement (ENI) and modified Rankin Scale (mRS) scores were reviewed retrospectively. Results: There were 93 (55%) cases with ENI and 75 (45%) without ENI. The times from onset to recombinant tissue-type plasminogen activator administration and recanalization in ENI cases were shorter than those in non-ENI cases. However, non-ENI cases had significantly higher Fazekas grades for white matter lesions. In multivariate analysis, the Fazekas grade was related to ENI (odds ratio [OR]=0.572, 95% confidence interval [CI]=0.345-0.948). The mRS score at discharge was 0-2 in 64 cases (good outcome) and 3-6 in 104 cases (poor outcome). Patients with a poor outcome had a significantly higher age, National Institutes of Health Stroke Scale (NIHSS) score, and Fazekas grade. Multivariate analysis revealed that the NIHSS score (OR=1.073, 95% CI=1.020-1.129) and Fazekas grade (OR=2.162, 95% CI=1.458-3.205) at hospitalization affected the mRS score at discharge. Conclusion: There is a correlation of greater severity of white matter lesions with poorer ENI and clinical outcomes at discharge post-MT.Keywords:
Stroke
Background and Purpose —Controversy regarding the risks and benefits of thrombolysis has not been helped by the perception that some trials were “positive” and others “negative” on their primary outcome measure of either “good” or “poor” functional outcome. We wondered whether the definition of good or poor functional outcome might have contributed to this perception, and what effect altering the definition might have on the individual trials and on the systematic review of all the trials combined. Methods —We analyzed data on functional outcome, extracted from the randomized trials of thrombolysis in acute ischemic stroke, according to good (modified Rankin scale scores of 0 to 1 versus 2 to 6) and poor (modified Rankin 0 to 2 versus 3 to 6) functional outcome, to determine the effects of thrombolysis. Results —Twelve trials (4342 patients, treated up to 6 hours after stroke) contributed to this analysis. Overall, there was no difference in the estimate of treatment effect between the 2 definitions (modified Rankin 0 to 2 versus 3 to 6, and 0 to 1 versus 2 to 6 [ORs 0.83 and 0.79, respectively]). However, the apparent “success” of several individual trials did alter. Conclusions —We should not place undue emphasis on the results of individual trials, when a change of a single point on the Rankin scale can make the difference between “success” and “failure.” Overall, by either analysis, there was a significant benefit in patients treated with thrombolysis up to 6 hours after stroke.
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Acute stroke
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A perceived weakness of the modified Rankin Scale is potential for interobserver variability. We undertook a systematic review of modified Rankin Scale reliability studies.Two researchers independently reviewed the literature. Crossdisciplinary electronic databases were interrogated using the following key words: Stroke*; Cerebrovasc*; Modified Rankin*; Rankin Scale*; Oxford Handicap*; Observer variation*. Data were extracted according to prespecified criteria with decisions on inclusion by consensus.From 3461 titles, 10 studies (587 patients) were included. Reliability of modified Rankin Scale varied from weighted kappa=0.95 to kappa=0.25. Overall reliability of mRS was kappa=0.46; weighted kappa=0.90 (traditional modified Rankin Scale) and kappa=0.62; weighted kappa=0.87 (structured interview).There remains uncertainty regarding modified Rankin Scale reliability. Interobserver studies closest in design to large-scale clinical trials demonstrate potentially significant interobserver variability.
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The utility-weighted modified Rankin Scale, representing patient perspectives of quality of life, is a newly proposed measure to improve the interpretability of the modified Rankin Scale. Despite obvious advantages, such weighting imperfectly reflects the multidimensional patterns of post-stroke burden.To investigate multidimensional patterns of post-stroke burden formed by individual domains of Assessment of Quality of Life and Barthel Index for each modified Rankin Scale category.In the A Very Early Rehabilitation Trial (n = 2104), modified Rankin Scale scores and modified Rankin Scale-stratified Barthel Index scores of Self-care and Mobility, and Assessment of Quality of Life scores of Independent Living, Senses, Mental Health and Relationships were collected at three months. The multivariate relationship between individual Assessment of Quality of Life and Barthel Index domains, and modified Rankin Scale was investigated using random effects linear regression models with respective interaction terms.Of 2104 patients, simultaneously collected Assessment of Quality of Life, Barthel Index and modified Rankin Scale scores at three months were available in 1870 patients. While individual Assessment of Quality of Life and Barthel Index domain scores decreased significantly as modified Rankin Scale increased (p < 0.0001), the patterns of decrease differed by domains (p < 0.0001). Patients with modified Rankin Scale 0-1 had the largest post-stroke burden in the Mental Health and Relationship domains, while patients with modified Rankin Scale >3 showed the greatest burden in Independent Living, Mobility and Self-care domains.Across the modified Rankin Scale, individual domains are varyingly impacted demonstrating unique patterns of post-stroke burden, which facilitates appropriate assessment, articulation and interpretation of the modified Rankin Scale and utility-weighted modified Rankin Scale.
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Background Resource use in the acute and subacute phases after stroke depends on the degree of disability. Aims To determine if direct costs after stroke also vary by level of disability as measured using the modified Rankin scale at the chronic stage after stroke. Methods In a multicentre study, we collected acute and chronic in- and outpatient resource use in survivors of ischemic stroke stratified by levels of disability according to the modified Rankin Scale. Statistical inference on costs at each level of the modified Rankin Scale was estimated using a general linear model for the first three months, the first year, and any subsequent year after ischemic stroke. Results A total of 569 survivors of ischemic stroke with a mean age of 71.7 years were enrolled (41% female) from 10 academic and nonacademic centers. Costs varied substantially over time and with each modified Rankin Scale level. The total average costs in the first year were estimated $33,147 per patient, ranging from $9,114 for modified Rankin Scale 0 to $83,236 for modified Rankin Scale 5. In the second year, medical costs were on average $14,039, varying from $2,921 to $39,723 for patients with modified Rankin Scale 0–5. The level of disability based on the modified Rankin Scale was a major determinant of resource use, irrespective of age, gender, atrial fibrillation, and vascular risk factors. Conclusion Long-term resource use after stroke is high and is mainly driven by degree of disability as measured by the modified Rankin scale.
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Approximately 20,000 stroke events, or three quarters of all stroke events in Sweden are included in Riks-Stroke, the National quality Register for Stroke Care, each year. Results from Riks-Stroke show that women, in comparison with men, are more often living in institutions three months after stroke. Women also less often receive secondary stroke prevention. Oral anticoagulants are the most efficient way to prevent stroke in patients with atrial fibrillation. There are wide variations in the use of oral anticoagulants in stroke patients with atrial fibrillation, not only between hospitals, but also between counties and health care regions. Riks-Stroke verifies that treatment in stroke units improves survival as well as functional outcome after stroke. Still more than one quarter of all stroke patients do not receive care in a stroke unit. Post-stroke fatigue is an unexplored long-term consequence that is frequent even late after stroke. It is also an independent predictor for functional dependence, institutional living and death late after stroke. Stroke care in Sweden has improved dramatically the last decades. However, results from Riks-Stroke indicated that there still are several differences and weaknesses and there are subsequently still room for improvements.
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The modified Rankin Scale (mRS) at 90 days after stroke onset has become the preferred outcome measure in acute stroke trials, including recent trials of interventional therapies. Reporting the range of modified Rankin Scale scores as a paired horizontal stacked bar graph (colloquially known as "Grotta bars") has become the conventional method of visualizing modified Rankin Scale results. Grotta bars readily illustrate the levels of the ordinal modified Rankin Scale in which benefit may have occurred. However, complementing the available graphical information by including additional features to convey statistical significance may be advantageous. We propose a modification of the horizontal stacked bar graph with illustrative examples. In this suggested modification, the line joining the segments of the bar graph (e.g. modified Rankin Scale 1-2 in treatment arm to modified Rankin Scale 1-2 in control arm) is given a color and thickness based on the p-value of the result at that level (in this example, the p-value of modified Rankin Scale 0-1 vs. 2-6)-a thick green line for p-values <0.01, thin green for p-values of 0.01 to <0.05, gray for 0.05 to <0.10, thin red for 0.10 to <0.90, and thick red for p-values ≥0.90 or outcome favoring the control group. Illustrative examples from four recent trials (ESCAPE, SWIFT-PRIME, IST-3, ASTER) are shown to demonstrate the range of significant and non-significant effects that can be captured using this proposed method. By formalizing a display of outcomes which includes statistical tests of all possible dichotomizations of the Rankin scale, this approach also encourages pre-specification of such hypotheses. Prespecifying tests of all six dichotomizations of the Rankin scale provides all possible statistical information in an a priori fashion. Since the result of our proposed approach is six distinct dichotomized tests in addition to a primary test, e.g. of the ordinal Rankin shift, it may be prudent to account for multiplicity in testing by using dichotomized p-values only after adjustment, such as by the Bonferroni or Hochberg-Holm methods. Whether p-values are nominal or adjusted may be left to the discretion of the presenter as long as the presence or absence is clearly stated in the statistical methods. Our proposed modification results in a visually intuitive summary of both the size of the effect-represented by the matched bars and their connecting segments-as well as its statistical relevance.
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Objectives To understand variability in modified Rankin Scale scores from discharge to 90 days in acute ischaemic stroke patients following treatment, and examine prediction of 90-day modified Rankin Scale score by using discharge modified Rankin Scale and discharge disposition. Materials and methods Retrospective analysis of acute ischaemic stroke patients following treatment was performed from January 2016 to March 2020. Data collection included demographic and clinical characteristics and outcomes data (modified Rankin Scale score at discharge, 30 days and 90 days and discharge disposition). Pearson’s χ 2 test assessed statistical differences in distribution of modified Rankin Scale scores at discharge, 30 days and 90 days. The predictive power of discharge modified Rankin Scale score and disposition quantified the association with 90-day outcome. Results A total of 280 acute ischaemic stroke patients (65.4% aged ≥65 years, 47.1% female, 60.7% white) were included in the analysis. The modified Rankin Scale score significantly changed between 30 and 90 days from discharge (p<0.001) after remaining stable from discharge to 30 days (p=0.665). The positive and negative predictive values of an unfavourable long-term outcome for discharge modified Rankin Scale scores of 3–5 were 67.7% (95% CI 60.4% to 75.0%) and 82.0% (95% CI 75.1% to 88.8%), and for non-home discharge disposition were 72.4% (95% CI 64.5% to 80.2%) and 74.5% (95% CI 67.8% to 81.3%), respectively. Conclusions Discharge modified Rankin Scale score and non-home discharge disposition are good individual predictors of 90-day modified Rankin Scale score for ischaemic stroke patients following treatment.
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Background Cognitive or communication issues may preclude direct modified Rankin Scale interview, necessitating interview with a suitable surrogate. The clinimetric properties of this proxy modified Rankin Scale assessment have not been described. Aims To describe reliability of proxy-derived modified Rankin Scale and compare with traditional direct patient interview. Methods Researchers assessed consenting stroke inpatients and their proxies using a nonstructured modified Rankin Scale approach. Paired interviewers (trained in modified Rankin Scale) performed independent and blinded modified Rankin Scale assessment of patients and appropriate proxies. Interobserver variability and agreement between patient and proxy modified Rankin Scale were described using kappa statistics ( k, 95% confidence interval) and percentage agreement. Results Ninety-seven stroke survivors were assessed. Proxies were family members ( n = 29), nurses ( n = 50), or physiotherapists ( n = 25). Median modified Rankin Scale from both patient and proxies was 3 [interquartile range (IQR): 2–4]. Reliability for patient modified Rankin Scale interview was weighted kappa = 0.70 (95% confidence interval: 0.30–1.00). Reliability for proxy modified Rankin Scale weighted kappa = 0.62 (95% confidence interval: 0.34–0.90). Subgroup analysis of various proxy information sources were as follows: family weighted kappa = 0.61; nurse weighted kappa = 0.58; therapist weighted kappa = 0.58. There was disagreement between patient-derived modified Rankin Scale and corresponding proxy modified Rankin Scale weighted kappa = 0.64 (95% CI: 0.42–0.86). Conclusions There is potential for substantial interobserver variability in proxy modified Rankin Scale and validity of certain proxy assessments is questionable. Direct modified Rankin Scale interview is preferred.
Proxy (statistics)
Clinical neurology
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