Picturing the Size and Site of Stroke With an Expanded National Institutes of Health Stroke Scale

Abstract

Background and Purpose—The National Institutes of Health Stroke Scale (NIHSS) includes minimal assessment of cognitive function, particularly in right hemisphere (RH) stroke. Descriptions of the Cookie Theft picture from the NIHSS allow analyses that (1) correlate with aphasia severity and (2) identify communication deficits in RH stroke. We hypothesized that analysis of the picture description contributes valuable information about volume and location of acute stroke.Methods—We evaluated 67 patients with acute ischemic stroke (34 left hemisphere [LH]; 33 RH) with the NIHSS, analysis of the Cookie Theft picture, and magnetic resonance imaging, compared with 35 sex- and age-matched controls. We evaluated descriptions for total content units (CU), syllables, ratio of left:right CU, CU/minute, and percent interpretive CU, based on previous studies. Lesion volume and percent damage to regions of interest were measured on diffusion-weighted imaging. Multivariable linear regression identified variables associated with infarct volume, independently of NIHSS score, age and sex.Results—Patients with RH and LH stroke differed from controls, but not from each other, on CU, syllables/CU, and CU/minute. Left:right CU was lower in RH compared with LH stroke. CU, syllables/CU, and NIHSS each correlated with lesion volume in LH and RH stroke. Lesion volume was best accounted by a model that included CU, syllables/CU, NIHSS, left:right CU, percent interpretive CU, and age, in LH and RH stroke. Each discourse variable and NIHSS score were associated with percent damage to different regions of interest, independently of lesion volume and age.Conclusions—Brief picture description analysis complements NIHSS scores in predicting stroke volume and location.

The myth and truth of a comprehensive stroke scale

“…A similar study took place in the Department of Neurology, Johns Hopkins University by Agis and colleagues in 2016 [12]. They enrolled 67 patients and another 35 healthy matched controls.…”

“…They enrolled 67 patients and another 35 healthy matched controls. In comparison to our study, we enrolled 86 patients with no control group [12]. We hypothesized that comparison between different ischemic stroke patients in characteristics like side, site, and size does not need the comparison with healthy controls especially if the cutoff points between normal and abnormal scores of the used scales either SPD-CAT or NIHSS are already determined and validated (normal values of SPD-CAT starting from 32 and above; and normal individuals score 0 in NIHSS).…”

“…Analyzed for only 40 patients (cannot be assessed for global aphasic or incommunicable patients) according to a previously designed checklist to assess the predictability of this step for the neglect and inattention [12].…”

“…However, such application especially in different population still needs validation and subsequent modification and culture adaptation [10]. Similar quantitative analysis of the picture description tasks for patients having right hemispheric functions deficits is integrated within the comprehensive aphasia test (CAT) under the spoken picture description subscale which has been modified and culturally adapted for the Egyptian Population and been validated very recently [11,12]. The more accurate and rapid prediction of the site, size, and side of the lesion using these scales, the more efficient and suitable to be clinically implemented [13].…”

To be or not 2b? To see or not 2c? Alas, the clock is ticking on TICI

“…Stroke location (especially in eloquent regions) is an independent predictor of both cognitive and global deficits,10 and innovative neurologists have begun testing the analysis of communication deficits as an adjunct to the NIH Stroke Scale 11. And yet, in TICI, as in many widely-applied stroke scales (including Alberta Stroke Program Early CT Score (ASPECTS)12 and RAPID13) eloquence is roundly ignored.…”