Thinking About the Future: A Review of Prognostic Scales Used in Acute Stroke

Abstract

Background: There are many prognostic scales that aim to predict functional outcome following acute stroke. Despite considerable research interest, these scales have had limited impact in routine clinical practice. This may be due to perceived problems with internal validity (quality of research), as well as external validity (generalizability of results). We set out to collate information on exemplar stroke prognosis scales, giving particular attention to the scale content, derivation, and validation. Methods: We performed a focused literature search, designed to return high profile scales that use baseline clinical data to predict mortality or disability. We described prognostic utility and collated information on the content, development and validation of the tools. We critically appraised chosen scales based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies (CHARMS). Results: We chose 10 primary scales that met our inclusion criteria, six of which had revised/modified versions. Most primary scales used 5 input variables (range: 4–13), with substantial overlap in the variables included. All scales included age, eight included a measure of stroke severity, while five scales incorporated pre-stroke level of function (often using modified Rankin Scale), comorbidities and classification of stroke type. Through our critical appraisal, we found issues relating to excluding patients with missing data from derivation studies, and basing the selection of model variable on significance in univariable analysis (in both cases noted for six studies). We identified separate external validation studies for all primary scales but one, with a total of 60 validation studies. Conclusions: Most acute stroke prognosis scales use similar variables to predict long-term outcomes and most have reasonable prognostic accuracy. While not all published scales followed best practice in development, most have been subsequently validated. Lack of clinical uptake may relate more to practical application of scales rather than validity. Impact studies are now necessary to investigate clinical usefulness of existing scales.

The Association Between an Antecedent of Transient Ischemic Attack Prior to Onset of Stroke and Functional Ambulatory Outcome

“…Several prognostic measures have been used to predict functional outcomes following thrombolytic therapy in patients with ischemic stroke. [9][10][11][12][13] These measures are based on clinical characteristics of the patient and provide cumulative evaluations for the management of poststroke treatment care. Accurate predictions of ambulatory functions are needed as well, so that clinicians can help patients set motor recovery goals to improve activities of daily living [14][15][16][17][18] following thrombolysis therapy.…”

Predictors of urinary tract infection in acute stroke patients

“…The factors include: NIHSS score, [ 63 ] age, a measure of stroke severity, prestrike function, comorbidities and stroke subtype, acute glucose, history of atrial fibrillation, congestive heart failure, cancer, kidney disease, preadmission dependency, and so on. [ 64 ] And, a review summarized the blood biomarkers that could predict the prognosis of stroke. They were sirtuin1, [ 65 ] serum retinoic, [ 66 ] interleukin-6, tumor necrosis factor alpha, C-reactive protein, cholesterol, high density lipoprotein cholesterol (HDL-C) and low density lipoprotein (LDL), glutamate, glutamic oxaloacetic transaminase, glutamic-pyruvic transaminase, brain-derived neurotrophic factor, and fibrinogen.…”

Diabetes and stroke

“…Any form of abnormal glycaemia seems to have an adverse prognostic effect and diabetes status or glucose feature in most acute stroke risk stratification tools . Hyperglycaemia within the first 48 hours increases the risk of a poorer functional outcome by 12.9% (95% CI 9.2–16.7) .…”