SPAN2 SCALE: A NEW PREDICTIVE SCALE OF DISABILITY IN MINOR STROKE WITHOUT LARGE-VESSEL OCCLUSION
Main Article Content
Abstract
Background: Currently there is no predictive model in acute minor stroke without large vessel occlusion.
Aims: Our objective was to evaluate the independent predictors that correlate with unfavourable outcome and to develop a predictive scale in acute setting.
Methods: Retrospective analysis of consecutive acute minor stroke (NIHSS <5) admitted within 4.5 hours to clinical onset who were previously not disabled and without large vessel occlusion on CT angiography (intracranial or extracranial occlusion or stenosis ≥50%). Unfavourable outcome was defined as modified Rankin Scale 3-6 at 90 days. Independent predictors of disability were included in the model.
Results: A total of 408 patients with acute minor stroke (NIHSS <5) were analyzed. Large vessel occlusion was detected in 83 (20%), who were excluded. The final analysis included 325 patients, with mean age of 68± 14 years, 59% were men and 14.5% had unfavourable outcome. On multivariate analysis, age >70 years, NIHSS >2, recurrent event, posterior circulation ischemia and previous stroke were associated with unfavourable outcome. Recurrent event was excluded to the model because this variable is not available in acute setting. With the variables detected in the logistic regression, a predictive model was made (SPAN2 scale: previous Stroke, Posterior ischemia, Age >70 or NIHSS >2). The model correctly classified 84% of the patients with unfavourable outcome. A score >2 points on the SPAN2 scale showed a sensitivity 95%, specificity 51%, PPV 25% and NPV 99% of unfavourable outcome at 90 days.
Conclusions: SPAN2 scale could be useful to stratify the risk of unfavourable outcome in acute phase of minor stroke without large vessel occlusion. Future studies may validate its usefulness in the selection of patients for thrombolytic therapy.
Keywords:
minor stroke, disability, recurrent event, outcome, LVO
Article Details
How to Cite
COCHO, Dolores et al.
SPAN2 SCALE: A NEW PREDICTIVE SCALE OF DISABILITY IN MINOR STROKE WITHOUT LARGE-VESSEL OCCLUSION.
Medical Research Archives, [S.l.], v. 11, n. 5, may 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/3883>. Date accessed: 27 july 2024.
doi: https://doi.org/10.18103/mra.v11i5.3883.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. National Institute of Neurological D, Stroke rt PASSG. Tissue plasminogen activator for acute ischemic stroke. The New England journal of medicine. Dec 14 1995;333(24):1581-1587.
2. Reeves M, Khoury J, Alwell K, et al. Distribution of National Institutes of Health stroke scale in the Cincinnati/Northern Kentucky Stroke Study. Stroke. Nov 2013;44(11):3211-3213.
3. Cocho D, Belvis R, Marti-Fabregas J, et al. Reasons for exclusion from thrombolytic therapy following acute ischemic stroke. Neurology. Feb 22 2005;64(4):719-720.
4. Fisher S. Not beyond reasonable doubt: Howard Temin's provirus hypothesis revisited. Journal of the history of biology. Winter 2010;43(4):661-696.
5. Shi L, Zhang M, Liu H, et al. Safety and outcome of thrombolysis in mild stroke: a meta-analysis. Medical science monitor : international medical journal of experimental and clinical research. Nov 2 2014;20:2117-2124.
6. Khatri P, Conaway MR, Johnston KC, Acute Stroke Accurate Prediction Study I. Ninety-day outcome rates of a prospective cohort of consecutive patients with mild ischemic stroke. Stroke. Feb 2012;43(2):560-562.
7. Ohara T, Nagakane Y, Tanaka E, Morii F, Koizumi T, Yamamoto Y. Clinical and Radiological Features of Stroke Patients with Poor Outcomes Who Do Not Receive Intravenous Thrombolysis because of Mild Symptoms. European neurology. 2013;69(1):4-7.
8. Smith EE, Fonarow GC, Reeves MJ, et al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With The Guidelines-Stroke. Stroke. Nov 2011;42(11):3110-3115.
9. Urra X, Arino H, Llull L, et al. The outcome of patients with mild stroke improves after treatment with systemic thrombolysis. PloS one. 2013;8(3):e59420.
10. Khatri P, Kleindorfer DO, Yeatts SD, et al. Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials. Stroke. Nov 2010;41(11):2581-2586.
11. Ng FC, Coote S, Frost T, Bladin C, Choi PM. Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke. Stroke. Jul 2016;47(7):1914-1916.
12. Choi JC, Jang MU, Kang K, et al. Comparative effectiveness of standard care with IV thrombolysis versus without IV thrombolysis for mild ischemic stroke. Journal of the American Heart Association. Jan 27 2015;4(1):e001306.
13. Yeo LL, Rathakrishnan R, Paliwal PR, Sharma VK. Should minor strokes be excluded from intravenous thrombolysis? Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. Jul 2015;36(7):1255-1256.
14. Greisenegger S, Seyfang L, Kiechl S, Lang W, Ferrari J, Austrian Stroke Unit Registry C. Thrombolysis in patients with mild stroke: results from the Austrian Stroke Unit Registry. Stroke. Mar 2014;45(3):765-769.
15. National Institute of Neurological Disorders Stroke rt PASSG. Recombinant tissue plasminogen activator for minor strokes: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study experience. Annals of emergency medicine. Sep 2005;46(3):243-252.
16. Nedeltchev K, Schwegler B, Haefeli T, et al. Outcome of stroke with mild or rapidly improving symptoms. Stroke. Sep 2007;38(9):2531-2535.
17. Rajajee V, Kidwell C, Starkman S, et al. Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology. Sep 26 2006;67(6):980-984.
18. Brott T, Adams HP, Jr., Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. Jul 1989;20(7):864-870.
19. Barnett HJ, Warlow CP. Carotid endarterectomy and the measurement of stenosis. Stroke. Sep 1993;24(9):1281-1284.
20. Adams HP, Jr., Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. Jan 1993;24(1):35-41.
21. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. Jun 22 1991;337(8756):1521-1526.
22. Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. Jan 27 2007;369(9558):275-282.
23. Cocho D, Sagales M, Cobo M, et al. Lowering bronchoaspiration rate in an acute stroke unit by means of a 2 volume/3 texture dysphagia screening test with pulsioximetry. Neurologia. Jan - Feb 2017;32(1):22-28.
24. Coull AJ, Lovett JK, Rothwell PM, Oxford Vascular S. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. Bmj. Feb 7 2004;328(7435):326.
25. Ois A, Gomis M, Rodriguez-Campello A, et al. Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke. Stroke. Jun 2008;39(6):1717-1721.
26. Sato S, Uehara T, Ohara T, et al. Factors associated with unfavorable outcome in minor ischemic stroke. Neurology. Jul 8 2014;83(2):174-181.
27. Wu L, Wang A, Wang X, et al. Factors for short-term outcomes in patients with a minor stroke: results from China National Stroke Registry. BMC neurology. Dec 9 2015;15:253.
28. Smith EE, Abdullah AR, Petkovska I, Rosenthal E, Koroshetz WJ, Schwamm LH. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke. Nov 2005;36(11):2497-2499.
29. Coutts SB, Modi J, Patel SK, et al. What causes disability after transient ischemic attack and minor stroke?: Results from the CT and MRI in the Triage of TIA and minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study. Stroke. Nov 2012;43(11):3018-3022.
30. Kim JT, Park MS, Chang J, Lee JS, Choi KH, Cho KH. Proximal arterial occlusion in acute ischemic stroke with low NIHSS scores should not be considered as mild stroke. PloS one. 2013;8(8):e70996.
31. Heldner MR, Jung S, Zubler C, et al. Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients. Journal of neurology, neurosurgery, and psychiatry. Jul 2015;86(7):755-760.
32. Mazya MV, Cooray C, Lees KR, et al. Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register. European stroke journal. Mar 2018;3(1):29-38.
33. Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM. Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology. Apr 24 2001;56(8):1015-1020.
34. Park TH, Hong KS, Choi JC, et al. Validation of minor stroke definitions for thrombolysis decision making. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. May 2013;22(4):482-490.
35. Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke? Stroke. Apr 2010;41(4):661-666.
36. Hassan AE, Zacharatos H, Hassanzadeh B, et al. Does mild deficit for patients with stroke justify the use of intravenous tissue plasminogen activator? Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. Mar 2010;19(2):116-120.
37. Huisa BN, Raman R, Neil W, Ernstrom K, Hemmen TM. Intravenous tissue plasminogen activator for patients with minor ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. Nov 2012;21(8):732-736.
38. group ISTc, Sandercock P, Wardlaw JM, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. Jun 23 2012;379(9834):2352-2363.
39. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. Nov 29 2014;384(9958):1929-1935.
40. Khatri P, Kleindorfer DO, Devlin T, et al. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. Jama. Jul 10 2018;320(2):156-166.
41. Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. The New England journal of medicine. May 9 2019;380(19):1795-1803.
2. Reeves M, Khoury J, Alwell K, et al. Distribution of National Institutes of Health stroke scale in the Cincinnati/Northern Kentucky Stroke Study. Stroke. Nov 2013;44(11):3211-3213.
3. Cocho D, Belvis R, Marti-Fabregas J, et al. Reasons for exclusion from thrombolytic therapy following acute ischemic stroke. Neurology. Feb 22 2005;64(4):719-720.
4. Fisher S. Not beyond reasonable doubt: Howard Temin's provirus hypothesis revisited. Journal of the history of biology. Winter 2010;43(4):661-696.
5. Shi L, Zhang M, Liu H, et al. Safety and outcome of thrombolysis in mild stroke: a meta-analysis. Medical science monitor : international medical journal of experimental and clinical research. Nov 2 2014;20:2117-2124.
6. Khatri P, Conaway MR, Johnston KC, Acute Stroke Accurate Prediction Study I. Ninety-day outcome rates of a prospective cohort of consecutive patients with mild ischemic stroke. Stroke. Feb 2012;43(2):560-562.
7. Ohara T, Nagakane Y, Tanaka E, Morii F, Koizumi T, Yamamoto Y. Clinical and Radiological Features of Stroke Patients with Poor Outcomes Who Do Not Receive Intravenous Thrombolysis because of Mild Symptoms. European neurology. 2013;69(1):4-7.
8. Smith EE, Fonarow GC, Reeves MJ, et al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With The Guidelines-Stroke. Stroke. Nov 2011;42(11):3110-3115.
9. Urra X, Arino H, Llull L, et al. The outcome of patients with mild stroke improves after treatment with systemic thrombolysis. PloS one. 2013;8(3):e59420.
10. Khatri P, Kleindorfer DO, Yeatts SD, et al. Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials. Stroke. Nov 2010;41(11):2581-2586.
11. Ng FC, Coote S, Frost T, Bladin C, Choi PM. Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke. Stroke. Jul 2016;47(7):1914-1916.
12. Choi JC, Jang MU, Kang K, et al. Comparative effectiveness of standard care with IV thrombolysis versus without IV thrombolysis for mild ischemic stroke. Journal of the American Heart Association. Jan 27 2015;4(1):e001306.
13. Yeo LL, Rathakrishnan R, Paliwal PR, Sharma VK. Should minor strokes be excluded from intravenous thrombolysis? Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. Jul 2015;36(7):1255-1256.
14. Greisenegger S, Seyfang L, Kiechl S, Lang W, Ferrari J, Austrian Stroke Unit Registry C. Thrombolysis in patients with mild stroke: results from the Austrian Stroke Unit Registry. Stroke. Mar 2014;45(3):765-769.
15. National Institute of Neurological Disorders Stroke rt PASSG. Recombinant tissue plasminogen activator for minor strokes: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study experience. Annals of emergency medicine. Sep 2005;46(3):243-252.
16. Nedeltchev K, Schwegler B, Haefeli T, et al. Outcome of stroke with mild or rapidly improving symptoms. Stroke. Sep 2007;38(9):2531-2535.
17. Rajajee V, Kidwell C, Starkman S, et al. Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology. Sep 26 2006;67(6):980-984.
18. Brott T, Adams HP, Jr., Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. Jul 1989;20(7):864-870.
19. Barnett HJ, Warlow CP. Carotid endarterectomy and the measurement of stenosis. Stroke. Sep 1993;24(9):1281-1284.
20. Adams HP, Jr., Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. Jan 1993;24(1):35-41.
21. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. Jun 22 1991;337(8756):1521-1526.
22. Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. Jan 27 2007;369(9558):275-282.
23. Cocho D, Sagales M, Cobo M, et al. Lowering bronchoaspiration rate in an acute stroke unit by means of a 2 volume/3 texture dysphagia screening test with pulsioximetry. Neurologia. Jan - Feb 2017;32(1):22-28.
24. Coull AJ, Lovett JK, Rothwell PM, Oxford Vascular S. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. Bmj. Feb 7 2004;328(7435):326.
25. Ois A, Gomis M, Rodriguez-Campello A, et al. Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke. Stroke. Jun 2008;39(6):1717-1721.
26. Sato S, Uehara T, Ohara T, et al. Factors associated with unfavorable outcome in minor ischemic stroke. Neurology. Jul 8 2014;83(2):174-181.
27. Wu L, Wang A, Wang X, et al. Factors for short-term outcomes in patients with a minor stroke: results from China National Stroke Registry. BMC neurology. Dec 9 2015;15:253.
28. Smith EE, Abdullah AR, Petkovska I, Rosenthal E, Koroshetz WJ, Schwamm LH. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke. Nov 2005;36(11):2497-2499.
29. Coutts SB, Modi J, Patel SK, et al. What causes disability after transient ischemic attack and minor stroke?: Results from the CT and MRI in the Triage of TIA and minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study. Stroke. Nov 2012;43(11):3018-3022.
30. Kim JT, Park MS, Chang J, Lee JS, Choi KH, Cho KH. Proximal arterial occlusion in acute ischemic stroke with low NIHSS scores should not be considered as mild stroke. PloS one. 2013;8(8):e70996.
31. Heldner MR, Jung S, Zubler C, et al. Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients. Journal of neurology, neurosurgery, and psychiatry. Jul 2015;86(7):755-760.
32. Mazya MV, Cooray C, Lees KR, et al. Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register. European stroke journal. Mar 2018;3(1):29-38.
33. Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM. Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology. Apr 24 2001;56(8):1015-1020.
34. Park TH, Hong KS, Choi JC, et al. Validation of minor stroke definitions for thrombolysis decision making. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. May 2013;22(4):482-490.
35. Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke? Stroke. Apr 2010;41(4):661-666.
36. Hassan AE, Zacharatos H, Hassanzadeh B, et al. Does mild deficit for patients with stroke justify the use of intravenous tissue plasminogen activator? Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. Mar 2010;19(2):116-120.
37. Huisa BN, Raman R, Neil W, Ernstrom K, Hemmen TM. Intravenous tissue plasminogen activator for patients with minor ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. Nov 2012;21(8):732-736.
38. group ISTc, Sandercock P, Wardlaw JM, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. Jun 23 2012;379(9834):2352-2363.
39. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. Nov 29 2014;384(9958):1929-1935.
40. Khatri P, Kleindorfer DO, Devlin T, et al. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. Jama. Jul 10 2018;320(2):156-166.
41. Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. The New England journal of medicine. May 9 2019;380(19):1795-1803.