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To test the hypothesis that the National Institutes of Health Stroke Scale (NIHSS) score is
associated with the findings of arteriography performed within the first hours after ischemic
stroke. NIHSS scores in basilar, internal carotid, and middle cerebral artery M1 and M2
segment occlusions (central occlusions) were higher than in more peripherally located,
nonvisible, or absent occlusions. Patients with NIHSS scores _10 had positive predictive
values (PPVs) to show arterial occlusions in 97% of carotid and 96% of vertebrobasilar
strokes. With an NIHSS score of _12, PPV to find a central occlusion was 91%. In a
multivariate analysis, NIHSS subitems such as level of consciousness questions, gaze,
motor leg, and neglect were predictors of central occlusions. (Fischer)
There is a significant association of NIHSS scores and the presence and location of a vessel
occlusion. With an NIHSS score _10, a vessel occlusion will likely be seen on arteriography,
and with a score _12, its location will probably be central. (Fischer)
Stroke is among the leading causes of death, disability, hospitalizations, and healthcare
expenditures in the United States. The National Institutes of Health Stroke Scale (NIHSS),
which is a validated tool for assessing the initial stroke severity, has been shown to predict
mortality in acute ischemic stroke in several prior studies.914 (Gregg)
The NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of
acute ischemic stroke on the levels of consciousness, language, neglect, visual-field loss,
extraocular movement, motor strength, ataxia, dysarthria, and sensory loss that provides a
quantitative measure of strokerelated neurologic deficit.7 The scale is designed to be a
simple, valid, and reliable tool that can be administered at the bedside consistently by
physicians, nurses, or therapists. A trained observer rates the patients ability to answer
questions and perform activities. Ratings for each item are scored with 3 to 5 grades with 0 as
normal. (Gregg)
The NIHSS was developed and subsequently validated as a tool for assessing the initial
stroke severity.20,21 It has subsequently been shown to be predictive of a variety of stroke
functional outcomes.710 Stroke severity as indexed by NIHSS has also been shown to be
predictive of mortality after acute ischemic stroke.914 (Gregg)

The NIHSS neurological examination includes 15 individual elements that measure motor
and sensory function, language and speech production, vision, level of consciousness and
attention, and neglect. The elements are summed to provide an overall assessment of stroke
severity, with the score ranging from 0 to 42. Stroke severity at onset has been associated
with mortality, functional disability, length of hospital stay, and recovery.3,4 (Sucharew)

The National Institutes of Health Stroke Scale (NIHSS) is widely used to assess the severity
of acute ischemic stroke.1 It has been used in many trials and is a validated tool to predict
stroke outcome.26 Specifically, it has been used in thrombolysis trials to include or exclude
patients from active treatment.79 (Fischer)
Patients with acute stroke and without visible vessel occlusion or peripheral occlusions on
intra-arterial digital subtraction arteriography (DSA) tend to have a low NIHSS score and a
favorable outcome.14 (Fischer)
Studies of 54 patients with magnetic resonance (MR) angiography and 43 patients with DSA
showed an increasing probability to find vessel occlusions with higher NIHSS scores.15,16
The presence of a symptomatic cerebral arterial occlusion may have clinical implications for
treatment decisions, especially if intra-arterial thrombolysis (IAT) is considered (Fischer).
From January 2000 to December 2003, 226 patients with acute ischemic stroke (94 women,
132 men; mean age 61.58_12.4 years) underwent DSA at our stroke unit because they had
been considered for IAT. Some aspects of these patients have been reported previously.
14,1719 IAT was considered in the carotid territory up to 6 hours after stroke onset and in
basilar artery (BA) occlusion up to 12 hours. (Fischer)
The neurological status was assessed by a neurologist in the emergency room using the 15item version of the NIHSS score.20 As soon as possible thereafter, all patients underwent
computed tomography (CT) or MRI scans to rule out intracranial hemorrhage. All 226
patients of this study were considered to be candidates for IAT after CT or MRI and went on
to arteriography. (Fischer)
Arteriograms were used to divide patients into 8 groups according to the location of their
arterial occlusion: (1) internal carotid artery (ICA) group, (2) main stem of the middle
cerebral artery (MCA; M1) group, (3) main branch of MCA (M2) group, (4) branches of
MCA (M3/4) group, (5) anterior cerebral artery (ACA) group, (6) posterior cerebral artery
(PCA) group, (7) BA group, and (8) no visible occlusion (no occlusion) group. If a patient
showed _2 occluded arteries, the patient was placed into the larger artery group (eg, if the
ICA and the ipsilateral M1 segment were occluded, the patient was allocated to the ICA

group). Ischemic lesions as seen on MRI or CT scans and clinical findings were used to
divide patients into a group with carotid territory (ICA, ACA, and MCA) and another with
vertebrobasilar territory (BA and PCA) strokes. (Fischer)
There were 33102 acute ischemic stroke patients with NIHSS documented in the study
cohort. (Gregg)
There were 4496 deaths within the first 30 days (13.6%). There were 2037 deaths that
occurred during the index hospitalization (inhospital mortality 6.4%). (Gregg)
Patients who died within 30 days from admission were older, female, more likely to be white,
had a higher frequency of atrial fibrillation, and prior history of coronary artery disease
(CAD). (Gregg)
The median NIHSS was substantially higher among patients who died compared with those
who were alive at 30 days (17 versus 4, P<0.0001). (Gregg)
The 30-daymortality ratewas 2.3% for patients with a score of 0 and was>75% for patients
with a score of 40. As a continuous variable, NIHSS provided excellent discrimination of
30-day mortality with a c-statistic 0.82, (95% confidence interval [CI], 0.810.83). (Gregg)
One study of 360 ischemic stroke patients admitted to a single hospital in Taiwan identified
admission stroke severity as measured by NIHSS score as the strongest predictor of 3-month
mortality, with an odds ratio of 1.17 (95% CI, 1.121.22) per point.12 Another study
analyzed 479 patients admitted to a single center in Switzerland, advanced age, and high
NIHSS were the only independent predictor of 30-day mortality.11 A study from 7 centers in
Germany found NIHSS obtained within the first 6 hours of admission to be highly predictive
of 100-day survival (Gregg)
In summary, the NIHSS provides substantial prognostic information regarding within the first
30 days among Medicare beneficiaries with acute ischemic stroke. This index of stroke.
Severity is a very strong discriminator of mortality risk whether evaluated as a continuous or
categorical risk determinate. With categorization of NIHSS into 3 or 4 groups, Medicare
beneficiaries with acute ischemic stroke can be readily identified as being at low, medium,
and high risk for 30-day mortality. These findings suggest that it may be critical to collect

and include stroke severity for optimal risk stratification and risk adjustment of 30-day
mortality for Medicare beneficiaries with acute ischemic stroke. (Gregg)
The study included 2152 patients; 2018 (93.8%) had acute ischemic strokes and 134 (6.2%)
had transient ischemic attacks. Furthermore, 1043 patients (48.5%) showed a VO on MRA or
CTA, 887 in the AC and 156 in the PC. Eight hundred sixty VOs were central, 775 in the AC
and 85 in the PC. In 1109 patients (51.5%), 712 with AC and 397 with PC events, MRA or
CTA did not reveal any VO. High NIHSS scores were associated with VOs (P<0.0001). The
probability of VOs increased as NIHSS scores became greater. Before 6 hours, the
probability of VOs at NIHSS scores 9 to 12 was 6.4- to 8-fold in AC and 4- to 5.5-fold higher
in PC events compared with lower NIHSS scores of 0 to 4. Central VOs at NIHSS scores 9 to
12 were 7.3- to 9-fold more likely than at NIHSS scores of 0 to 4 (supplemental file II in the
online-only Data Supplement). Previous studies on the association of the NIHSS score and
VO were somehow conflicting. In patients with severe strokes undergoing digital subtraction
arteriography for endovascular treatment, optimal cut-offs for VOs were higher than in this
study.5 Olavarra et al4 found a time-dependent association, good before but poor after 6
hours from symptom onset. Maas et al3 reported a poor sensitivity of CTA to detect central
VOs at an average of 7.5 hours. Our analysis of 2152 patients with acute ischemic events
shows a significant association of NIHSS scores and VOs as seen on MRA and CTA. This
association is time-dependent and best within the first hours after symptom onset. In addition,
this association is good in the AC but poor in the PC. The question arises whether there is any
use of the NIHSS score to predict VO in acute ischemic stroke. To date, small randomized
trials showed the effectiveness of intra-arterial thrombolysis in proximal middle cerebral
artery occlusion.2 In addition, bridging intravenous to endovascular therapy and retrievable
stents might provide even better results.79 Therefore, in stroke networks it is important to
triage patients for intravenous or endovascular treatment strategies as early as possible. For
triage purposes, the NIHSS score can be useful, especially in smaller hospitals without access
to emergency vessel imaging. In conclusion, there is a significant association of NIHSS
scores and VOs in patients with AC strokes. This association is time-dependent. It is best
within the first hours after symptom onset. Thereafter and in the PC the association is poor.
Stroke is frequently associated with autonomic dysfunction, which causes secondary








complications, but it is only available at specialized centers. Widely available surrogate

markers are needed. This study tested whether stroke severity, as assessed by National
Institutes of Health Stroke Scale (NIHSS) scores, correlates with autonomic dysfunction and
thus predicts risk of autonomic complications. In 50 ischemic stroke patients, we assessed
NIHSS scores and parameters of autonomic cardiovascular modulation within 24 hours after
stroke onset and compared data with that of 32 healthy controls. Increasing stroke severity
was associated with progressive loss of overall autonomic modulation, decline in
parasympathetic tone, and baroreflex sensitivity, as well as progressive shift toward
sympathetic dominance. All autonomic changes put patients with more severe stroke at
increasing risk of cardiovascular complications and poor outcome. NIHSS scores are suited
to predict risk of autonomic dysregulation and can be used as premonitory signs of autonomic
failure. Autonomic cardiovascular dysfunction is common after stroke.18 Sympathetic
hyperactivity and parasympathetic dysfunction9 may cause tachy- or bradyarrhythmias,6,7
troponin T increase,10 myocardial infarction, or sudden death11,12 depending on brain area
affected by the stroke.8,12,13 Altered or reduced heart rate variability during acute stroke
may be prognostically unfavorable.9,14,15 Sykora et al16 showed reduced baroreflex
sensitivity (BRS), ie, compromised autonomic
adjustment of heart rate and vascular tone to sudden blood pressure (BP) changes, in acute
and subacute stroke patients.5,17 They concluded that sympathetic overactivity and blunted
BRS predict poor prognosis after stroke.5,15,18 Thus, early diagnosis of autonomic
dysregulation has prognostic and therapeutic relevance in acute stroke.5,18 However,
diagnosis of impaired autonomic BP and heart rate modulation requires specific techniques
and expertise that is not widely available. Therefore, easily determined clinical surrogate
markers of autonomic failure are desirable. To determine whether acute clinical deficits
reflect risk of autonomic cardiovascular dysregulation, we studied correla tions between
parameters of autonomic modulation and the National Institutes of Health Stroke Scale
(NIHSS) scores20 in acute stroke patients. In 50 stroke patients, NIHSS scores ranged from 1
to 21. Our stroke patients had higher BP, heart rate, and respiratory frequency than did
controls, indicating increased sympathetic cardiovascular modulation.6,7,9,2830 However,
the lower RRILF- powers, lower sympathetically and parasympathetically mediated RRISDs, RRI-CVs, and RRI-total powers23,24 in patients than in controls show a general loss of
autonomic cardiac modulation; this has been reported in previous stroke studies.6,7,28 In
contrast to the increase in BP, heart rate, and respiratory frequency of our patients, similar
RRI-LF/HFratios between patients and controls seem to suggest that there is no major change

in sympatho-vagal balance after stroke. Yet, increasing RRI-LF/HF-ratios in patients with

higher NIHSS scores, as well as the lower RMSSDs and RRI-HF-powers in patients than in
controls, confirm a loss in parasympathetic modulation after stroke, and predominant
sympathetic tone with increasing stroke severity. Previous studies support the conclusion that
autonomic imbalance depends on stroke severity. Korpelainen et al4 report no increase in
RRI-LF/HF-ratios in patients with stroke severity similar to that of our patients.4,31 In
contrast, Tokgo zoglu et al found increased RRI-LF/HF-ratios in patients who had higher
NIHSS scores than did our patients.6 The correlations seen in our patients between NIHSS
scores and parameters of autonomic modulation (Figure) indicate a higher risk of autonomic
complications in patients with more severe strokes. Tokgozoglu et al observed an association
between sudden death and reduced parasympathetic, but increased sympathetic activity in
their 62 stroke patients.6 The 7 patients who died unexpectedly during hospitalization had
higher RRI-LF/HF-ratios than did surviving patients.6 Among 44 stroke patients, Orlandi et
al found increased RRI-LF/HF-ratios in the 31 patients with arrhythmias.7 Sympathetic








infarctions,10,12 myofibrillary necrosis, perivascular and interstitial fibrosis, and myocyte

vacuolization10,32; it additionally increases the risk of secondary
brain injury and edema caused by sympathetically driven inflammation with fever,
hyperglycemia, polycythemia, and increased blood-brain barrier permeability.18,33
Consequently, increased sympathetic outflow compromises stroke outcome.29 The
progressive decline in parasympathetic activity in our patients with more severe strokes adds
to the risk of cardiovascular and cerebral complications.34 Parasympathetic deficiency







vasodilatation in animal stroke studies, and subsequently furthers cerebral vasoconstriction37

and secondary brain damage.38 The overall loss in autonomic modulation, ie, the decreasing
RRI-SDs and RRI-total powers in patients with higher NIHSS scores, is associated with a
growing risk of cardiac complications and sudden death.14,39 Declining autonomic
modulation predicts poor outcome, as shown in patients with myocardial infarction,40
chronic heart failure,41 multiple organ dysfunction syndrome,42 and in ischemic stroke.4,14
Progressive loss in autonomic modulation in patients with more severe stroke also causes
deteriorating heart rate and BP adjustment to instantaneous changes of either parameter
because of declining BRS.17 Sykora et al showed that BRS impairment depends on the
volume of the stroke and involvement of the insula16; they confirm the conclusions of
Robinson et al that BRS deterioration after stroke reflects central autonomic dysfunction.15

Similar to our results, Sykora et al found correlations between decreasing BRS and increasing
NIHSS scores.19 Reduced BRS is associated with poor outcome in cardiac, renal, or
metabolic diseases,40,43 and in stroke.5,15 According to Robinson et al, BRS impairment
during acute stroke is associated with a 4.5-fold increase in mortality rates.15 Baroreflex
failure results in increased BP fluctuations44 that may exceed cerebral autoregulation
buffering capacity45; this causes secondary cerebral lesions,46 particularly in patients with
more severe stroke and more deficient BRS. BP fluctuations worsen stroke outcome, as they
cause more severe end-organ damage than does nonfluctuating arterial hypertension.47 In our
patients, coefficients of correlation between increasing NIHSS scores and deteriorating
autonomic parameters range from Spearman Rho values of 0.29 to 0.47. Still, the high
consistency of correlations between stroke severity and all measures of autonomic
dysregulation confirms that more severe stroke is associated with more pronounced
autonomic failure and subsequent risk of secondary cardiovascular6,7,10,12,18,29,30 or
cerebral complications.18,33,37,38 (Hilz)
Initial NIHSS total score is highly predictive of outcome after ischemic stroke (IS). However,
even among patients with mild strokes, defined by NIHSS scores between 0 and 5,
approximately one third have significant disability after stroke. (Sucharew)
The original intent of the NIHSS was to be scored at the time of patient evaluation with
symptoms of stroke, but this is not always possible. Williams et al10 developed an algorithm
for computing the NIHSS score from the patients medical record of physical examination
and history. The retrospective NIHSS (rNIHSS) has been shown to be scored adequately from
the initial history and physical examination documented by a stroke team physician, and the
magnitude of the NIHSS score does not influence the validity of the retrospective scoring
method.11,12 We found that the profiles representing the more severe strokes included
patients who tended to be older, not current smokers, with history of atrial fibrillation,
congestive heart failure, prior stroke, and higher rNIHSS total scores; similar to the findings
noted by Kleindorfer et al.15 Our findings among mild IS differ from those reported by Leira
et al.16 Their work indicated that increased prospectively collected baseline NIHSS total
scores were associated with poor 3-month outcome, but that no individual NIHSS tems or
syndromic combination of NIHSS scores were found to be associated with outcome. In
conclusion, the NIHSS is a well-validated and highly

useful tool for capturing stroke severity, with uses in both the clinical and research setting.
The rNIHSS profiles identified in this study might be clinically useful for prognosis and
could conceivably be used in future clinical trial design.(Sucharew)
Physicians face dilemmas deciding whether to treat patients with mild ischemic strokes with
recombinant tissue plasminogen activator (rtPA). This is an important public health issue
because over half of the strokes in the United States have a NIHSS _5.1 Physicians do not
want to expose patients with low NIHSS scores to the hemorrhagic risks of rtPA9 because
they are likely to have a favorable outcome despite any intervention. We found that the type
of neurological deficits, as detected by the NIHSS examination, does not independently
predict poor outcome among patients with a low baseline NIHSS score. (Leira)
The most discriminating NIHSS end point was a prognosis-adjusted end point that defined
favorable outcome as a final score of _1 at 90 days or an improvement from baseline of at
least 11 points. In conclusion, we found benefits from using the NIHSS at 90 days as an end
point. We speculate that this will translate into more powerful clinical trials. Clinical trials of
acute stroke therapies should consider the use of neurologic impairment scales to assess
benefit from treatment. (Fiona)
The aim of the current study was to design a new simpler form of National Institutes of Health Stroke
Scale (NIHSS) for use in emergency settings, and compare its predictive ability with original NIHSS
score for mortality. A total of 152 consecutive patients with first ever ischemic stroke admitted to a
university affiliated hospital were recruited. NIHSS score on admission was estimated and the
predictive ability of NIHSS items for mortality at 28 days was evaluated by logistic regression.
Cumulative rate of mortality was 11.8% for 28-day follow-up period. Among NIHSS items, scores of
visual field, limb ataxia and extinction neglect were not associated with mortality (P>0.05). On the
contrary, level of consciousness-commands, language and gaze were determined as independent
indicators of mortality (P<0.05), and their coefficients on discriminant function were equal to 0.65,
0.44 and 0.30, respectively. In addition, area under the ROC curve of the calculated discriminant
function was not statistically different from NIHSS score (P>0.05). The suggested discriminant
function, comprising NIHSS items of level of consciousness-commands, language and gaze, can
predict 28-day mortality after ischemic stroke in a similar way to the original NIHSS score and can
provide a baseline for stroke severity in emergency settings. (Zandieh)

The presence of a thrombus on initial arteriography is directly related to the baseline NIHSS score.
Magnetic resonance angiography (MRA) offers a noninvasive and rapid assessment of large cerebral
vessel patency. We aimed at evaluating (1) the baseline NIHSS score as a tool for predicting the
likelihood of an occluded artery on MRA and (2) the course of stroke within the first week according
to the presence of a cerebral arterial occlusion.
None of the patients with an NIHSS score of 1-6 (11 patients) had visible occlusion, whereas 9 (43%)
out of 21 patients with an NIHSS score of 7-15 and 14 (78% ) out of 18 patients with an NIHSS score
above 16 had an arterial occlusion. For an increase by one point in the NIHSS score, the odds ratio for
the presence of occlusion was 1.28 (95% CI: 1.11-1.46). The course of the stroke as assessed by
follow-up NIHSS score was significantly more severe if an occlusion was detected. Median day 0,
day 1 and day 7 NIHSS score were, respectively, 18, 16 and 13 in patients who had an occlusion
versus 7, 4 and 0 in patients who had no visible occlusion (p < 0.01). A direct relation between the
baseline NIHSS score and the likelihood of the presence of an occlusion on initial MRA is
demonstrated. The presence of a cerebral arterial occlusion on MRA is significantly linked to a poor
neurological outcome. (Derex)
We determine the symptoms and stroke localization of patients with brain infarction and an NIHSS
score of 0. We studied all patients who presented with acute neurologic symptoms to our stroke center
from 2004 to 2008 and had persistent symptoms at the evaluation in the emergency department, an
NIHSS score of 0, and an infarct on diffusion-weighted imaging. We characterized the symptoms,
signs, lesion location, demographics, and stroke causes. Twenty patients met inclusion criteria.
Symptoms frequently experienced were headache, vertigo, and nausea. The posterior circulation was
commonly infarcted in this group. Truncal ataxia was the most common neurologic sign. Ischemic
stroke may cause symptoms that are associated with no deficits on the NIHSS score. (Martin)