professional regarding any medical questions or conditions.

The use of this website is governed by the UpToDate Terms of Use 2015
Stroke prognosis in adults
INTRODUCTION Stroke is the third most common cause of disability and second most common cause of death worldwide (see "Etiology,
classification, and epidemiology of stroke", section on 'Epidemiology'). Clinicians are often asked to predict outcome after stroke by the patient,
family, other healthcare workers, and insurance providers. A wide variety of factors influence stroke prognosis, including age, stroke severity,
stroke mechanism, infarct location, comorbid conditions, clinical findings, and related complications. In addition, interventions such as
thrombolysis, stroke unit care, and rehabilitation can play a major role in the outcome of ischemic stroke. Knowledge of the important factors
that affect prognosis is necessary for the clinician to make a reasonable prediction for individual patients, to provide a rational approach to
patient management, and to help patient and family understand the course of the disease.
This topic will review the factors that affect stroke prognosis, with a focus on the acute phase of ischemic stroke. The prognosis of intracerebral
hemorrhage and subarachnoid hemorrhage is reviewed separately. (See "Treatment of aneurysmal subarachnoid hemorrhage", section on
'Prognosis' and "Spontaneous intracerebral hemorrhage: Treatment and prognosis", section on 'Prognosis'.)
MAJOR PREDICTORS In the acute phase of stroke, the strongest predictors of outcome are stroke severity and patient age. Stroke severity
can be judged clinically, based upon the degree of neurologic impairment (eg, altered mentation, language, behavior, visual field deficit, motor
deficit) and the size and location of the infarction on neuroimaging with MRI or CT. Other important influences on stroke outcome include
ischemic stroke mechanism, comorbid conditions, epidemiologic factors, and complications of stroke.
Neurologic severity The severity of stroke on neurologic exam is probably the most important factor affecting short- and long-term outcome
[1-14]. As a general rule, large strokes with severe initial clinical deficits have poor outcomes compared with smaller strokes.
Neurologic impairment is measured quantitatively in many research studies, and increasingly in clinical practice, by use of the National
Institutes of Health Stroke Scale (NIHSS), which measures neurologic impairment using a 15-item scale (table 1) or less often by use of the
Canadian Neurological Scale (table 2). As an example, the combination of neurologic findings in patients with a large infarction involving the
middle cerebral artery vascular territory typically includes forced gaze deviation, visual field deficit, hemiplegia, and aphasia or neglect,
depending on the hemisphere involved, and yields a NIHSS score >15 for a right hemisphere infarction and >20 for a left hemisphere infarction.

Several studies have demonstrated that the NIHSS is a good predictor of stroke outcome [2,15-17]. One report analyzed NIHSS scores obtained
within 24 hours of acute ischemic stroke symptom onset from over 1200 patients enrolled in a clinical trial [2]. Each additional point on the
NIHSS decreased the odds of an excellent outcome at three months by 17 percent. At three months, the proportion of patients with excellent
outcomes for NIHSS scores of 7 to 10 and 11 to 15 was approximately 46 and 23 percent, respectively. An NIHSS score of 6 predicted a good
recovery (able to live independently, whether or not able to return to work or school), while a score 16 was associated with a high probability of
death or severe disability. In many such studies, descriptors such as "good recovery" are based upon discharge location to home or independence
in activities of daily living such as mobility. However, the NIHSS does not evaluate more complex goals such as return to prior level of
employment, participation in leisure activities, or social participation. In general, recovery of these areas is less than those measured by the
NIHSS.
The relationship of NIHSS score with final outcome varies according to the time elapsed from stroke onset [9,15], in part because early strokerelated deficits tend to be unstable, and because many patients experience gradual recovery. Thus, the NIHSS score associated with a specific
disability outcome shifts to lower values over time [9]. One study found that the best predictor of poor prognosis at 24 hours was an NIHSS of
>22, and the best predictor at 7 to 10 days was an NIHSS score of >16 [15]. In addition, the correlation of the NIHSS score with final disability
outcome increases with time [9].
The Canadian Neurological Scale (CNS) is also useful for predicting outcome after acute ischemic stroke. A CNS score of <6.5 on admission is
associated with increased 30-day mortality and a poor outcome at six months [17,18]. Although comparative data are limited, the results of one
study suggest that the NIHSS is more accurate than the CNS for predicting outcome at three months [16].
An important limitation of both the NIHSS and the CNS scales is that they do not capture all stroke-related impairments. (See "Use and utility of
stroke scales and grading systems", section on 'Stroke impairment scales'.)
Age Advancing age has a major negative impact on stroke morbidity, mortality, and long-term outcome [1,5,7,10,12,19-23]. The influence of
age in stroke outcome is seen in both minor and major strokes. Older adults (over 65 years) have increased chance of dying in two months after
stroke and being discharged to the skilled nursing facility if they survive [24,25]. Advancing age is used in several predictive models. (See
'Global prognostic scales' below.)
Neuroimaging Findings on neuroimaging including stroke size and location are an important adjunct to the neurologic exam when gauging
prognosis. Early after stroke, the neurologic exam alone can suggest a falsely grim or favorable prognosis. For example, a patient may have a

small stroke on neuroimaging and present with stupor or coma caused by seizure or metabolic derangement that is reversible. Conversely, a
patient presenting with mild stroke and a low NIHSS score on examination may have large vessel occlusion and a large perfusion deficit on
neuroimaging, suggesting the possibility of stroke progression and worse outcome.
Infarct volume The volume of acute infarction on neuroimaging studies may be used to estimate stroke outcome [26]. In one small study, the
volume of ischemic tissue determined by diffusion-weighted MRI within 36 hours of stroke onset combined with the NIHSS score and time
from stroke onset to imaging predicted the functional outcome at three months better than any of the individual factors alone [11]. A much larger
study analyzed data from over 1800 patients who had CT or MRI within 72 hours of ischemic stroke onset and found that initial infarct volume
was an independent predictor of stroke outcome at 90 days, along with age and NIHSS score [8]. In these and most other reports [8,11,26], the
vast majority of infarcts analyzed were supratentorial (eg, anterior circulation, middle cerebral artery territory) and the results may not apply to
posterior circulation or infratentorial infarcts, in which an infarct of small volume can result in severe disability.
Infarct location The prognosis for stroke recovery may vary by the affected vascular territory and site of ischemic brain injury.
Acute occlusion of the cervical internal carotid artery [27,28], basilar artery [29], or a large intracranial artery is associated with an increased
risk of poor outcome [30-32]. It follows that involvement of total anterior circulation or posterior circulation also portends poor prognosis
[18,33-35].
Strokes in the insular region (supplied by the insular branch of the middle cerebral artery) have been associated with increased mortality, which
is often attributed to autonomic dysregulation [36,37]. However, this association may be confounded by infarct size [38]. Insular infarcts may
undergo early expansion due to associated large vessel occlusion and progression of infarction in surrounding areas of initially viable but
ischemic brain tissue [39].
Anterior choroidal artery infarctions may be more likely to progress in the first few days after stroke than other subtypes [40,41]. In a
prospective study of over 1300 patients with acute ischemic stroke, anterior choroidal territory infarcts had intermediate long-term prognosis
between lacunar infarcts and large artery territory hemispheric infarcts [40].
A retrospective report of 75 survivors of ischemic stroke in the middle cerebral artery territory found that strokes located in the internal capsule
demonstrated a worse prognosis for recovery of hand motor function at one year than strokes in the corona radiata or motor cortex after
controlling for infarct size [42].

There are limited and conflicting data regarding borderzone infarcts (ie, infarcts that occur along the boundaries of adjacent arterial territories,
such as the middle cerebral and anterior cerebral artery territories) and outcome; some studies suggest a lower severity at onset and a good
prognosis in most cases [43], while others describe severe impairment and poor recovery in a substantial proportion [44,45].
Other imaging findings In addition to stroke volume and location, there are other features identifiable on neuroimaging that may suggest poor
prognosis:
Diffusion-perfusion mismatch (ie, an ischemic brain lesion characterized by a core of infarcted tissue on MRI diffusion imaging that is
embedded within a still viable but ischemic penumbral region on MRI perfusion imaging), which may be a risk factor for lesion enlargement
(see "Neuroimaging of acute ischemic stroke", section on 'Identifying reversible ischemia')
Poor collateral blood flow [46,47]
Development of cerebral edema in nonlacunar ischemic stroke [48]
Acute corticospinal tract Wallerian degeneration [49]
Ischemic stroke mechanism The etiology or mechanism of ischemic stroke influences prognosis for recovery [50].
Patients with lacunar infarcts have a better prognosis up to one year after onset than those with infarcts due to other stroke mechanisms.
However, the longer-term prognosis after lacunar stroke may not differ greatly from nonlacunar stroke. (See "Lacunar infarcts", section on
'Prognosis'.)
Compared with other ischemic stroke subtypes, cryptogenic stroke, where no mechanism of stroke is identified, tends to have a better
prognosis up to one year following onset. (See "Cryptogenic stroke", section on 'Natural history and prognosis'.)
Patients with strokes of cardioembolic or large artery etiology tend to have worse prognosis for recovery compared with other ischemic stroke
subtypes [50-53].

Comorbidities A host of prestroke comorbid conditions are associated with an increased risk of poor outcome following ischemic stroke,
including the following:
Atrial fibrillation [4,7,15,54,55]
Cancer [4,54]
Coronary artery disease [4]
Dementia [4,10,56]
Dependency [4,22,54]
Diabetes mellitus [14,57,58]
Hyperglycemia (eg, blood glucose >6.1 mmol/L [>110 mg/dL]) on admission [58,59]
Heart failure [4,54]
Myocardial infarction [60,61]
Periventricular white matter disease or leukoaraiosis [62,63]
Renal dysfunction or dialysis [4,64-68]
Poor nutritional status [69]
Low hemoglobin level [70]

The relationship between blood pressure in the acute phase of ischemic stroke and outcome is complex and is discussed separately. (See "Initial
assessment and management of acute stroke", section on 'Blood pressure management'.)
Body mass index appears to be inversely related to stroke prognosis, such that patients who are underweight or normal weight have
paradoxically higher mortality rates and worse functional outcomes than patients who are overweight or obese [71-73].
Finally, ischemic stroke that occurs in the postoperative period has a high short-term morbidity [74].
Epidemiologic factors Differences in sex, race, and socioeconomic status may affect stroke recovery. There are conflicting data regarding sex
differences and stroke outcome. While some studies found that men were more likely than women to have poor outcomes after ischemic stroke
[4,70,75,76], others found that women had worse outcomes [6,77-83], and still others found no significant difference in outcomes according to
gender [2,10].
There are racial and ethnic differences in outcome after stroke. In studies from the United States, black or nonwhite race is associated with a
higher risk for poor outcome [62,80,84]. Lower levels of educational attainment [85,86], socioeconomic status [86-88], and lesser degrees of
social support have been correlated with poor outcome following ischemic stroke, and a lower socioeconomic status has been associated with a
worse health-related quality of life at five years [89,90]. However, it is unclear if these are independent prognostic factors, since lower
socioeconomic status may also be associated with increased comorbidities and greater stroke severity [91,92].
Complications of stroke Medical complications of acute ischemic stroke are common and influence outcome after ischemic stroke. The most
frequent serious medical complications include pneumonia, the need for intubation and mechanical ventilation, gastrointestinal bleeding,
congestive heart failure, cardiac arrest, deep vein thrombosis, pulmonary embolism, and urinary tract infection. (See "Medical complications of
stroke" and "Stroke-related pulmonary complications and abnormal respiratory patterns" and "Cardiac complications of stroke".)
Early neurologic deterioration during the acute phase of ischemic stroke affects a significant minority and is associated with an increased risk of
morbidity and mortality [93-98]. The mechanisms of early neurologic deterioration are heterogeneous and include extension of the infarct into
surrounding areas of hypoperfused brain tissue, progressive edema, increased intracranial pressure, seizure, and hemorrhagic conversion of the
infarct.

Neurologic complications of ischemic stroke can include the development of seizures, cerebral edema, hemorrhagic transformation, and
increased intracranial pressure. Delirium, characterized by a disturbance of consciousness with decreased attention and disorganized thinking, is
another potential complication of stroke.
Poststroke depression has a high prevalence and a negative impact on stroke outcome [56]. Stroke severity with subsequent disability and
cognitive impairment are likely risk factors. (See "Medical complications of stroke", section on 'Depression'.)
PREDICTING RECOVERY In the period from 12 hours to seven days after ischemic stroke onset, many patients who are without
complications experience moderate but steady improvement in neurologic impairments [99].
The greatest proportion of recovery after stroke occurs in the first 3 to 6 months [3,6,100,101], though some patients experience further
improvement up to 18 months [6]. In a prospective study that evaluated more than 1100 patients from Denmark with acute stroke, those who had
mild disability tended to recover within two months and those who had moderate disability recovered within three months [3,101]. Patients with
severe disability who recovered did so within four months, and those with the most severe disability within five months from onset (figure 1).
Functional recovery was preceded by neurologic recovery by two weeks on average.
Other data suggest that functional outcome at three months after stroke predicts survival at four years [62], and functional status at six months
predicts long-term survival [102].
Specific neurologic deficits Attempting to predict recovery from specific neurologic deficits is challenging and best provided by an
experienced neurologist or physiatrist after careful clinical examination and review of pertinent neuroimaging. The time course and degree of
improvement may vary for specific deficits, but as a general rule, mild deficits improve more rapidly and more completely than severe deficits
[100].
Arm and hand weakness An early study found that in patients with hemiplegic stroke, the first voluntary movements were observed
between 6 to 33 days after onset [103]. In a prospective report of patients with arm disability, the maximum degree of functional recovery was
reached within three weeks from stroke onset by 80 percent of patients, and within nine weeks by 95 percent [104]. Complete functional arm
recovery was achieved by patients with initial mild and severe arm paresis in 79 and 18 percent, respectively.

The return of arm and hand function after stroke is particularly important to a good functional recovery. The flexor synergy seen after stroke
limits the ability to isolate joint movements, so the ability to extend the fingers and release grasp is a significant component of a good motor
outcome. Several studies have found that early active finger extension, grasp release, shoulder shrug, shoulder abduction, and active range of
motion are associated with a favorable prognosis for arm and hand recovery at six months [105-108]. As an example, in a prospective cohort
study of 188 patients with monoparesis or hemiparesis from anterior circulation ischemic stroke observed, patients with some voluntary finger
extension and shoulder abduction of the hemiplegic limb on day two after stroke onset had a high probability (0.98) to regain some dexterity by
six months [109]. In contrast, the probability for patients without these voluntary movements at two and nine days was 0.25 and 0.14,
respectively.
Leg weakness and ambulation In a study of 154 patients who were unable to walk after first ischemic stroke, multivariate modeling showed
that patients who could maintain sitting balance for 30 seconds and perform muscle contraction (with or without actual limb movement) in the
paretic leg within the first 72 hours after stroke had a probability for ambulating independently at six months of 98 percent [110]. For those who
did not reach either functional level within 72 hours, the probability for ambulating independently at six months was only 27 percent.
Aphasia Patients with poststroke aphasia are likely to experience some improvement from the initial impairment. Not surprisingly, the
prognosis for full recovery is greatest when patients have milder degrees of aphasia at onset. The time course for recovery from aphasia is
similar to that of motor function. One prospective study included over 300 patients with aphasia at admission; the time to maximal language
recovery in 95 percent of patients with initially mild, moderate, and severe aphasia was 2, 6, and 10 weeks, respectively [111]. (See "Aphasia:
Prognosis and treatment".)
Dysphagia Early after stroke, approximately 50 percent of patients have difficulty swallowing, placing them at risk for aspiration [112].
Swallowing impairments commonly improve over time. A large multicenter trial found no benefit to early enteral feeding via a percutaneous
endoscopic gastrostomy (PEG) tube compared with no tube feeding [113]. Risk factors for more longstanding dysphagia eventually requiring
PEG tube placement include high National Institutes of Health Stroke Scale (NIHSS) score and bihemispheric infarcts [114,115]. In a
retrospective cohort study of 563 patients admitted for stroke rehabilitation, feeding tubes were placed in 6 percent [116]. Of these,
approximately one-third of feeding tubes were discontinued before patients were discharged from rehabilitation, and almost all of the rest were
discontinued by one year. Persons with stroke lesions that were bilateral or in the posterior fossa were least likely to return to oral feeding. (See
"Medical complications of stroke", section on 'Dysphagia and aspiration'.)

Sensory loss Sensory impairment is found in 65 to 94 percent of stroke survivors; the reported incidence depends greatly on the method of
assessment, with formal quantitative testing being the most sensitive [117]. Sensory loss is also common on the apparently unaffected side.
Sensory impairment is associated with reduced mobility and less independence in activities of daily living [118]. However, there are currently no
reliable predictors of recovery from sensory loss. Patients with infarcts involving the spinothalamic or trigeminothalamic pathways sometimes
develop a debilitating central poststroke pain syndrome [119]. (See "Approach to the patient with sensory loss", section on 'Thalamic lesions'.)
Visuospatial neglect Limited data suggest that full recovery from visuospatial neglect occurs in 70 to 80 percent of affected patients within
three months of stroke onset [120,121].
Hemianopia A study of 99 patients with acute stroke and homonymous hemianopia (HH) found that 17 percent of those with complete HH
had full recovery at one month, whereas 72 percent with partial HH had full recovery [122]. It is important to counsel patients with hemianopia
after stroke not to drive until they are cleared by an ophthalmologist or pass a formal driver rehabilitation program (offered at select
rehabilitation centers). (See "Homonymous hemianopia", section on 'Driving'.)
Global prognostic scales In stroke rehabilitation venues, the Orpington Prognostic Scale (OPS) [123,124] and the Reding three-factor
approach [125] are in wide clinical use.
The OPS (table 3) includes assessments of arm motor function, proprioception, balance, and cognition, making it easier to perform than the
NIHSS. The OPS is better at predicting return of function than NIHSS in those with mild to moderate stroke [123], possibly because balance is
so critical to carrying out activities of daily living.
The Reding three-factor approach provides a useful way to gauge the speed and degree of recovery for an individual patient [125]. Patients are
divided into one of three groups:
Motor deficit only
Motor deficit plus somatic sensory deficit
Motor deficit plus somatic sensory deficit plus homonymous visual field deficit

Once the group is determined for the individual patient, their recovery can be compared with a cohort of similar patients (figure 2) to estimate
the probability of return to Barthel Index (table 4) score of 60. This level of function is a useful benchmark because most patients with a
Barthel Index score 60 are able to walk with assistance and contribute to their activities of daily living; in addition, the likelihood of a
supported discharge to the community rises substantially. With a Barthel Index score of 100, a discharge to the community at a level of
independence becomes plausible, but requires adequate cognitive function.
A number of other prognostic models may be useful for predicting global outcome from acute ischemic stroke; however, none of the current
models is established as generally valid, and none is widely used in clinical practice. These models include the ASTRAL score [126,127],
DRAGON score [128], iScore [129,130], and PLAN score [54]. These stroke prognostic models are intended to be easy to calculate from data
available on admission. However, they disregard information available from follow-up and testing, such as stroke etiology, treatment, and
complications, that has an important impact on outcome [62,131]. The course of stroke often changes in the first days after onset, and assessment
at later times (eg, from 1 to 10 days after stroke onset) is likely to provide a more reliable prognosis [9].
MORBIDITY AND MORTALITY The estimated worldwide 30-day case fatality rate after first ischemic stroke ranges from 16 to 23 percent,
though there is wide variation in reports from different countries [132,133]. Even minor ischemic strokes portend a diminished long-term
prognosis. In a 10-year follow-up study of 322 patients with minor ischemic stroke, the cumulative mortality rate was 32 percent, almost twice
that of the general population [134].
Intracerebral hemorrhage and subarachnoid hemorrhage are associated with higher morbidity and mortality than ischemic stroke [5,20,21,135137]. (See "Spontaneous intracerebral hemorrhage: Treatment and prognosis", section on 'Prognosis' and "Treatment of aneurysmal subarachnoid
hemorrhage", section on 'Prognosis'.)
In a community-based study from the United States that evaluated 220 ischemic stroke survivors (age 65 years), the following neurologic
deficits were observed at six months after stroke [138]:
Hemiparesis, 50 percent
Cognitive deficits, 46 percent
Hemianopia, 20 percent

Aphasia, 19 percent
Sensory deficits, 15 percent
Disability measures at six months after stroke were as follows [138]:
Depression symptoms, 35 percent
Unable to walk unassisted, 31 percent
Social disability, 30 percent
Institutionalization, 26 percent
Bladder incontinence, 22 percent
A systematic review from 2009 identified only three studies that specifically evaluated work status after stroke and used appropriate analytic
methods [139]. In these reports, the proportion of patients at 6 to 12 months after stroke who had returned to paid employment was just over 50
percent [140-142]. A subsequent report evaluated a hospital-based cohort of 694 working-age (18 to 50 years) patients with transient ischemic
attack (TIA), ischemic stroke, or hemorrhagic stroke and found that the risk of unemployment after eight years of follow-up was two- to
threefold higher compared with the general population of vocational age [143].
Outcome from ischemic stroke can be assessed with the modified Rankin Scale and the Barthel Index. The modified Rankin Scale (table 5)
measures functional independence on a seven grade scale. The Barthel Index (table 4) measures 10 basic aspects of self-care and physical
dependency. These indices are reviewed in greater detail elsewhere. (See "Use and utility of stroke scales and grading systems", section on
'Modified Rankin Scale' and "Use and utility of stroke scales and grading systems", section on 'Barthel Index'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a

patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
Basics topics (see "Patient information: Recovery after stroke (The Basics)")
SUMMARY AND RECOMMENDATIONS
In the acute phase of stroke, the strongest predictors of outcome are stroke severity and patient age. Stroke severity can be judged clinically,
based upon the degree of neurologic impairment (eg, altered mentation, language, behavior, visual field deficit, motor deficit), and the size and
location of the infarction on neuroimaging with MRI or CT. Other important influences on stroke outcome include infarct location, ischemic
stroke mechanism, comorbid conditions, epidemiologic factors, and complications of stroke. (See 'Major predictors' above.)
In the period from 12 hours to seven days after ischemic stroke onset, many patients who are without complications experience moderate but
steady improvement in neurologic impairments. The greatest proportion of recovery occurs in the first three to six months after stroke, with
lesser improvements thereafter. (See 'Predicting recovery' above.)
The return of arm and hand function after stroke is particularly important to a good functional recovery. Early active finger extension, grasp
release, shoulder shrug, shoulder abduction, and active range of motion are associated with a favorable prognosis for arm and hand recovery at
six months. (See 'Specific neurologic deficits' above.)
The estimated 30-day case fatality rate after first ischemic stroke ranges from 16 to 23 percent. Available data suggest that persistent neurologic
deficits observed at six months after stroke include hemiparesis and cognitive deficits in 40 to 50 percent of patients, and hemianopia, aphasia, or
sensory deficits in 15 to 20 percent. Disability outcomes at six months after stroke include depression, inability to walk unassisted, and social
impairments in approximately 30 percent, and institutional care in approximately 25 percent. (See 'Morbidity and mortality' above.)