Department of Neurology (E.A.M.), Vanderbilt University Medical Center, Nashville, TN.
Public Health Sciences, Medical University of South Carolina, Charleston (S.Y.).
Stroke. 2021 Aug;52(8):2547-2553. doi: 10.1161/STROKEAHA.120.032487. Epub 2021 May 18.
The National Institutes of Health Stroke Scale (NIHSS) measured at an early time point is an appealing surrogate marker for long-term functional outcome of stroke patients treated with endovascular therapy. However, definitions and analytical methods for an early NIHSS-based outcome measure that optimize power and precision in clinical studies are not well-established.
In this post-hoc analysis of our prospective observational study that enrolled endovascular therapy-treated patients at 12 comprehensive stroke centers across the US, we compared the ability of 24-hour NIHSS, ΔNIHSS (baseline minus 24-hour NIHSS), and percentage change (NIHSS×100/baseline NIHSS), analyzed as continuous and dichotomous measures, to predict 90-day modified Rankin Scale (mRS) using logistic regression (adjusted for age, baseline NIHSS, glucose, hypertension, Alberta Stroke Program Early CT Score, time to recanalization, recanalization status, and intravenous thrombolysis) and Spearman ρ.
Of 485 patients in the BEST (Blood Pressure After Endovascular Stroke Therapy) cohort, 446 (92%) with 90-day follow-up data were included. An absolute 24-hour NIHSS, adjusted for baseline in multivariable modeling, had the highest predictive power of all definitions evaluated (aR 0.368 and adjusted odds ratio 0.79 [0.75-0.84], <0.001 for mRS score 0-2; aR 0.444 and adjusted odds ratio 0.84 [0.8-0.86] for ordinal mRS). For predicting mRS score of 0-2 with a cut point, the second most efficient approach, the optimal threshold for 24-hour NIHSS score was ≤7 (sensitivity 80.1%, specificity 80.4%; adjusted odds ratio 12.5 [7.14-20], <0.001), followed by percent change in NIHSS (sensitivity 79%, specificity 58.5%; adjusted odds ratio 4.55 [2.85-7.69], <0.001).
Twenty-four-hour NIHSS, adjusted for baseline, was the strongest predictor of both dichotomous and ordinal 90-day mRS outcomes for endovascular therapy-treated patients. A dichotomous 24-hour NIHSS score of ≤7 was the second-best predictor. Although ΔNIHSS, continuous and dichotomized at ≥4, predicted 90-day outcomes, absolute 24-hour NIHSS definitions performed better.
美国国立卫生研究院卒中量表（NIHSS）在早期时间点的测量值是一种有吸引力的替代标志物，可以预测接受血管内治疗的卒中患者的长期功能结局。然而，在临床研究中，尚未确定最佳的基于早期 NIHSS 的结局测量定义和分析方法，以提高效能和精度。
本研究是一项在美国 12 家综合卒中中心进行的前瞻性观察性研究的事后分析，共纳入了接受血管内治疗的患者。我们比较了 24 小时 NIHSS、ΔNIHSS（基线减去 24 小时 NIHSS）和百分比变化（NIHSS×100/基线 NIHSS）这三种作为连续和二分变量的测量值在预测 90 天改良 Rankin 量表（mRS）方面的能力，采用 logistic 回归（调整年龄、基线 NIHSS、血糖、高血压、阿尔伯塔卒中计划早期 CT 评分、再通时间、再通状态和静脉溶栓）和 Spearman ρ 进行分析。
在 BEST（血管内卒中治疗后血压）队列的 485 例患者中，有 446 例（92%）具有 90 天随访数据，包括在内。在多变量模型中，经基线调整的绝对 24 小时 NIHSS 对所有评估定义的预测能力最高（mRS 评分 0-2 的绝对风险增加[AR]0.368 和调整后的比值比[OR]0.79[0.75-0.84]，<0.001；mRS 有序量表的 AR0.444 和调整后的 OR0.84[0.8-0.86]）。对于使用截断值预测 mRS 评分 0-2，第二有效的方法是 24 小时 NIHSS 评分的最佳阈值为≤7（敏感性 80.1%，特异性 80.4%；调整后的 OR 12.5[7.14-20]，<0.001），其次是 NIHSS 的百分比变化（敏感性 79%，特异性 58.5%；调整后的 OR 4.55[2.85-7.69]，<0.001）。
经基线调整的 24 小时 NIHSS 是接受血管内治疗的患者的二分类和有序 90 天 mRS 结局的最强预测因子。二分类 24 小时 NIHSS 评分≤7 是第二好的预测因子。虽然 ΔNIHSS、连续和二分变量≥4 也可以预测 90 天的结局，但绝对的 24 小时 NIHSS 定义表现更好。
