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!tro"e prognosis in adults

#$T%&DU'T#&$ ( !tro"e is the third most common cause of disability and second most common cause of death worldwide )see *+tiology,

classification, and epidemiology of stro"e*, section on -+pidemiology-

. 'linicians are often as"ed to predict outcome after stro"e by the patient,

family, other healthcare wor"ers, and insurance providers. / wide variety of factors influence stro"e prognosis, including age, stro"e severity,

stro"e mechanism, infarct location, comorbid conditions, clinical findings, and related complications. #n addition, interventions such as

thrombolysis, stro"e unit care, and rehabilitation can play a maor role in the outcome of ischemic stro"e. nowledge of the important factors

that affect prognosis is necessary for the clinician to ma"e 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 stro"e prognosis, with a focus on the acute phase of ischemic stro"e. The prognosis of intracerebral

hemorrhage and subarachnoid hemorrhage is reviewed separately. )!ee *Treatment of aneurysmal subarachnoid hemorrhage*, section on-rognosis- and *!pontaneous intracerebral hemorrhage3 Treatment and prognosis*, section on -rognosis-.

4/5&% %+D#'T&%! ( #n the acute phase of stro"e, the strongest predictors of outcome are stro"e severity and patient age. !tro"e severity

can be udged clinically, based upon the degree of neurologic impairment )eg, altered mentation, language, behavior, visual field deficit, motor

deficit and the si6e and location of the infarction on neuroimaging with 4%# or 'T. &ther important influences on stro"e outcome include

ischemic stro"e mechanism, comorbid conditions, epidemiologic factors, and complications of stro"e.

 $eurologic severity ( The severity of stro"e on neurologic e7am is probably the most important factor affecting short8 and long8term outcome

9181:;. /s a general rule, large stro"es with severe initial clinical deficits have poor outcomes compared with smaller stro"es.

 $eurologic impairment is measured quantitatively in many research studies, and increasingly in clinical practice, by use of the $ational

#nstitutes of <ealth !tro"e !cale )$#<!!, which measures neurologic impairment using a 18item scale )table 1

or less often by use of the

'anadian $eurological !cale )table 2. /s an e7ample, the combination of neurologic findings in patients with a large infarction involving themiddle cerebral artery vascular territory typically includes forced ga6e deviation, visual field deficit, hemiplegia, and aphasia or neglect,depending on the hemisphere involved, and yields a $#<!! score =1 for a right hemisphere infarction and =20 for a left hemisphere infarction.

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!everal studies have demonstrated that the $#<!! is a good predictor of stro"e outcome 92,181>;. &ne report analy6ed $#<!! scores obtained

within 2: hours of acute ischemic stro"e symptom onset from over 1200 patients enrolled in a clinical trial 92;. +ach additional point on the

 $#<!! decreased the odds of an e7cellent outcome at three months by 1> percent. /t three months, the proportion of patients with e7cellent

outcomes for $#<!! scores of > to 10 and 11 to 1 was appro7imately :? and 2@ percent, respectively. /n $#<!! score of A? predicted a good

recovery )able to live independently, whether or not able to return to wor" or school, while a score B1? was associated with a high probability of 

death or severe disability. #n 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. <owever, the $#<!! does not evaluate more comple7 goals such as return to prior level of

employment, participation in leisure activities, or social participation. #n general, recovery of these areas is less than those measured by the

 $#<!!.

The relationship of $#<!! score with final outcome varies according to the time elapsed from stro"e onset 9C,1;, in part because early stro"e8

related deficits tend to be unstable, and because many patients e7perience gradual recovery. Thus, the $#<!! score associated with a specificdisability outcome shifts to lower values over time 9C

;. &ne study found that the best predictor of poor prognosis at 2: hours was an $#<!! of

=22, and the best predictor at > to 10 days was an $#<!! score of =1? 91;. #n addition, the correlation of the $#<!! score with final disability

outcome increases with time 9C;.

The 'anadian $eurological !cale )'$! is also useful for predicting outcome after acute ischemic stro"e. / '$! score of ?. on admission is

associated with increased @08day mortality and a poor outcome at si7 months 91>,1E;. /lthough comparative data are limited, the results of one

study suggest that the $#<!! is more accurate than the '$! for predicting outcome at three months 91?

;.

/n important limitation of both the $#<!! and the '$! scales is that they do not capture all stro"e8related impairments. )!ee *Use and utility of 

stro"e scales and grading systems*, section on -!tro"e impairment scales-.

/ge ( /dvancing age has a maor negative impact on stro"e morbidity, mortality, and long8term outcome 91,,>,10,12,1C82@;. The influence of

age in stro"e outcome is seen in both minor and maor stro"es. &lder adults )over ? years have increased chance of dying in two months after

stro"e and being discharged to the s"illed nursing facility if they survive 92:,2;. /dvancing age is used in several predictive models. )!ee-Flobal prognostic scales-  below.

 $euroimaging ( Gindings on neuroimaging including stro"e si6e and location are an important adunct to the neurologic e7am when gauging

 prognosis. +arly after stro"e, the neurologic e7am alone can suggest a falsely grim or favorable prognosis. Gor e7ample, a patient may have a

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small stro"e on neuroimaging and present with stupor or coma caused by sei6ure or metabolic derangement that is reversible. 'onversely, a

 patient presenting with mild stro"e and a low $#<!! score on e7amination may have large vessel occlusion and a large perfusion deficit on

neuroimaging, suggesting the possibility of stro"e progression and worse outcome.

#nfarct volume ( The volume of acute infarction on neuroimaging studies may be used to estimate stro"e outcome 92?;. #n one small study, the

volume of ischemic tissue determined by diffusion8weighted 4%# within @? hours of stro"e onset combined with the $#<!! score and time

from stro"e onset to imaging predicted the functional outcome at three months better than any of the individual factors alone 911;. / much larger

study analy6ed data from over 1E00 patients who had 'T or 4%# within >2 hours of ischemic stro"e onset and found that initial infarct volume

was an independent predictor of stro"e outcome at C0 days, along with age and $#<!! score 9E;. #n these and most other reports 9E,11,2?;, the

vast maority of infarcts analy6ed 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.

#nfarct location ( The prognosis for stro"e recovery may vary by the affected vascular territory and site of ischemic brain inury.

H/cute occlusion of the cervical internal carotid artery 92>,2E

;, basilar artery 92C;, or a large intracranial artery is associated with an increasedris" of poor outcome 9@08@2;. #t follows that involvement of total anterior circulation or posterior circulation also portends poor prognosis

91E,@@8@;.

H!tro"es 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 9@?,@>;. <owever, this association may be confounded by infarct si6e 9@E;. #nsular infarcts may

undergo early e7pansion due to associated large vessel occlusion and progression of infarction in surrounding areas of initially viable but

ischemic brain tissue 9@C;.

H/nterior choroidal artery infarctions may be more li"ely to progress in the first few days after stro"e than other subtypes 9:0,:1;. #n a

 prospective study of over 1@00 patients with acute ischemic stro"e, anterior choroidal territory infarcts had intermediate long8term prognosis

 between lacunar infarcts and large artery territory hemispheric infarcts 9:0

;.

H/ retrospective report of > survivors of ischemic stro"e in the middle cerebral artery territory found that stro"es located in the internal capsuledemonstrated a worse prognosis for recovery of hand motor function at one year than stro"es in the corona radiata or motor corte7 after

controlling for infarct si6e 9:2;.

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'omorbidities ( / host of prestro"e comorbid conditions are associated with an increased ris" of poor outcome following ischemic stro"e,

including the following3

H/trial fibrillation 9:,>,1,:,;

H'ancer 9:,:;

H'oronary artery disease 9:;

HDementia 9:,10,?;

HDependency 9:,22,:

;

HDiabetes mellitus 91:,>,E;

H<yperglycemia )eg, blood glucose =?.1 mmolLK 9=110 mgLdK; on admission 9E,C;

H<eart failure 9:,:;

H4yocardial infarction 9?0,?1;

Heriventricular white matter disease or leu"oaraiosis 9?2,?@

;

H%enal dysfunction or dialysis 9:,?:8?E;

Hoor nutritional status 9?C;

HKow hemoglobin level 9>0;

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The relationship between blood pressure in the acute phase of ischemic stro"e and outcome is comple7 and is discussed separately. )!ee *#nitial

assessment and management of acute stro"e*, section on -Mlood pressure management-.

Mody mass inde7 appears to be inversely related to stro"e prognosis, such that patients who are underweight or normal weight have

 parado7ically higher mortality rates and worse functional outcomes than patients who are overweight or obese 9>18>@;.

Ginally, ischemic stro"e that occurs in the postoperative period has a high short8term morbidity 9>:;.

+pidemiologic factors ( Differences in se7, race, and socioeconomic status may affect stro"e recovery. There are conflicting data regarding se7

differences and stro"e outcome. Jhile some studies found that men were more li"ely than women to have poor outcomes after ischemic stro"e

9:,>0,>,>?;, others found that women had worse outcomes 9?,>>8E@;, and still others found no significant difference in outcomes according to

gender 92,10;.

There are racial and ethnic differences in outcome after stro"e. #n studies from the United !tates, blac" or nonwhite race is associated with a

higher ris" for poor outcome 9?2,E0,E:;. Kower levels of educational attainment 9E,E?;, socioeconomic status 9E?8EE;, and lesser degrees ofsocial support have been correlated with poor outcome following ischemic stro"e, and a lower socioeconomic status has been associated with a

worse health8related quality of life at five years 9EC,C0;. <owever, it is unclear if these are independent prognostic factors, since lower

socioeconomic status may also be associated with increased comorbidities and greater stro"e severity 9C1,C2;.

'omplications of stro"e ( 4edical complications of acute ischemic stro"e are common and influence outcome after ischemic stro"e. 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. )!ee *4edical complications of

stro"e* and *!tro"e8related pulmonary complications and abnormal respiratory patterns* and *'ardiac complications of stro"e*.

+arly neurologic deterioration during the acute phase of ischemic stro"e affects a significant minority and is associated with an increased ris" of

morbidity and mortality 9C@8CE;. The mechanisms of early neurologic deterioration are heterogeneous and include e7tension of the infarct intosurrounding areas of hypoperfused brain tissue, progressive edema, increased intracranial pressure, sei6ure, and hemorrhagic conversion of the

infarct.

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 $eurologic complications of ischemic stro"e can include the development of sei6ures, cerebral edema, hemorrhagic transformation, and

increased intracranial pressure. Delirium, characteri6ed by a disturbance of consciousness with decreased attention and disorgani6ed thin"ing, is

another potential complication of stro"e.

oststro"e depression has a high prevalence and a negative impact on stro"e outcome 9?;. !tro"e severity with subsequent disability andcognitive impairment are li"ely ris" factors. )!ee *4edical complications of stro"e*, section on -Depression-.

%+D#'T#$F %+'&N+%O ( #n the period from 12 hours to seven days after ischemic stro"e onset, many patients who are without

complications e7perience moderate but steady improvement in neurologic impairments 9CC

;.

The greatest proportion of recovery after stro"e occurs in the first @ to ? months 9@,?,100,101;, though some patients e7perience further

improvement up to 1E months 9?;. #n a prospective study that evaluated more than 1100 patients from Denmar" with acute stro"e, those who had

mild disability tended to recover within two months and those who had moderate disability recovered within three months 9@,101;. atients withsevere disability who recovered did so within four months, and those with the most severe disability within five months from onset )figure 1

.

Gunctional recovery was preceded by neurologic recovery by two wee"s on average.

&ther data suggest that functional outcome at three months after stro"e predicts survival at four years 9?2;, and functional status at si7 months

 predicts long8term survival 9102;.

!pecific neurologic deficits ( /ttempting to predict recovery from specific neurologic deficits is challenging and best provided by an

e7perienced neurologist or physiatrist after careful clinical e7amination 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

9100;.

HArm and hand weakness P /n early study found that in patients with hemiplegic stro"e, the first voluntary movements were observed

 between ? to @@ days after onset 910@;. #n a prospective report of patients with arm disability, the ma7imum degree of functional recovery wasreached within three wee"s from stro"e onset by E0 percent of patients, and within nine wee"s by C percent 910:;. 'omplete functional arm

recovery was achieved by patients with initial mild and severe arm paresis in >C and 1E percent, respectively.

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The return of arm and hand function after stro"e is particularly important to a good functional recovery. The fle7or synergy seen after stro"e

limits the ability to isolate oint movements, so the ability to e7tend the fingers and release grasp is a significant component of a good motor

outcome. !everal studies have found that early active finger e7tension, grasp release, shoulder shrug, shoulder abduction, and active range of

motion are associated with a favorable prognosis for arm and hand recovery at si7 months 910810E;. /s an e7ample, in a prospective cohort

study of 1EE patients with monoparesis or hemiparesis from anterior circulation ischemic stro"e observed, patients with some voluntary fingere7tension and shoulder abduction of the hemiplegic limb on day two after stro"e onset had a high probability )0.CE to regain some de7terity by

si7 months 910C;. #n contrast, the probability for patients without these voluntary movements at two and nine days was 0.2 and 0.1:,

respectively.

HLeg weakness and ambulation P #n a study of 1: patients who were unable to wal" after first ischemic stro"e, multivariate modeling showed

that patients who could maintain sitting balance for @0 seconds and perform muscle contraction )with or without actual limb movement in the

 paretic leg within the first >2 hours after stro"e had a probability for ambulating independently at si7 months of CE percent 9110;. Gor those whodid not reach either functional level within >2 hours, the probability for ambulating independently at si7 months was only 2> percent.

HAphasia P atients with poststro"e aphasia are li"ely to e7perience some improvement from the initial impairment. $ot 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. &ne prospective study included over @00 patients with aphasia at admissionI the time to ma7imal language

recovery in C percent of patients with initially mild, moderate, and severe aphasia was 2, ?, and 10 wee"s, respectively 9111;. )!ee */phasia3

rognosis and treatment*.

HDysphagia P +arly after stro"e, appro7imately 0 percent of patients have difficulty swallowing, placing them at ris" for aspiration 9112;.

!wallowing impairments commonly improve over time. / large multicenter trial found no benefit to early enteral feeding via a percutaneous

endoscopic gastrostomy )+F tube compared with no tube feeding 911@;. %is" factors for more longstanding dysphagia eventually requiring

+F tube placement include high $ational #nstitutes of <ealth !tro"e !cale )$#<!! score and bihemispheric infarcts 911:,11;. #n a

retrospective cohort study of ?@ patients admitted for stro"e rehabilitation, feeding tubes were placed in ? percent 911?;. &f these,

appro7imately one8third of feeding tubes were discontinued before patients were discharged from rehabilitation, and almost all of the rest werediscontinued by one year. ersons with stro"e lesions that were bilateral or in the posterior fossa were least li"ely to return to oral feeding. )!ee

*4edical complications of stro"e*, section on -Dysphagia and aspiration-.

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HSensory loss P !ensory impairment is found in ? to C: percent of stro"e survivorsI the reported incidence depends greatly on the method of

assessment, with formal quantitative testing being the most sensitive 911>;. !ensory loss is also common on the apparently unaffected side.

!ensory impairment is associated with reduced mobility and less independence in activities of daily living 911E;. <owever, there are currently no

reliable predictors of recovery from sensory loss. atients with infarcts involving the spinothalamic or trigeminothalamic pathways sometimes

develop a debilitating central poststro"e pain syndrome 911C;. )!ee */pproach to the patient with sensory loss*, section on -Thalamic lesions-.

HVisuospatial neglect P Kimited data suggest that full recovery from visuospatial neglect occurs in >0 to E0 percent of affected patients within

three months of stro"e onset 9120,121;.

HHemianopia P / study of CC patients with acute stro"e and homonymous hemianopia )<< found that 1> percent of those with complete <<

had full recovery at one month, whereas >2 percent with partial << had full recovery 9122;. #t is important to counsel patients with hemianopia

after stro"e not to drive until they are cleared by an ophthalmologist or pass a formal driver rehabilitation program )offered at select

rehabilitation centers. )!ee *<omonymous hemianopia*, section on -Driving-.

Flobal prognostic scales ( #n stro"e rehabilitation venues, the &rpington rognostic !cale )&! 912@,12:; and the %eding three8factorapproach 912; are in wide clinical use.

HThe &! )table @ includes assessments of arm motor function, proprioception, balance, and cognition, ma"ing it easier to perform than the

 $#<!!. The &! is better at predicting return of function than $#<!! in those with mild to moderate stro"e 912@;, possibly because balance is

so critical to carrying out activities of daily living.

HThe %eding three8factor approach provides a useful way to gauge the speed and degree of recovery for an individual patient 912;. atients are

divided into one of three groups3

Q4otor deficit only

Q4otor deficit plus somatic sensory deficit

Q4otor deficit plus somatic sensory deficit plus homonymous visual field deficit

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&nce 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 Marthel #nde7 )table : score of B?0. This level of function is a useful benchmar" because most patients with a

Marthel #nde7 score B?0 are able to wal" with assistance and contribute to their activities of daily livingI in addition, the li"elihood of a

supported discharge to the community rises substantially. Jith a Marthel #nde7 score of 100, a discharge to the community at a level of

independence becomes plausible, but requires adequate cognitive function.

/ number of other prognostic models may be useful for predicting global outcome from acute ischemic stro"eI however, none of the current

models is established as generally valid, and none is widely used in clinical practice. These models include the /!T%/K score 912?,12>;,

D%/F&$ score 912E;, i!core 912C,1@0;, and K/$ score 9:;. These stro"e prognostic models are intended to be easy to calculate from data

available on admission. <owever, they disregard information available from follow8up and testing, such as stro"e etiology, treatment, and

complications, that has an important impact on outcome 9?2,1@1;. The course of stro"e often changes in the first days after onset, and assessment

at later times )eg, from 1 to 10 days after stro"e onset is li"ely to provide a more reliable prognosis 9C;.

4&%M#D#TO /$D 4&%T/K#TO ( The estimated worldwide @08day case fatality rate after first ischemic stro"e ranges from 1? to 2@ percent,

though there is wide variation in reports from different countries 91@2,1@@;. +ven minor ischemic stro"es portend a diminished long8term prognosis. #n a 108year follow8up study of @22 patients with minor ischemic stro"e, the cumulative mortality rate was @2 percent, almost twice

that of the general population 91@:;.

#ntracerebral hemorrhage and subarachnoid hemorrhage are associated with higher morbidity and mortality than ischemic stro"e 9,20,21,1@8

1@>;. )!ee *!pontaneous intracerebral hemorrhage3 Treatment and prognosis*, section on -rognosis- and *Treatment of aneurysmal subarachnoid

hemorrhage*, section on -rognosis-.

#n a community8based study from the United !tates that evaluated 220 ischemic stro"e survivors )age B? years, the following neurologic

deficits were observed at si7 months after stro"e 91@E;3

H<emiparesis, 0 percent

H'ognitive deficits, :? percent

H<emianopia, 20 percent

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H/phasia, 1C percent

H!ensory deficits, 1 percent

Disability measures at si7 months after stro"e were as follows 91@E;3

HDepression symptoms, @ percent

HUnable to wal" unassisted, @1 percent

H!ocial disability, @0 percent

H#nstitutionali6ation, 2? percent

HMladder incontinence, 22 percent

/ systematic review from 200C identified only three studies that specifically evaluated wor" status after stro"e and used appropriate analytic

methods 91@C;. #n these reports, the proportion of patients at ? to 12 months after stro"e who had returned to paid employment was ust over 0 percent 91:081:2;. / subsequent report evaluated a hospital8based cohort of ?C: wor"ing8age )1E to 0 years patients with transient ischemic

attac" )T#/, ischemic stro"e, or hemorrhagic stro"e and found that the ris" of unemployment after eight years of follow8up was two8 to

threefold higher compared with the general population of vocational age 91:@;.

&utcome from ischemic stro"e can be assessed with the modified %an"in !cale and the Marthel #nde7. The modified %an"in !cale )table

measures functional independence on a seven grade scale. The Marthel #nde7 )table : measures 10 basic aspects of self8care and physical

dependency. These indices are reviewed in greater detail elsewhere. )!ee *Use and utility of stro"e scales and grading systems*, section on

-4odified %an"in !cale- and *Use and utility of stro"e scales and grading systems*, section on -Marthel #nde7-.

#$G&%4/T#&$ G&% /T#+$T! ( UpToDate offers two types of patient education materials, *The Masics* and *Meyond the Masics.* The

Masics patient education pieces are written in plain language, at the th to ?th grade reading level, and they answer the four or five "ey questions a

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 patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy8to8read

materials. Meyond the Masics 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 in8depth information and are comfortable with some medical argon.

<ere are the patient education articles that are relevant to this topic. Je encourage you to print or e8mail these topics to your patients. )Oou canalso locate patient education articles on a variety of subects by searching on *patient info* and the "eyword)s of interest.

HMasics topics )see *atient information3 %ecovery after stro"e )The Masics*

!U44/%O /$D %+'&44+$D/T#&$!

H#n the acute phase of stro"e, the strongest predictors of outcome are stro"e severity and patient age. !tro"e severity can be udged clinically,

 based upon the degree of neurologic impairment )eg, altered mentation, language, behavior, visual field deficit, motor deficit, and the si6e and

location of the infarction on neuroimaging with 4%# or 'T. &ther important influences on stro"e outcome include infarct location, ischemic

stro"e mechanism, comorbid conditions, epidemiologic factors, and complications of stro"e. )!ee -4aor predictors- above.

H#n the period from 12 hours to seven days after ischemic stro"e onset, many patients who are without complications e7perience moderate but

steady improvement in neurologic impairments. The greatest proportion of recovery occurs in the first three to si7 months after stro"e, with

lesser improvements thereafter. )!ee -redicting recovery- above.

HThe return of arm and hand function after stro"e is particularly important to a good functional recovery. +arly active finger e7tension, grasp

release, shoulder shrug, shoulder abduction, and active range of motion are associated with a favorable prognosis for arm and hand recovery at

si7 months. )!ee -!pecific neurologic deficits- above.

HThe estimated @08day case fatality rate after first ischemic stro"e ranges from 1? to 2@ percent. /vailable data suggest that persistent neurologic

deficits observed at si7 months after stro"e include hemiparesis and cognitive deficits in :0 to 0 percent of patients, and hemianopia, aphasia, or sensory deficits in 1 to 20 percent. Disability outcomes at si7 months after stro"e include depression, inability to wal" unassisted, and social

impairments in appro7imately @0 percent, and institutional care in appro7imately 2 percent. )!ee -4orbidity and mortality- above.