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July2010 Vol.47 Issue:      3 (Supp.) Table of Contents
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Role of Early CT in Predicting Recovery of Ischemic Stroke

Mohamed Abdelsalam, Tamer Belal, Maha Hazem, Mohamed Saad

 



ABSTRACT

Background: Prediction of functional outcome immediately after stroke onset is difficult but become easier once it is clear that the patient is likely to survive. Several prognostic factors have been identified for outcome after stroke. Infarction size and site may have a role in motor and functional recovery after stroke. Objective: This study was carried out to evaluate the role of early CT in predicting motor function recovery after stroke. Methods: This is a prospective hospital–based clinical study includes 78 patients with ischemic stroke with specific inclusion and exclusion criteria. Clinical assessment was also done at 1, 7, 30, and 90 days poststroke. CT Brain was carried out in day one after stroke and repeated after one week. Results: According to NIHSS values, 65.4% of patients had no motor recovery and 34.6% of them experienced motor recovery. Infarction size positively influence stroke severity (NIH30) 30 days after stroke onset and this was statistically significant (p=.026). Regarding CT changes one week after stroke onset, the subcortical infarction has a higher significant negative interaction with the motor score (MRC score of upper limb) of the patients (p=.007) in comparison to cortical stroke (p=.020). Conclusion: Overt role of early CT changes is obtained in predicting functional motor recovery of ischemic cerebral stroke if it was accompanied with clinical evaluation. [Egypt J Neurol Psychiat Neurosurg. 2010; 47(3): 407-412]

 

Key words: Ischemic stroke, CT Brain, Recovery.

 

Correspondence for  Mohamed Abdelsalam, Department of neurology, Mansoura University, Egypt.

Tel.: 0502235123/0108626726. Email dr_mabdelsalam@yahoo.com.





INTRODUCTION

 

Early prediction of stroke outcome remains one of the most important and unresolved issue in neurological rehabilitation. The already known predictors of outcome help us to ascertain the chances of recovery poststroke, but none of them, alone or in combination, permits us to determine whether a patient can recuperate from a disability.

A valid prognosis for each stroke patient is needed as early as possible after stroke onset to initiate optimal rehabilitation according to realistic therapy goals. Several clinical and demographic variables have been identified as valid predictors for functional recovery, including age, sitting balance, severity of paresis, disability on admission, urinary incontinence, previous stroke, and the impact of social support.1

Localization and severity of the stroke is discussed in many studies. Large cerebral involvement predicts unfavorable activity of daily living (ADL) after 3 years2. Mortality in young stroke patients (15 to 45 years) is raised after six years if the stroke includes large vessels3. Higher mortality within three months4 as well as a raised risk for incontinence after six months is predicted by

 

the severity of the stroke. Also, a lesion in the right parietal lobe is associated with more unfavorable scores in the Barthel Index at discharge and three months after the event5,6.

This study was carried out to evaluate the role of early CT in predicting motor function recovery after stroke.

 

PATIENTS AND METHODS

 

Seventy eight patients (42 males, 36 females) with ischemic cerebral stroke, admitted to neurology department at Mansoura university hospitals with a mean age of 62.74±10.21 were included in the study. The diagnosis of ischemic stroke was based on clinical history taking and examination and confirmed by CT Brain. The inclusion criteria of patients in this study were: (1) The current episode is the first ever infarction in the territory of the middle cerebral and/or anterior cerebral arteries confirmed by radiological examination (CT Brain), (2) The patients were admitted within 24 hours of the onset of symptoms, (3) No neurological disease other than migraine, and (4) Sufficient cooperation for clinical and neurologic testing.

Exclusion criteria of patients were (1) the history of previous stroke, (2) Presentation one day after the onset of the stroke, (3) those who suffered other neurological disorders especially epilepsy (4) severe moribund patients, comatose or in terminal stage, (5) those who suffered intracerebral hemorrhage, (6) history of craniotomy or spinal operation, (8) Cardiac prosthesis (valve or pacemaker) and (9) history of antiepileptic, neuroleptic and hypnotic drug intake.

 

Clinical Assessment:

§   The patients eligible for the study were conducted to thorough medical history taking and clinical examination, with all patients subjected to a CT scan to evaluate infarct location and size.

§   The patients were studied by the same examiner in the first week. (First clinical examination).

§   The clinical data on neurological status was gathered by the NIH stroke score (National institute of health of America)7.

§   From day one all patients received physiotherapy to maintain optimal joint mobility and to regulate muscle tone. No specific therapy was initiated to improve motor recovery.

 

Functional Assessment

§   Functional capacity was determined by the Barthel index8, and the medical research council scale (MRC)9 to assess the muscle strength of the upper and the lower limbs.

§   A clinical follow up study was performed in all patients again with application of NIH, Barthel index and MRC at day 7, 30 and 90 post strokes. The patients who recover completely within the second month will not be studied at day 90 post stroke. To identify patients with complete recovery as advocated for clinical trials, a cut-off BI value of  ≥ 90 Vs < 90 is used and for NIHSS > 4 Vs  ≤ 4.

 

The stroke localization was categorized as cortical (C), subcortical (S), combined cortical and subcortical (CS), the basal ganglia (BG), or combined cortical, subcortical and basal ganglion (CSBG). The lesion size was measured and classified as small Lacunar infarction (<2cm), moderate (2-5cm), Large (5-10cm).1

 

Statistical Analysis

Frequency, mean, standard deviation, standard error of mean, median, minimum and maximum were used to describe data. For scores data, non-parametric Mann-Whiney m test was used to test for between group significance of difference between groups and Wilcoxon matched-pairs test was used two test for significance between two variables in the same group. For quantitative data, parametric student t-test and paired t-test were used to test for between groups and within group significance of difference. Chi-square test and backward stepwise logistic regression were used to test for association between improvement and different risk factors. Discriminance analysis was used to select variables affecting improvement. P value was considered significant if less than 0.05.   

RESULTS

 

According to the side of weakness, 46 patients (59%) had right hemiparesis and 32 patients (41%) had left hemiparesis. According to CT brain finding, Table (1) showed the distribution of infarction site and size both in day one after stroke and one week later.

Backward stepwise logistic regression revealed prognostic models for the occurrence of motor recovery using NIHSS based on age (Odds ratio [OR] 1.96, Confidance Interval 1.166-3.295; p=0.011) and stroke site (subcortical) (Odds ratio [OR] 0.205, CI 0.051-0.825; p=0.026) as a parameters, respectively. In early days after stroke, the product-term of age (p=0.011) and stroke site (subcortical) (p=0.026) for motor recovery reached a significance level indicating good interaction (Table 2).

Backward stepwise logistic regression revealed prognostic models for the occurrence of motor recovery using MRC of upper limbs based on cortical infarction on day 1 (Odds ratio[OR] 10.190, CI 0.691-150.249; p=0.091), cortical infarction on day 7 (Odds ratio[OR] 0.074, CI 0.008-0.664; p=0.020), subcortical infarction on day 1 (Odds ratio[OR] 23.744, CI 1.673-337.013; p=0.019) and subcortical infarction on day 7 (Odds ratio [OR] 0.015, CI 0.001-.0319; p=0.007) as a parameters respectively. The product-term of subcortical infarction in day 1 (p=0.019) and in day 7 (p=0.007) and cortical  infarction in day 7 (p=0.02) for motor recovery did reach the significance level indicating good interaction, while those of cortical infarction on day 1 did not reach a significant level (p=0.091) indicating no interaction (Table 3).

Backward stepwise logistic regression revealed prognostic models for the occurrence of motor recovery using MRC of lower limbs based on subcortical infarction on day 1 (Odds ratio [OR] 31.346, CI 0.829-184.519; p=0.063) and subcortical infarction on day 7 (Odds ratio[OR] 0.016, CI 0.000-0.671; p=0.030) as a parameters respectively. The product-term of, subcortical infarction on day 1 and for motor recovery did not reach the significance level indicating no interaction, while those of subcortical small infarction on day 7 had a significant value (p = 0.028, 0.030, 0.005) (Table 4).

According to Barthel index (BI) values, patients whom completed the three months follow up period were divided into two groups, first with no functional recovery (58 patients with percentage of 74.4%) and second group who showed functional recovery (20 patients with percentage of 25.6%). There were insignificant differences between the two groups regarding stroke localization and lesion size. There were significant differences between the two groups in considering NIHSS 1, 7, 30 and 90 days post stroke, UMRC and LMRC 90 days post stroke, and Barthel scales values on day 7 and 30 post stroke (Table 5).

According to NIHSS values, patients whom completed the three months follow up period were divided into two groups, first with no motor recovery (51 patients with percentage of 65.4%) and second group who showed motor recovery (27 patients with percentage of 34.6%). There were insignificant differences between the two groups regarding stroke localization and lesion size. There were significant differences between the two groups in considering NIHSS 1, and 90 days post stroke and Barthel scales values on day 7, and 90 post stroke. (Table 6).


 

Table 1. CT brain findings of patients with ischemic strokes on Day 1and Day 7 from onset of stroke.

 

 

Site (day1)

Site (day7)

Number

Percentage

Number

Percentage

Normal

16

20.5

6

7.7

Cortical (C)

9

11.5

8

10.3

Subcortical (S)

42

53.8

40

51.3

Cortio -Subcortial (CS)

7

9

14

17.9

Basal Ganglion (BG)

3

3.8

9

11.5

Cortio Subcortical and Basal Ganglion (CSBG)

1

1.3

1

1.3

Total

78

100

78

100

 

Size (day1)

Size (day7)

Number

Percentage

Number

Percentage

Normal

16

20.5

6

7.7

Small

34

43.6

32

41

Moderate

13

16.7

17

21.8

Large

15

19.2

23

29.5

Total

78

100

78

100

 

Table 2. Backward stepwise regression test of NIHSS 30 with many variables of patients with ischemic strokes.

 

Variables

Partial R

SE of partial R

Wald X²

P value

Odd Ratios

Value

95% CI for value

Lower

Upper

Age

0.470

0.218

4.670

0.031

1.600

1.045

2.451

SS1

-1.582

0.709

4975

0.026

0.205

0.051

0.825

SS7

1.369

0.708

3.736

0.053

3.933

9.81

15.766

Constant

-2.929

1.374

4.542

0.033

0.053

 

 

CI confidence interval, NIHSS National institute of health stroke scale, SE standard error, SS1 subcortical stroke of initial CT examination, SS7 subcortical stroke of CT examination after one week.

 

Table 3. Backward stepwise regression test of UMRC score 90 with many variables of patients with ischemic strokes.

 

Variables

Partial R

S.E of partial R

Wald X²

P value

Odd Ratios

Value

95% CI for value

Lower

Upper

CS 1

2.321

1.373

2.859

.091

10.190

.691

150.249

SS 1

3.167

1.353

5.476

.019

23.744

1.673

337.013

CS 7

-2.609

1.122

5.406

.020

0.074

0.008

0.664

SS 7

-4.197

1.559

7.248

.007

0.015

0.001

0.319

Constant

3.643

1.076

11.466

.001

38.204

 

 

CI Confidence interval, CS1 cortical stroke of initial CT examination, CS7 cortical stroke of CT examination after one week, SE standard error, SS1 subcortical stroke of initial CT examination, SS7 subcortical stroke of CT examination after one week, UMRC medical research council scale of the upper limb.

 

Table 4. Backward stepwise regression test of LMRC score 90 with many variables of patients with ischemic strokes.

 

Variables

Partial R

S.E of partial R

Wald X²

P value

Odd Ratios

Value

95% CI for value

Lower

Upper

SS 1

3.445

1.853

3.456

0.063

31.346

.829

1184.519

SS 7

-4.167

1.923

4.697

0.030*

.016

.000

.671

Constant

10.389

3.035

11.716

0.001*

32487.135

 

 

CI Confidence interval, CS1 cortical stroke of initial CT examination, CS7 cortical stroke of CT examination after one week, LMRC medical research council scale of the lower limb.SE standard error, SS1 subcortical stroke of initial CT examination, SS7 subcortical stroke of CT examination after one week.

*Significant at p<0.05

 

Table 5. CT brain findings and other variables according to functional recovery in patients with ischemic strokes.

 

Variable

Functional recovery

Significance

No

Yes

Site 1

 

 

0.384

Normal

13

3

CS

2

5

BG

3

0

S

31

11

CSBG

1

0

C

8

1

Size 1

 

 

0.984

 Normal

13

3

 Small

24

10

 Moderate

9

4

 Large

12

3

Site 7

 

 

0.402

Normal

5

1

CS

9

5

BG

6

3

S

30

10

BGCS

1

0

C

7

1

Size 7

 

 

0.919

 Normal

5

1

 Small

23

9

 Moderate

13

4

 Large

17

6

BG Basal Ganglion, C Cortical, CS Cortio–Subcortial, CSBG Cortio Subcortical and Basal Ganglion, S Subcortical

 

Table 6. CT brain findings and other variables according to motor recovery in patients with ischemic strokes.

 

Variable

Motor recovery

Significance

No

Yes

Site 1

 

 

0.750

Normal

12

4

CS

2

5

BG

3

0

S

26

16

CSBG

1

0

C

7

2

Size 1

 

 

0.276

 Normal

12

4

 Small

22

12

 Moderate

9

4

 Large

8

7

Site 7

 

 

0.487

Normal

4

2

CS

8

6

BG

6

3

S

26

14

CSBG

1

0

C

6

2

Size 7

 

 

0.298

 Normal

4

2

 Small

22

10

 Moderate

13

4

 Large

12

11

BG Basal Ganglion, C Cortical, CS Cortio–Subcortial, CSBG Cortio Subcortical and Basal Ganglion, S Subcortical


DISCUSSION

 

Several clinical and demographic variables have been identified as valid predictors for functional recovery, including age, sitting balance, severity of paresis, disability on admission, urinary incontinence, previous stroke, and the impact of social support1.

Lacunar infarction had a significantly higher likelihood of an excellent outcome at days 7 and 3 months than did patients with non lacunar stroke10. Appelros et al. (2005) had concluded that lacunar infarction patients have a good functional outcome at 5 years11.

Rothrock et al. (1995), observed that patients with lacunar stroke were more probable to enjoy early spontaneous improvement, but over half 64% of their lacunar stroke patients were still impaired 1 week after stroke onset12.

In the present work, considering infarction size, there were no statistical significant differences between those who functionally recovered and those who did not (p= 0.0984 for first CT finding and p=0.919 for CT finding after one week). Also there were no statistical significant differences between those who had motor recovery and those who did not (p= 0.276 for first CT finding and p=0.298 for CT finding after one week). (There were insignificant changes in infarction size between those who experienced functional and motor recovery and those who did not).

In the current study, the incidence of lacunar syndrome was approximately 41% in day 1 post stroke and 40,9% in day 7 which was higher than that observed by Jacques de Reuck 2005 (15%) and other previous studies13,14.  

Infarction size and site in the first day after stroke strongly affects stroke severity (NIH30) after 30 days poststroke. This is in agree with Jacques de Reuke (2003) who stated that not only the presence of severe leukoaraiosis points to a bad outcome but also larger lacunes on day 3 and 10 are associated with an unfavorable prognosis. On the other hand, smaller lacunes, observed on day 3 and further decrease in size or even disappearance on day 10, are associated with a favorable outcome14.

Early improvement can be predicted by the absence of early CT hypodensity and is highly predictive of good outcome. Presence of collateral blood supply and presumably early spontaneous recanalization, are likely to be the mechanisms underlying early improvement15.

As severity differs between stroke subtypes, it is not surprising that early recovery also differs, with small vessel occlusive stroke improving most and cardioembolic the least16.

Nikola Sprigg et al. (2007) found that lesion size, location, and causal mechanism are also related to recovery, diffusion-weighted imaging may be useful to predict prognosis, and early recovery in lacunar stroke is well recognized.17

In an inpatient stroke rehabilitation population, observed that patients with purely cortical stroke have better motor outcome than patients with purely subcortical stroke18. Furthermore, patients with mixed cortical plus subcortical stroke tended to do better than patients with purely subcortical stroke despite the expected larger size of mixed lesions19.

De Nap et al. (2001) summarized for patients with a virtually plegic upper limb 2 weeks after stroke, recovery of isolated limb movement can be predicted on the basis of lesion location: (a) 75% for those with lesions restricted to the cortex (b) 38.5% for those with subcortical or mixed cortical plus subcortical lesions not affecting the posterior limb of internal capsule; and (c) 3.6% for those with involvement of the posterior limb of internal capsule plus adjacent corona radiata, basal ganglia, or thalamus18.

In our study, both the cortical and subcortical (basal ganglion and internal capsule) ischemia have greater influence on motor score of the upper limb three months after stroke. Regarding CT changes one week after stroke onset, the subcortical infarction has a higher significant negative interaction with the motor score (MRC score of upper limb) of the patients (p=0.007) in comparison to cortical stroke (p=0.020). Also, subcortical stroke significantly affect the stroke severity (NIH30) one month after the stroke (p=0.026). However, no interaction between the stroke size and site with other functional score (BI) in our study. These results are in agreed with that previously observed by Shelton and Reding18.

 

Conclusion

We concluded that overt role of CT is obtained in predicting functional motor recovery of ischemic cerebral stroke if it was accompanied with clinical evaluation (NIHSS, BI, MRC scales).

 

[Disclosure: Authors report no conflict of interest]

 

 

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9.      Medical research council. Aids to the examination of the peripheral nervous system. Memorandum No. 45. London: Her Majesty`s stationary office 1976. Quoted from Heyen Petra. The principle of biomedical statistics: Scales and scores in neurology. In: Quantification of neurological deficit in research and practice: Masur H, Papke K, Althoff S, Oberwittler C. Scales and scores in neurology; quantification of neurological deficit in research and practice. Stuttgart New York: Thieme; 2004.

10.    Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53: 126-31.

11.    Appelros A, Samuelsson M, Lindell D. Lacunar Infarcts: Functional and Cognitive Outcomes at Five Years in Relation to MRI Findings. Cerebrovasc Dis. 2005; 20: 34-40.

12.    Rothrock JF, Clark WM, Lyden PD. Spontaneous early improvement following ischemic stroke. Stroke 1995; 26: 1358-60.

13.    Lindgren A, Norrving B, Rudling O, Johansson BO. Comparison of clinical and neuroradiological findings in first-ever stroke: a population-based study. Stroke. 1994; 25: 1371-7.

14.    De Reuck J, Hemelsoet D , NieuwenhuisL , Van Maele G. Computed tomographic changes in lacunar syndromes. Clin Neurol Neurosurg. 2005; 108: 18–24.

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16.    Sprigg N, Willmot MR, Gray LJ, Sunderland A, Pomeroy V, Walker M, et al. Amphetamine increases blood pressure and heart rate but has no effect on motor recovery or cerebral haemodynamics in ischaemic stroke: a randomized controlled trial (ISRCTN 36285333). J Hum Hypertens. 2007; 21(8): 616-24.

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الملخص العربى

 

مازال التنبأ بالتحسن الوظيفي لمرضي السكتة الدماغية من الموضوعات الأكثر أهمية – الأقل استبياناً. وقد تتنبأ العديد من المتغيرات الإكلينيكية. الديموجرافية بالتحسن الوظيفي لما بعد السكتة ومن هذه المتغيرات عمر المريض شدة الضعف الحركي وسلسل البول بالإضافة إلي التاريخ المرضي لحدوث سكتة دماغية. كما أن مكان وشدة حدوث الجلطة المخية قد يؤثر في التنبؤ بالتحسن الوظيفي والحركي لمرضي السكتة الدماغية.

وتهدف هذه الدراسة إلي توضيح دور التغيرات في الأشعة المقطعية للمخ في التنبؤ بالتحسن الحركي والوظيفي لمرضي السكتة الدماغية . وقد تم دراسة 78 مريضاً يعانون من احتشاء مخي وخضع هؤلاء المرضي لعمل فحص أشعة مقطعية علي المخ في اليوم الأول من حدوث الجلطة وتم إعادة الفحص بعد أسبوع من المرض. كما خضع المرضي لدراسة الاختبارات الإكلينيكية المختلفة لمعرفة شدة المرض ولتتبع التحسن الحركي والوظيفي لهم.

وأظهرت الدراسة أن دور الأشعة المقطعية في التنبؤ بالتحسن الحركي والوظيفي لمرضي السكتة الدماغية قد يصبح أكثر فاعلية إذا أقرن بالدراسات الإكلينيكية المختلفة لهولاء المرضي.



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