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NIHSS Score: Insights and Implications in Stroke Assessment
NIHSS Score and Arteriographic Findings in Acute Ischemic Stroke
The National Institutes of Health Stroke Scale (NIHSS) score is a critical tool in assessing the severity of stroke and predicting arteriographic findings. Research indicates a significant association between NIHSS scores and the presence and location of vessel occlusions. Specifically, patients with NIHSS scores of 10 or higher have a high probability of showing arterial occlusions in carotid and vertebrobasilar strokes, with positive predictive values (PPVs) of 97% and 96%, respectively. Furthermore, an NIHSS score of 12 or higher is strongly predictive of central occlusions.
Reliability and Validity of Retrospective NIHSS Scoring
The NIHSS can be reliably estimated retrospectively from medical records, which is crucial for retrospective observational studies. Studies have shown that estimated NIHSS scores from medical records closely approximate actual scores, with high interrater reliability (intraclass correlation coefficient of 0.82) and a probability of 0.86 for correctly ranking patients according to 5-point interval categories. This finding supports the use of NIHSS in retrospective studies for acute stroke outcome analysis.
Expanded NIHSS (e-NIHSS) for Posterior Circulation Strokes
The traditional NIHSS has limitations in evaluating posterior circulation strokes. The e-NIHSS, an expanded version of the NIHSS, includes additional elements to better assess signs and symptoms of posterior circulation strokes. Studies have shown that the e-NIHSS scores are significantly higher for patients with posterior circulation infarcts compared to the classical NIHSS, indicating improved sensitivity and potential impact on clinical trials and outcomes.
Baseline NIHSS Score as a Predictor of Stroke Outcomes
The baseline NIHSS score is a strong predictor of stroke outcomes. Each additional point on the NIHSS decreases the likelihood of excellent outcomes at 7 days by 24% and at 3 months by 17%. Patients with NIHSS scores of 7 to 10 have a 46% chance of excellent outcomes at 3 months, while those with scores of 11 to 15 have a 23% chance. A score of 16 or higher forecasts a high probability of death or severe disability.
NIHSS and Hemispheric Stroke Volume Discrepancies
The NIHSS may favor left hemisphere strokes due to its scoring structure, which allocates more points to language-related deficits. Research has shown that for a given NIHSS score, the median volume of right hemisphere strokes is consistently larger than that of left hemisphere strokes. This discrepancy suggests that the NIHSS may not equally represent the severity of strokes in both hemispheres.
NIHSS in Chronic Hemiparetic Stroke
The NIHSS lacks validity in chronic hemiparetic stroke. There is no significant association between NIHSS scores and health status measures such as the Stroke Impact Scale (SIS) in chronic stroke survivors. This finding indicates that the NIHSS is not suitable for assessing long-term outcomes and health status in chronic stroke patients.
NIHSS in the Era of Acute Stroke Intervention
With the increasing use of acute stroke interventions, baseline NIHSS scores are less reliable in predicting post-stroke functional outcomes. Studies have shown that 24-hour and discharge NIHSS scores have higher predictive accuracy for favorable outcomes at three months compared to baseline scores, especially in patients receiving mechanical thrombectomy.
NIHSS as a Predictor in Intracerebral Hemorrhage
The NIHSS is also used to predict outcomes in patients with intracerebral hemorrhage (ICH). Admission NIHSS scores correlate with mortality and functional outcomes at 6 months. Higher NIHSS scores at admission are associated with worse outcomes, demonstrating the scale's utility in clinical monitoring and prognostication for ICH patients.
Limitations of NIHSS in Detecting All Stroke Symptoms
The NIHSS does not capture all stroke symptoms, particularly those associated with posterior circulation strokes. Patients with an NIHSS score of 0 can still have significant symptoms such as headache, vertigo, and nausea, often linked to posterior circulation infarcts. This limitation highlights the need for comprehensive clinical evaluation beyond the NIHSS.
Conclusion
The NIHSS is a valuable tool in stroke assessment, with strong predictive capabilities for acute ischemic stroke outcomes and arteriographic findings. However, its limitations in chronic stroke, posterior circulation strokes, and certain symptomatology necessitate complementary assessment methods. The expanded NIHSS (e-NIHSS) and careful retrospective scoring can enhance its utility, ensuring more accurate and comprehensive stroke evaluation.
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