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Author Spotlight: Assessing Ischemic Stroke Damage Through Middle Cerebral Artery Occlusion Model
Published on: August 11, 2023
Time Course of Evolution of Disability and Cause-Specific Mortality After Ischemic Stroke: Implications for Trial
Aravind Ganesh1, Ramon Luengo-Fernandez1,2, Rose M Wharton1
1Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.
Background:
Outcome in stroke trials is often based on a 3-month modified Rankin scale (mRS). How 3-month mRS relates to longer-term outcomes will depend on late recovery, delayed stroke-related deaths, recurrent strokes, and nonstroke deaths. We evaluated 3-month mRS and death/disability at 1 and 5 years in a population-based cohort study.
Methods And Results:
In 3-month survivors of ischemic stroke (Oxford Vascular Study; 2002-2014), we related 3-month mRS to disability (defined as mRS >2) at 1 and 5 years and/or death rates (age/sex adjusted). Accrual of disability and index-stroke-related and nonstroke deaths in each poststroke year was categorized according to 3-month mRS. Among 1606 patients with acute ischemic stroke, 181 died within 3 months, but 126 index-stroke-related deaths and 320 other deaths occurred during the subsequent 4866 patient-years of follow-up up to 5 years. Although 69/126 (54.8%) post-3-month index-stroke-related deaths occurred after 1 year, mRS>2 at 1 year strongly predicted these deaths (adjusted hazard ratio=21.94, 95%CI 7.88-61.09, P<0.0001). Consequently, a 3-month mRS >2 was a strong independent predictor of death at both 1 year (adjusted hazard ratio=6.67, 95%CI 4.16-10.69, P<0.0001) and 5 years (adjusted hazard ratio=2.93, 95%CI 2.38-3.60, P<0.0001). Although mRS improved by ≥1 point from 3 months to 1 year in 317/1266 (25.0%) patients with 3-month mRS ≥1, improvement in mRS after 1 year was limited (improvement by ≥1 point: 91/858 [10.6%]; improvement to mRS ≤2: 13/353 [3.7%]).
Conclusions:
Our results reaffirm use of the 3-month mRS outcome in stroke trials. Although later recovery does occur, extending follow-up to 1 year would capture most long-term stroke-related disability. However, administrative mortality follow-up beyond 1 year has the potential to demonstrate translation of early disability gains into additional reductions in long-term mortality without much erosion by non-stroke-related deaths.
Insights
The 3-month modified Rankin scale (mRS) effectively predicts long-term death and disability after ischemic stroke. While some late recovery occurs, extending follow-up to one year captures most outcomes, supporting its use in stroke trials.
Area of Science:
- Neurology
- Clinical Trials
- Public Health
Background:
- Stroke outcome assessment often relies on the 3-month modified Rankin scale (mRS).
- Longer-term outcomes depend on factors like late recovery, delayed deaths, and recurrent strokes.
- This study evaluates the relationship between the 3-month mRS and death/disability at 1 and 5 years post-stroke.
Purpose of the Study:
- To assess the predictive value of the 3-month modified Rankin scale (mRS) for long-term outcomes in ischemic stroke survivors.
- To determine the extent of late recovery and its impact on mortality and disability up to 5 years post-stroke.
- To inform the optimal follow-up duration for stroke clinical trials.
Main Methods:
- Analysis of a population-based cohort (Oxford Vascular Study, 2002-2014) of ischemic stroke survivors.
- Correlation of the 3-month mRS with disability (mRS >2) and mortality rates at 1 and 5 years.
- Age and sex-adjusted analyses to determine hazard ratios for death and disability.
Main Results:
- A 3-month mRS >2 strongly predicted death at both 1 year (aHR=6.67) and 5 years (aHR=2.93).
- Late stroke-related deaths (after 1 year) were predicted by a 1-year mRS >2 (aHR=21.94).
- While 25% showed mRS improvement from 3 months to 1 year, significant improvement after 1 year was limited (10.6%).
Conclusions:
- The 3-month mRS is a valid outcome measure for stroke trials.
- Extending follow-up to 1 year captures the majority of long-term stroke-related disability.
- Extended mortality follow-up beyond 1 year can demonstrate the benefits of early disability improvements on long-term survival.
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