stroke patient and stroke therapies assessment ed nihss stroke scales use for ed stroke therapies l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Stroke Patient and Stroke Therapies Assessment: ED NIHSS & Stroke Scales Use for ED Stroke Therapies PowerPoint Presentation
Download Presentation
Stroke Patient and Stroke Therapies Assessment: ED NIHSS & Stroke Scales Use for ED Stroke Therapies

Loading in 2 Seconds...

play fullscreen
1 / 34

Stroke Patient and Stroke Therapies Assessment: ED NIHSS & Stroke Scales Use for ED Stroke Therapies - PowerPoint PPT Presentation


  • 1095 Views
  • Uploaded on

Stroke Patient and Stroke Therapies Assessment: ED NIHSS & Stroke Scales Use for ED Stroke Therapies. 4 th EuSEM Congress Crete, Greece October 5-7, 2006.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Stroke Patient and Stroke Therapies Assessment: ED NIHSS & Stroke Scales Use for ED Stroke Therapies' - Mia_John


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
stroke patient and stroke therapies assessment ed nihss stroke scales use for ed stroke therapies
Stroke Patient and Stroke Therapies Assessment: ED NIHSS & Stroke Scales Use for ED Stroke Therapies
slide3

Andrew Asimos, MD, FACEP Adjunct Associate ProfessorDepartment of Emergency MedicineUniversity of North Carolina School of Medicine at Chapel HillChapel Hill, NC

slide4
Attending PhysicianEmergency MedicineCarolinas Medical CenterDepartment of Emergency MedicineCharlotte, NC
session objectives
Session Objectives
  • Discuss how the NIHSS should be utilized by emergency physicians in assessing ischemic stroke patients in the Emergency department.
  • Determine what emergency physicians need to know about stroke scales when evaluating stroke therapies that could be utilized in treating ED ischemic stroke patients.
case presentation
Case Presentation…
  • 67 yo male transported as a “Code stroke” based on a positive Prehospital Stroke Screen
  • Symptom onset 30 minutes before paramedic arrival
    • Left arm weakness, slurred speech and facial droop
  • PMHx of hypertension
    • Admits to being non-compliant with his medications
  • In the ED, alert with a right sided gaze preference and weakness of his left arm and face
  • Accucheck is 97, BP 170/90 mm Hg
clinical questions

Clinical Questions

What is the role of the NIHSS in the evaluation of ED ischemic stroke patients?

How should the NIHSS be used to assess the potential use of IV tPA in ED ischemic stroke patients?

What are the Modified Rankin Scale and Barthel index, and what do they measure?

clinical questions8

Clinical Questions

How have the NIHSS, MRS, and BI used as a measure of outcome in clinical trials of stroke therapies?

How can the MRS and BI be used to determine the utility of stroke therapies in the ED?

How can the number needed to treat calculation be performed based on these scales and study outcomes, and what does it mean to the clinical practice of Emergency Medicine?

nih stroke scale nihss
NIH Stroke Scale (NIHSS)
  • First developed for acute stroke trials as a research study tool
  • Standardized mechanism for defining stroke severity based on neurologic deficits
    • 15 item ordinal scale designed to rate neurological impairment
  • Widely used in US clinical practice
  • Helps to predict outcome with or without t-PA treatment
  • Helps to assess risk of hemorrhage after t-PA treatment

Brott T et al. Stroke 1989;20:864-70.

Goldstein LB et al. Arch Neurol 1989;46:660-2.

Adams HP et al. Neurology 1999;53:126-31.

Goldstein LB et al. Arch Neurol 1989;46:660-2.

Muir KW. et al. Stroke 1996;27(10):1817-20.

nih stroke scale

1a

1b

1c

2

3

4

5

6

7

8

9

10

11

12

13

Level of Consciousness

LOC Questions

LOC Commands

Best Gaze

Best Visual

Facial Palsy

Motor Arm Left

Motor Arm Right

Motor Leg Left

Motor Leg Right

Limb Ataxia

Sensory

Neglect

Dysarthria

Best Language

0 – 3

0 – 2

0 – 2

0 – 2

0 – 3

0 – 3

0 – 4

0 – 4

0 – 4

0 – 4

0 – 2

0 – 2

0 – 2

0 – 2

0 – 3

NIH Stroke Scale

Item

Description

Range

reliability of nihss items
Reliability of NIHSS Items

Goldstein LB and Simel DL. JAMA 2005;293(19):2391–2402

slide13

Reliability of the NIHSS:Analysis of Video Ratings

Josephson SA et al. ISC January 17, 2006

slide14

Reliability of the NIHSS:Analysis of Video Ratings

Josephson SA et al. ISC January 17, 2006

slide15

Reliability of the NIHSS:Analysis of Video Ratings

  • Conclusions
    • Substantial variability in the overall Stroke Scale score
      • High levels of agreement for many items does not necessarily translate into the total score being highly reliable
    • Facial palsy and aphasia items least reliably assessed
    • Physicians didn't score better than the other professionals
    • Reliability did not improve with testing experience

Josephson SA et al. ISC January 17, 2006

symptomatic ich in ninds effect of baseline nihss
Symptomatic ICH in NINDS:Effect of Baseline NIHSS

% of TPA Patients with Symptomatic ICH

0-5 6-10 11-15 16-20 >20

Baseline NIH Stroke Scale Score

The NINDSrt-PA Stroke Study Group.

Stroke1997;28(11):2109-2118.

1 year follow up of ninds study patients effect of baseline nihss
1 Year Follow-up of NINDS Study Patients: Effect of Baseline NIHSS

% with Favorable Outcome

Presenting NIHSS Score

Kwiatkowski TG et al. N Engl J Med 1999;340:1781-7.

3 month outcome of toast study patients effect of baseline nihss
3 Month Outcome of TOAST Study Patients:Effect of baseline NIHSS

Adams HP et al. Neurology 1999;53:126-31.

measuring outcomes with stroke scales modified rankin scale
Measuring Outcomes with Stroke Scales:Modified Rankin Scale

0

Symptom

free

1

Symptomatic, but

performing previous

activities

2

Unable to do some previous

activities, but independent

3

Requires some help, but can

walk without assistance

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

5

dichotomizing stroke outcomes
Dichotomizing Stroke Outcomes

0

Symptom

free

1

Symptomatic, but

performing previous

activities

Independent

2

Unable to do some previous

activities, but independent

3

Requires some help, but can

walk without assistance

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

5

dichotomizing stroke outcomes21
Dichotomizing Stroke Outcomes
  • Does the treatment make all patients achieve a “good” outcome?
  • Advantages
    • Simple statistical analysis
    • Straightforward clinical interpretation
  • Disadvantages
    • Functional continuum of stroke is broad
    • Eliminates some outcome information
      • Both directions
ecass ii efficacy results
ECASS II: Efficacy Results

Modified Rankin Scale

mRS 0,1,2

=8.3%

p=0.024

mRS 0,1

=3.7%

p=0.277

t-PA

placebo

0 1 2 3 4 5 6

% patients

Hacke W et al. Lancet 1998;352:1245-1251.

sliding dichotomy
Sliding Dichotomy

Symptom

free

0

Symptomatic, but

performing previous

activities

1

NIHSS 0-7

Unable to do some previous

activities, but independent

2

Requires some help, but can

walk without assistance

3

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

5

sliding dichotomy24
Sliding Dichotomy

Symptom

free

0

Symptomatic, but

performing previous

activities

1

Unable to do some previous

activities, but independent

2

NIHSS 8-14

Requires some help, but can

walk without assistance

3

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

5

sliding dichotomy25
Sliding Dichotomy

Symptom

free

0

Symptomatic, but

performing previous

activities

1

Unable to do some previous

activities, but independent

2

Requires some help, but can

walk without assistance

3

Needs assistance with walking and

attending to bodily needs

4

NIHSS >14

Bedridden, incontinent, requires

constant care

5

sliding dichotomy26
Sliding Dichotomy
  • Does the treatment make the patient better based on the patient’s initial status?
  • Advantages
    • Adjustment for baseline severity
      • Nor fixed target outcome inappropriate for mild or severe patients
  • Disadvantages
    • Still a dichotomous analysis
    • Potential to ignore harmful effects occurring at non-specified transitions
    • Requires estimate of treatment effect to identify outcome transitions
modified rankin scale
Modified Rankin Scale

Symptom

free

Symptom free

0

Able to do all usual activities

Symptomatic, but

performing previous

activities

1

Able to look after self

Unable to do some previous

activities, but independent

2

Able to walk without assistance

Requires some help, but can

walk without assistance

3

Not bedridden

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

Bedridden

5

shift analysis
Shift Analysis

Symptom

free

Symptom free

0

Able to do all usual activities

Symptomatic, but

performing previous

activities

1

Able to look after self

Unable to do some previous

activities, but independent

2

Able to walk without assistance

Requires some help, but can

walk without assistance

3

Not bedridden

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

Bedridden

5

shift analysis29
Shift Analysis

Symptom

free

Symptom free

0

Able to do all usual activities

Symptomatic, but

performing previous

activities

1

Able to look after self

Unable to do some previous

activities, but independent

2

Able to walk without assistance

Requires some help, but can

walk without assistance

3

Not bedridden

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

Bedridden

5

shift analysis30
Shift Analysis

Symptom

free

Symptom free

0

Able to do all usual activities

Symptomatic, but

performing previous

activities

1

Able to look after self

Unable to do some previous

activities, but independent

2

Able to walk without assistance

Requires some help, but can

walk without assistance

3

Not bedridden

Needs assistance with walking and

attending to bodily needs

4

Bedridden, incontinent, requires

constant care

Bedridden

5

shift analysis31
Shift Analysis
  • Does the treatment make the patient somewhat better?
  • Advantages
    • Analyzes benefit or harm throughout the continuum of disability
    • Does not rely on an estimate of treatment effect to identify outcome transitions
  • Disadvantages
    • Statistically complex
    • NNT calculations from theoretical models
conclusions

Conclusions

The NIHSS helps to predict outcome, with or without t-PA treatment, and hemorrhage risk after t-PA treatment

Different stroke study endpoint analyses have been applied to outcome scales, with each technique offering its own advantages and disadvantages

Some stroke trials may have missed beneficial or harmful treatment effects because the criteria for judging treatment response were inappropriate for many of the patients studied

recommendations

Recommendations

Understand how to measure the NIHSS and the limitations of the score obtained

Be knowledgeable of the stroke outcome scores used in trials and how the outcomes were analyzed

Understand the fundamental questions that can be answered by each study endpoint analysis strategy

questions
Questions?

www.FERNE.org

aasimos@carolinas.org

704 355 4212

ferne_eusem_2006_asimos_scales_092506_revised

3/10/2014 7:01 PM