Assessment of Stroke Outcome Based on Initial Stroke Severity Measured on Different Stroke Severity Scales

Background: Stroke is the second most common cause of death globally and the major cause of disability. Though a number of studies have been conducted on stroke outcome and recovery of walking function, the list and effects of predictive factors are still a major challenge to stroke rehabilitation. Materials and methods: This was a randomized prospective study to evaluate whether initial stroke severity influences the stroke outcome. The patients were categorized after CT scan into two groups (group Iinfarction type and group II haemorrhagic type). Initial stroke severity was evaluated in Scandinavian Stroke Scale (SSS). Functional status was evaluated after admission in Functional Independence Measure (FIM), Barthel Index (BI) and Short Form36 (SF36).To see the outcome in relation to time patients were evaluated with FIM, BI and SF36 four weeks after discharge. Results: Analysis of Scandinavian Stroke Scale indicated that the overall score was higher among the patients with cerebral infarct (mean score 29.25) compared to patients with cerebral hemorrhage (mean score 20.08) and the mean difference was statistically significant (p<0.001). Analysis of Barthel Index indicated that the percentage of improvement was significantly high among the patients with cerebral hemorrhage compared to cerebral infarct in terms of transfers from bed to chair or vice versa (p<0.001). However, improvement was also high among the patients with cerebral hemorrhage as well as cerebral infarct, but the difference was not statistically significant (p>0.05) Conclusion: This study indicates that initial motor, sensory and cognitive impairment can be good predictor in amount and time period of recovery of mobility function and other aspect in acute stroke patients, as data shows that milder the initial impairment faster and more is the recovery. Keyword: Stroke, cerebrovascular accident, outcome assessment 1. Consultant, Department of Medicine, Sylhet MAG Osmani Medical College Hospital, Sylhet 2. Associate Professor, Department of Neurology, Sylhet MAG Osmani Medical College, Sylhet 3. Associate Professor, Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet 4. Associate Professor, Department of Neurology, Dhaka Medical College, Dhaka 5. Postgraduate resident, Department of Neurology, Dhaka Medical College Hospital, Dhaka Correspondence: Abdul Quddus, Consultant, Department of Medicine, Sylhet MAG Osmani Medical College Hospital, Sylhet another study it was found that age, gender, initial severity of the stroke, functional status at admission to hospital, urinary incontinence, impairment in cognitive function, unilateral neglect syndrome are determining the outcomes of the disorder.6 The present study was designed to see whether initial stroke severity as evaluated in Scandinavian Stroke Scale (SSS) and functional status as evaluated in Functional Independence Measure (FIM), Barthel Index (BI) and Short Form36 (SF36) influences outcome of stroke evaluated by same methods. Materials and method The study was done on stroke patients admitted in Medicine and Neurology units, Sylhet MAG Osmani Medical College Hospital. Patients were selected randomly by lottery method. The study was done during a period of one year (from April J MEDICINE 2010; 11 : 137-142

another study it was found that age, gender, initial severity of the stroke, functional status at admission to hospital, urinary incontinence, impairment in cognitive function, unilateral neglect syndrome are determining the outcomes of the disorder. 6The present study was designed to see whether initial stroke severity as evaluated in Scandinavian Stroke Scale (SSS) and functional status as evaluated in Functional Independence Measure (FIM), Barthel Index (BI) and Short Form-36 (SF-36) influences outcome of stroke evaluated by same methods.

Materials and method
The study was done on stroke patients admitted in Medicine and Neurology units, Sylhet MAG Osmani Medical College Hospital.Patients were selected randomly by lottery method.The study was done during a period of one year (from April 2005 to March 2006).The patients were studied of both sexes from age 20 to 80 years.After admission all stroke patients were evaluated by detailed history and physical examination.It was specially noted whether patients were hypertensive, diabetic,smoker or presence of other relevant risk factors.It was also recorded whether there is any family history of hypertension, diabetes, ischaemic heart disease or stroke.CT scan of brain, ECG, CXR PA view, FBS and lipid profile, serum creatinine, complete blood count, urine for routine and microscopic examination were done in all patients.Stroke patients having bleeding disorders, previous stroke, unconsciousness for more than two weeks and associated with other life threatening illness were excluded from this study.
The patients were categorized after CT scan of head into two groups (group I-infarction type and group II haemorrhagic type).Initial stroke severity was evaluated in Scandinavian Stroke Scale (SSS).Functional status was evaluated after admission in Functional Independence Measure (FIM), Barthel Index (BI) and Short Form-36 (SF-36).To see the outcome in relation to time patients were evaluated in FIM, BI and SF-36 at four weeks after discharge.All data collected were recorded in predesigned data sheet.After collection and entry of data, analysis was done by unpaired t test, chi-square test and ANOVA test using SPSS version 10.

Results
A total of 55 patients were included by lottery methods out of 94 stroke patients and they were categorized into two groups on the basis of CT scan.The patients with infarct were considered as group I and with hemorrhage considered as group II patients.Out of 55 patients, 3 died and were excluded from analysis and rest 52 patients were followedup.The mean age of the patients was 57.1±12.4 years ranging from 28 to 80 years.The mean age of the group I patients was 56.0±13.4 years and for group II patients was 58.4±11.2years.Analysis revealed no statistically significant mean age difference between two groups of patients (p>0.05) as shown in Table-I.
Out of 52 patients, 28(53.8%)patients had cerebral infarct and 24 (46.2%) had cerebral hemorrhage.Analysis of risk factors revealed that the proportion of smoking, hypertension, diabetes mellitus and ischemic heart disease were higher among the patients with cerebral infarct than the patients with cerebral hemorrhage, however, there was no statistically significant difference between two groups of patients (p>0.05).The family history of risk factors indicated that the proportion of hypertension, diabetes mellitus were higher among the patients with cerebral hemorrhage compared to patients with cerebral infarct.
Analysis of Scandinavian Stroke Scale indicated that the overall score was higher among the patients with cerebral infarct (mean score 29.25) compared to patients with cerebral hemorrhage (mean score 20.08) and the mean difference was statistically significant (p<0.001) as shown in Table-II.Analysis of individual parameter indicated that score was better in patient with cerebral infarct than hemorrhage in terms of consciousness, eye movement, leg motor power,  Analysis of functional Independence Measure indicated that overall improvement was higher among the patients with infarct compared to patients with cerebral hemorrhage.

Variables
However, percentage of improvement indicated that grooming, toileting, bladder control, locomotion in stairs, compression and expression significantly improved in patients with cerebral infarct.As a results, the overall motor subtotal, cognitive subtotal score was higher among the patients with cerebral infarct than cerebral hemorrhage (Table-III).
Analysis of Barthel Index indicated that the percentage of improvement was significantly high among the patients with cerebral hemorrhage compared to cerebral infarct in terms of transfers from bed to chair or vice versa (p<0.001).However, improvement was also high among the patients with cerebral hemorrhage as well as cerebral infarct, but the difference was not statistically significant (p>0.05)(table-IV).
Repeated measure analysis of variance (ANOVA) as shown in Table -V indicated that quality of life significantly improved from admission to 4 th week after discharge on observation in all the patients (p<0.05).However, lifting or carrying groceries and climbing one several flights of stairs was significantly high among the patients with cerebral infarct compared to cerebral hemorrhage (p<0.005),whereas bending, kneeling, or stooping was high among the patients with cerebral hemorrhage compared to cerebral infarct (p<0.05).

Discussion
The age range of patients in this study was 28-80 years.Maximum age group was 55-70 years (57.2%)mean age was 57±12.4years.Anwarullah et al found 34 percent patients in the sixth decade and 27 percent in the seventh decade. 7This observation was in conformity with that of Haque and Mannan and Liu and Chia. 8,9In this study hypertension, diabetes mellitus, IHD were found in 71.2%, 46.2%, 15.4% of study population respectively.Family history of stroke, hypertension, diabetes mellitus, IHD were 36.5%,63.5%, 53.8% and 28.8% respectively.Hypertension was the most principal risk factor for both ischaemic and haemorrhagic stroke. 10,11These observations are in conformity with that of the present study.In this study smoking/ tobacco consumption was 71.2%, which was almost equal as Hypertension.Rozenthal et al found smoking (53.6%), hypertension (43.4%), hyperlipidaemia (22%) and diabetes mellitus (21%) as main risk factors for stroke. 12Similar findings was also noted by Rahman M et al. 3 Increasing age i.e. age >55 years in this study was 57.1%.Increasing age (age greater than 67 years) is itself a risk factor for stroke. 10In this study family history of stroke was found in 36.5%.In a study by Hannan A in BSMMU, Dhaka family history of stroke was found in 21.29%. 14Diabetes mellitus was found in 46.2% in present study was simillar to Hannan et al and Rahman M et al. 13,14  Multivariate regression models were used to determine the predictive value of the observed measures.After 3 months, 17% of patients had died; 21% were alive but being cared for in institutional settings; and 62% were alive and living at home.Functional status at discharge indicated 16% of patients had died, poor function in 50%, and good function in 34% of patients.Initial stroke severity, measured by National Institute of Health Stroke Scale and dependence on a ventilator predicts 3-month mortality and poor outcome in all stroke patients. 16Vibo et al also commented the outcome of stroke was mainly determined by the initial severity of stroke and by elevated blood glucose value on admission. 17

Conclusion
This study indicated that initial motor, sensory and cognitive impairment can be good predictor in amount and time period of recovery of mobility function and other aspect in acute stroke patients, as data shows that milder the initial impairment faster and more is the recovery.This study also shows that improvement was more in infarct group than haemorrhagic stroke.

Table - II
Distribution of the patients by Scandinavian Stroke Scale p value reached from unpaired student's t test

Table - III
Distribution of the patients by Functional Independence Measure (p<0.05)than patients with hemorrhage.However, no statistically significant mean difference of score was found between two groups in terms of speech, facial palsy and gait (p>0.05).But the score was higher in infarct patients than hemorrhagic patients.
p value reached fro unpaired student's t test orientation

Table - IV
Distribution of the patients by Barthel Index

Table - V
Distribution of the patients by SF 36 health status 15Measures of interest were analyzed for three types of outcome: 3-month mortality or institutional care, and poor functional outcomes at discharge.Poor functional outcomes were defined as a Barthel index <80 or a Rankin scale >2.