Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Mar;35(1):141-150.
doi: 10.1007/s00062-024-01459-3. Epub 2024 Oct 15.

Factors Influencing the Association of 24-hour National Institutes of Health Stroke Scale & 90-day Modified Rankin Score

Alexander Stebner  1   2   3 , Salome L Bosshart  1   2 , Andrew Demchuk  1 , Alexandre Poppe  4 , Raul Nogueira  5 , Ryan McTaggart  6 , Brian Buck  7 , Aravind Ganesh  2 , Michael Hill  1   2 , Mayank Goyal  1   2 , Johanna Ospel  8   9   10
Affiliations

Factors Influencing the Association of 24-hour National Institutes of Health Stroke Scale & 90-day Modified Rankin Score

Alexander Stebner et al. Clin Neuroradiol. 2025 Mar.

Abstract

Purpose: The modified Rankin Scale (mRS) at 90 days is the primary outcome in most acute stroke studies, but the long follow-up period has disadvantages. The National Institutes of Health Stroke Scale (NIHSS) at 24 h shows a strong, but imperfect, association with 90-day mRS. This study examines the association between 24-hour NIHSS and 90-day mRS and reasons for discrepancies.

Methods: Data are from the ESCAPE-NA1 thrombectomy patients. To address the non-normality distribution of the NIHSS and include deceased patients, a 7-point ordinal score was generated by grouping 24-hour NIHSS. The association of ordinal 24-hour NIHSS and 90-day mRS was assessed with adjusted ordinal logistic regression. Differences in baseline and treatment/post-treatment variables were compared between patients with discordant and concordant outcomes.

Results: One-thousand-seventy-six patients with available 24-hour NIHSS and 90-day mRS were included (median 24-hour NIHSS 6[IQR: 2-14], median 90-day mRS 2[IQR: 1-4]). Ordinal 24-hour NIHSS was associated with 90-day mRS (adjusted cOR 2.53 [95%CI 2.33-2.74]). Forty-eight (4.5%) patients had discordant outcomes. Of those, 19(1.8%) had 24-hour NIHSS < 6 and 90-day mRS5-6; all of which had ≥ 1 severe adverse event, most commonly pneumonia (6[31.6%]) or recurrent stroke (4[21.1%]). Twenty-nine patients (2.7%) had 24-hour NIHSS > 14 and 90-day mRS 0-2. In these patients, baseline NIHSS and ASPECTS was lower, and collateral status was worse.

Conclusion: An ordinal NIHSS score that includes death at 24 h shows a strong association with 90-day mRS, suggesting that it could be used as an alternative outcome. Patients with discrepant outcomes differed from the remaining patients regarding their baseline NIHSS, ASPECTS, collateral status, and post-stroke complications.

Keywords: Acute ischemic stroke; Cerebrovascular disease; Clinical outcomes; Modified Rankin Scale; National Institutes of Health Stroke Scale.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest: A. Stebner, S.L. Bosshart, A. Demchuk, A. Poppe, R. Nogueira, R. McTaggart, B. Buck, A. Ganesh, M. Hill, M. Goyal and J. Ospel declare that they have no competing interests. A. Stebner: received a stipend for his Research Fellowship in Calgary from the Swiss Society of Radiology. M. D. Hill: reports grants from Canadian Institutes for Health Research, Alberta Innovates, and NoNO, for the conduct of the study; reports personal fees from Merck; reports non-financial support from Hoffmann-La Roche Canada; reports grants from Covidien (Medtronic), Boehringer-Ingleheim, Stryker, and Medtronic, outside the submitted work; reports a patent for systems and methods for assisting in decision-making and triaging for acute stroke patients, issued to US Patent office Number 62/086,077; owns stock in Calgary Scientific; is a director of the Canadian Federation of Neurological Sciences and Circle NeuroVascular; and has received grant support from Alberta Innovates Health Solutions, CIHR, Heart & Stroke Foundation of Canada, and the National Institutes of Neurological Disorders and Stroke. M. Goyal: holds grants from Johnson & Johnson and Medtronic and is a consultant to Medtronic, Mentice, Microvention, Philips and Stryker. J. Ospel: is a consultant for Nicolab.

References

    1. Donkor ES. Stroke in the 21(st) century: a snapshot of the burden, epidemiology, and quality of life. Stroke Res Treat. 2018; https://doi.org/10.1155/2018/3238165 . - DOI - PubMed - PMC
    1. Goyal M, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31. https://doi.org/10.1016/s0140-6736(16)00163-x . - DOI - PubMed
    1. Robbins BT, Howington GT, Swafford K, Zummer J, Woolum JA. Advancements in the management of acute ischemic stroke: a narrative review. J Am Coll Emerg Physicians Open. 2023;4(1):e12896. https://doi.org/10.1002/emp2.12896 . - DOI - PubMed - PMC
    1. Menon BK, et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. Lancet. 2022;400(10347):161–9. https://doi.org/10.1016/s0140-6736(22)01054-6 . - DOI - PubMed
    1. Saver JL, et al. Thrombectomy for distal, medium vessel occlusions: a consensus statement on present knowledge and promising directions. Stroke. 2020;51(9):2872–84. https://doi.org/10.1161/STROKEAHA.120.028956 . - DOI - PubMed

LinkOut - more resources