Annals of African Medicine Annals of African Medicine Society ISSN: 1596-3519 Vol. 10, Num. 1, 2011, pp. 55-58

Annals of African Medicine, Vol. 10, No. 1, January-March, 2011, pp. 55-58

Short Report

Efficacy of a clinical stroke score in monitoring complications in acute ischaemic stroke patients could be used as an independent prognostic factor

Clara Olakunbi Dawodu, RT Bamisile

Department of Medicine, Lagos State College of Medicine, [LASUCOM] Ikeja, Lagos, Nigeria

Correspondence Address: Clara Olakunbi Dawodu, P.O. Box 228 80, Ikeja, Lagos, Nigeria, brainattack2003@yahoo.com

Code Number: am11012

PMID: 21311158

DOI: 10.4103/1596-3519.76589

Abstract

Keywords: Complications, outcome, prognostic score, stroke

Introduction

Knowledge of complications, frequency, and timing after an incidence of stroke is important in terms of direct patient care and planning of future services. ^[1]

Complications are disease[s] concurrent with another disease. ^[2] This could be acute [<7 days], sub-acute [>7 days], and chronic [>30 days]. ^[3] Risk factors for medical complications that have been reported in the past include severity of stroke, admission disability level, length of rehabilitation stay, low serum albumin level, pre--stroke disability, location of stroke in the anterior cerebral circulation region, urinary incontinence, ^[4] and implementation of the acute care prospective payment system. Frequency of medical complications during inpatient stroke rehabilitation have been reported from 48%-96%, depending on criteria for defining complications, method of investigations and specific patient group studied. Davenport et al. found that complications in ischaemic and haemorrhagic stroke patients were associated with an increased risk of death during admission. ^[4] Roth et al. looked at potential prognostic factors in predicting outcome in stroke patients and concluded that death after two weeks were primarily due to cardiac and pulmonary complications. ^[5] Most of the complications are potentially preventable when recognised early, though some clinical interventions might not be effective when started immediately after a stroke. ^[6],[7] The National Institute of Health Stroke Scale (NIHSS) is a physical deficit scale, used as a prognostic score in acute ischaemic stroke patients. ^[8] The aim of this report was to evaluate the different types of complications and the outcome using a standard clinical stroke scale (NIHSS).

Materials and Methods

This was a prospective non-interventional study, carried out in Lagos University Teaching Hospital (LUTH) from April 2000 to July 2001, a study period of 16 months after approval of the research by the Ethics Board of LUTH. A total of 137 consenting patients presented at the medical emergency unit; of these, 87 had ischaemic stroke following the World health Organisation (WH0) ^[9] criteria and the Siri-raj Stroke Score ^[10] (SSS).

Exclusion Criteria: All patients having hemiplegia from other causes like subdural haematoma and brain tumours. Patients who presented with haemorrhagic strokes by the WHO and SSS criteria and patients who did not give consent were excluded.

The Study Instrument: A standard questionnaire was used to obtain all the relevant information, which included detailed aspects of the following: personal and clinical data, investigations, treatment, complications, WHO ^[9] criteria, Siri-raj stroke scale, ^[10] NIHSS, ^[8] the Glasgow outcome scale, ^[11] and the Glasgow coma scale. ^[12] Acute presentations were defined as complications observed 7 days before and sub-acute as those observed after 7 days, and chronic complications for those that persist after 30 days. ^[3] The outcome in terms of morbidity and mortality was measured using the Glasgow outcome scale. ^[11]

Statistical Analysis: Sample size for the study was based on the objective, which sought to compare the mean NIHSS score at presentation with the means score after treatment. The minimum difference between the scores at presentation and end of treatment was set at 2 points. ^[8] Quantitative variables, NIHSS scores were computed with measures of mean and standard deviation. For discrete variables, the Chi-square test for paired observations was used. Paired t test was used for the significance of difference between the continuous variables. Statistical significance will be achieved where P values are ≤0.05.

Results

Subject characteristics [Table - 1a], [Table - 1b]

Different kinds of complications were observed within the study period. Infection-related complications were observed in 54% of patients [which was 36.7% of the study population]. Urinary tract infections were the most common followed by patients who had pneumonia. A total of 59 patients (67.8% of the study population) developed complications. About 40 patients had single complications, while 19 patients had more than one complication. Complications were observed within the first 30 days. All neurological complications, 19 patients (21.8%) presented within the first 7 days.

NIHSS subgroups and frequency of complications [Table - 2]

The 87 patients presenting with NIHSS scores were in the range of 3-30. All sub-classes had patients with complications. There was a direct relationship from subgroup 15-19 and more complications as well. It was also observed that subgroup 6-10 had the largest group of patients [39%] with no complications.

Mean NIHSS among patients with complications [Table - 3]

The highest scores (21.7) were found in those with pure neurological complications and the lowest scores (15.6) among those with non-neurological complications. However, the mean NIHSS score in all patients with complications was greater than 15.

Mean NIHSS of two groups at specific times [Figure - 1] and [Figure - 2]

The two different groups of patients at different times during the study period had sustained decline in scores, though a significant observation was that the scores in the complication group were lagging behind prognostically when compared with that of the no complications group. Declining scores in the complications group was secondary to the death of patients with higher scores.

Discussion

Types and frequency of complications

Of the 87 patients studied, 59 (67%) had complications, a finding that agrees with those in previous studies. ^[7] Of these, 32% had single complications and 52% had more than one complication in comparison with Davenport et al. study, which had 59% and 62,% respectively. ^[4]

Infections dominated in the different types of complications observed. Langhorne et al. in their study confirmed the relative frequency of infections, particularly urinary tract infections. ^[7] Our study had 32 (37%) patients, of which 20 patients had at least one episode of urinary tract infection.

NIHSS and Complications

Complications peaked in patients with NIHSS scores greater than 15-19, which was consistent with the scores in a study by Roth et al. ^[5] Roth et al. also suggested that severe strokes contribute to an increased risk of complications. The mean NIHSS score for patients with complications in our study were within this range. However, the NIHSS subgroup 6-10 had the highest number of patients with no complications. Since higher NIHSS scores were a reflection of severe neurological deficit, we observed the proportionate increase in complications with higher scores in this study as observed in previous studies. ^[4],[5]

NIHSS, Complications, and Mortality

Mortality was total in patients with only neurological complications and least in those with non-neurological complications. However, mortality was high irrespective of NIHSS score in patients with combined complications. The overall mortality in patients with complications was 39%, which is similar to the findings by Silver et al. who reported 40%, but at variance to studies by Bounds et al. who reported more than 50% and Kalra et al. who reported the mortality at 60%. ^[6] Overall mortality in this study population was 26%. Mortality was not observed in patients without complications. Previous authors have noted a strong association between post-stroke complications and poor outcome and have suggested that complications may act as barriers to recovery. ^[7]

The NIHSS scores in this study were reflective of the minimum score for complications to commence, different types of complications, and a predictable outcome.

References

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