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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 51, Num. 2, 2003, pp. 285-286

Neurology India, Vol. 51, No. 2, April-June, 2003, pp. 285-286

Letter to Editor

Predicting long-term morbidity in Indian patients with ischemic stroke

S. Kumar
Neurology Unit, Department of Neurological Sciences, Christian Medical College Hospital, Vellore, Tamilnadu- 632004, India.

Code Number: ni03094


I read with great interest the recent article by Panicker JN et al.1 Based on a prospective study, they conclude that patients with upper limb power of grade 3/5 or less, aphasia or CRP positivity have greater disability at six months as assessed by Barthel's index of activities of daily living. I would like to make certain observations.

Firstly, data regarding the percentage of patients with severe disability at six months has not been provided. Also, it is not clear whether patients who expired were included in the final analysis. It would be more meaningful to include expired patients in the severely disabled group for final analysis.

Secondly, I have concerns regarding the mode of follow up- telephonic and postal. The information provided by relatives may have been correct but it could have been otherwise too. Researchers were not blinded and this could also lead to bias in the results obtained. In addition, we need to assess parameters other than those that can be assessed by Barthel's index for predicting long-term outcome in stroke. These include presence of cognitive impairment, post-stroke seizures, and vascular parkinsonism. A physician could best assess these.

The most robust predictors of disability at five years after stroke were found to be increasing age, stroke severity and recurrent strokes.2 In the present study, the authors have confirmed the point about stroke severity (upper limb power of grade 3/5 or less and presence of aphasia), however data regarding the role of increasing age and recurrent strokes on the outcome has not been elaborated.

The most important finding of this study is that C reactive protein (CRP) positivity at admission predicts a greater disability at six months. However, the timing of CRP assessment (in relation to stroke onset) is not clear from the study. It was found in an earlier study3 that a CRP increase between 12 to 24 hours after symptom onset predicts an unfavorable outcome, whereas a CRP rise within 12 hours of symptom onset is not independently related to poor outcome. However, in another study,4 CRP at discharge (as against within 24 hours or between 48-72 hours after stroke onset) was better related to one-year outcome.


1. Panicker JN, Thomas M, Pavithran K, Nair D, Sarma PS. Morbidity predictors in ischemic stroke. Neurology India 2003;51:49-51.
2. Hankey GJ. Long-term outcome after alchemic stroke/transient ischemic attack. Cerebrovasc Dis. 2003;16(Suppl 1):14-9.
3. Winbeck K, Poppert H, Etgen T, Conrad B, Sander D. Prognostic relevance of early serial C-reactive protein measurements after first ischemic stroke. Stroke 2002;33:2459-64.
4. Di Napoli M, Papa F, Bocola V. C-reactive protein in ischemic stroke: an independent prognostic factor. Stroke 2001;32:917-24.

Authors' Reply

J. N. Panicker, M. Thomas, K. Pavithran,* M. D. Nair,** P. S. Sarma**
Department of Medicine and *Hematology, Medical College, Thiruvananthapuram, Kerala-695011, India, and Department of **Neurology, Achutha Menon Centre for Health Science Studies, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala695011, India.


We appreciate the observations made regarding our article Morbidity predictors in ischemic stroke. Neurology India 2003;51:49-51. The analysis done at 6 months was regarding predictors of morbidity. Hence patients who expired were not included. This analysis is unique, as previous studies had studied only the relationship between C reactive protein (CRP) positivity and mortality.

During follow up, disability was assessed telephonically independent of degree of disability at discharge. Activities of daily living (ADL) reported by telephone interviews have been shown to correlate highly with ADL measured from direct examination.1 Barthel index, an important ADL scale, was used to assess outcome, as ADL independence is the overall major goal for stroke survivors. Recurrence of stroke and age were not found to be significant predictors. Difference in observation may be due to smaller sample size in the present study. CRP was studied within 24-48 hours of admission.


1. Shinar D, Gross CR, Bronstein KS, Licata-Gehr EE, Eden DT, Cabrara AR, et al. Reliabilities of the activities of daily living scale and its use in the telephone interview. Arch Phys Med Rehabil 1987;68:723-8.

Copyright 2003 - Neurology India. Also available online at

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