Technical Journal of Engineering and Applied Sciences

Available online at www.tjeas.com

©2013 TJEAS Journal-2013-3-17/1954-1957
ISSN 2051-0853 ©2013 TJEAS

A Comparative Study OF NIHSS between Ischemic

Stroke Patients with and without Risk Factors
Davar Altafi1, Maryam Hosseini Khotbesara2*, Mahsa Hosseini Khotbesara3, Amin
Bagheri4
1. Department of Neurology, Ardabil University of Medical Sciences, Ardabil, Iran
2. Department of Medicine, Ardabil Branch, Islamic Azad University, Ardabil, Iran
3. Department of Medicine, Guilan University of Medical Sciences, Rasht, Guilan, Iran
4. Department of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran

Corresponding Author: Maryam Hosseini Khotbesara

ABSTRACT: Stroke is the third common reason of death in worldwide. Utility of the national
Institutes of health stroke scale as a predictor of care disposition among stroke patients on
admission could reduce the costly process, rehabilitation and unnecessary length of stay at hospital
and with regard to the impact of cerebrovascular accident risk factors in developing atherosclerosis;
we decided to do this study. In this study 100 patients with ischemic stroke were evaluated who their
average age was 65.83±15.32 years and also 54.54% were men and 46% were women. 25% of
patients were with no stroke risk factors and 45% were with one risk factor. 50% had hypertension,
13% diabetes, 18% hyperlipidemia, 14% a recent MI history and 31% had smoking history. NIHSS
average among patients was 6.59±4.33 and majority of patients were in minor range. NIHSS level
were evaluated with gender (p=0.058), age (p=0.876), HTN (P=0.070), HLP (P=0.103), DM
(P=0.999), and history of MI (P=0.262) and history of CVA (P=0.964) and also NIHSS level with
smoking (P=0.109). We concluded that multiple vascular risk factors is not compatible with the
severity of clinical symptoms and worsening of neurological symptoms based on NIHSS score in
patients with CVA. It shows that CVA with high NIHSS score could possibly occur even in patients
without vascular risk factors due to absence of collateral vessels in the brain and not response of
brain hemodynamic. Hence it is necessary to consider CVA as a diagnostic and therapeutic priority
in patients without vascular risk factors.

Key words: Cerebrovascular accident, Risk factors

INTRODUCTION

Stroke is the third common cause of death and also the leading cause of long-term disability worldwide
(Ali et al., 2013). Atherosclerotic plaque rupture causes thrombus formation which finally can lead to heart
attacks and strokes (Atanassova et al., 2007). Atherosclerosis is the most important underlying causes of
ischemic cerebrovascular accident (CVA). CVA risk factors include hypertension (HTN), hyperlipidemia (HLP),
diabetes mellitus (DM) and smoking (Daroff et al., 2012; Davies, 1995). Management of these patients is
important; hence national Institutes of health stroke scale (NIHSS) was designed to measure acute CVA
severity. It is composed of 11 items such as level of consciousness, horizontal eye movement, visual field test,
facial palsy, motor arm, motor leg, limb ataxia, sensory, language, speech, extinction and inattention (Fischer et
al., 2005). Utility of the NIHSS as a predictor of care disposition among stroke patients on admission could
reduce the costly process and time-consuming hospitalization, rehabilitation and unnecessary length of stay at
hospital (6) and with regard to the impact of CVA risk factors in developing atherosclerosis, (Atanassova et al.,
2007) we decided to research about any relationship between acute CVA severity and CVA risk factors,
perhaps will be found any way to decrease mortality, costs of hospitalization, consequences of disability and
death.

MATERIALS AND METHODS

This cross-sectional study was performed on patients with focal ischemic neurologic lesions who
referred to neurology department of Alavi hospital in Ardebil. Brain computed tomography (Brain CT) or
Tech J Engin & App Sci., 3 (17): 1954-1957, 2013

magnetic resonance imaging (Brain MRI) was performed for patients to rule out hemorrhage. After proving
ischemic cerebrovascular damage, 100 patients were enrolled in this study. The patients information was
formed as a check list consisted of demographic information, diabetes history, hypertension, smoking and etc.
also NIHSS score was investigated and NIHSS level was classified based on NIHSS scoring as follows: without
stroke symptoms: 0 /1-4= Minor / 5-15= Moderate stroke/ 16-20=Mod to Severe/ 21-42= severe stroke (Li et al.,
2003) Data was calculated and entered on SPSS software, version 16 and analyzed with Chi-Square Test and
the T-Test.
RESULTS AND DISCUSSION

In this study 100 patients with ischemic stroke were evaluated. The mean age of patients was
65.83±15.32 years. Among the patients 54.54% were men and 46% were women. Twenty-five percent of
patients had no stroke risk factors and 45% had at least one risk factor.

Table 1. The frequency and percentage of vascular risk factors in our study
Risk factor Frequency Percent
HTN 50 50
DM 13 13
HLP 18 18
Smoking 31 31
Recent MI history 14 14
History of CVA 26 26

50% had hypertension, 13% diabetes, 18% hyperlipidemia, 14% a recent MI history and 31% had
smoking history. Seventy-four percent of patients were with no stroke history. Also we evaluated NIHSS score
on admission. The NIHSS average among patients was 6.59±4.33 and majority of patients were in minor range.
The relationship between NIHSS level and patients gender were evaluated and analyzed with T-Test.
The result demonstrated the NIHSS level in male was less (P=0.058) The NIHSS level was evaluated
in smoking and non smoking patients that no significant relationship was found (P=0.109).

60

50

40
Axis Title

30

20

10

0
Minor moderate Mod to severe
severe
Frequency 41 53 4 2

Figure 1. The frequency of patients divided into NIHSS level

Also the relationship between NIHSS level and HTN, HLP, DM, history of MI and CVA was evaluated.
The T-Test’s results showed that there was no significant relationship between NIHSS level and HTN
(P=0.070), NIHSS level with HLP (P=0.103), NIHSS level with DM (P=0.999). Statistically significant
relationship was not obtained between patients with history of MI (P=0.262) and CVA with NIHSS level
(P=0.964) too. There were not also observed significant relationship between NIHSS level with number of CVA
risk factors (P=0.383).
In Mazdeh study (Masoud et al., 2009), cases were with the mean age of 50 years and 56.9% were
men. In Masoud study (Mazdeh et al., 2006) was observed 52.5% of patients were women, 48.75% men

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and also 52.5% of all were older than 70 years. In Moini and Javad Mousavi study (Meiklejohn et al., 2001)
the mean age of patients was 58.42 years and 57.7% were men. In Zonget study (Moini and Mousavi,
2008) was also observed that in cases with stroke the average age is 62.19 years, 66.66% men and
33.34% were women. In Li study (Monshi Karimi et al., 2011) the average age in cases is 60.3 years and
63.5% men. In Atanassova study (NSCT) in cases the average age of patients was 46.4 years and 75.6%
were men. In study of Meiklejohn (Schlegel et al., 2003) the average age of men was 57.2 years and for
women was 56.5 years and 56.6% of them were men. After evaluation of subjects in terms of age and
gender in this study with similar studies, was observed that age and gender of patients was like other
studies. In study of Monshi-Karimi (15) results indicated that 17.4% were with hyper lipidemia, 43.5% with
hypertension, 41.3% with diabetes Miletus and 45.7% were smokers. In Li study (Monshi Karimi et al.,
2011), 15.2% of cases were with previous CVA history, 63.2% with hypertension and 12.4% with diabetes
history. Atanassova study (NSCT) illustrated that 48.8% of patients with CVA history were smokers.
Meiklejohn study (Schlegel et al., 2003) showed the frequency of 6.6% diabetes, 50% smoking, 41.5%
hypertension history, 13.2% hyperlipidemia history and 14.2% of subjects had no risk factor. Evaluation of
current and other studies showed that the hypertension is one of the most prevalence of cardiovascular risk
factors that this is probably due to the high prevalence of this disease in older patients. History of previous
MI incidence in this study was frequent. Stöllberger study (Stöllbergeret al., 2005) showed in their study
that intracranial hemorrhage was more prevalent in diabetic (P = 0.0001) however, there was no
relationship between mortality of patients and DM (P = 0.355) and also was stated that the increase in
blood glucose in non-diabetic patients with acute stroke aggravate prognosis of patients. Ali study (Ver
Hage, 2011) showed smoker patients had lower NIHSS and lower in-hospital mortality after stroke
compared to nonsmokers. The possible etiology is assumed to be ischemic preconditioning in smokers
secondary to episodic hypoxia and chronic changes in vasomotor tone and presence of small vessel
cerebral collaterals leading to better cerebral perfusion. Nevertheless it should not be considered as a
benefit of cigarette smoking. Because smoking doubles the risk of ischemic stroke and occurred in younger
ages compared to nonsmokers based on ali's study. In our study, the NIHSS level was evaluated in
smoking and non smoking patients that no significant relationship was found. Schlegel study (Greenberg et
al., 2012) stated that any major complication such as infection, MI, recurrent stroke and respiratory failure
leading to increased level of NIHSS and also reduced level discharge of patients possibility and in Fischer
study (Zongte et al., 2008) also illustrated although risk factors cannot predict the central obstruction in
digital subtraction arteriography (DSA) but several scoring items of NIHSS such as consciousness, gaze,
motor leg and neglect are considered as predictors components in this topic significantly. Meanwhile such
a result was not observed in present study. It seems that although stroke risk factors have a role in the
incidence of atherosclerosis that is one of the major underlying reasons of ischemic stroke in patients, but
have not had a significant role in the severity of stroke. However further studies are recommended. Finally
we concluded that multiple vascular risk factors is not compatible with the severity of clinical symptoms and
worsening of neurological symptoms based on NIHSS score in patients with CVA and therefore cannot be
considered as a predictor factor of CVA. It shows that CVA with high NIHSS score could possibly occur
even in patients without vascular risk factors due to absence of collateral vessels in the brain and not
response of brain hemodynamic. Hence it is necessary to consider brain diseases such as CVA as a
diagnostic and therapeutic priority in patients without vascular risk factors.

ACKNOWLEDGEMENT

Conflicts of Interest Disclosure: The authors declare that there are no conflicts of interest with any
financial organization.

REFERENCES
Ali SF, Smith EE, Bhatt DL, Fonarow GC, Schwamm LH. 2013. Paradoxical association of smoking with in-hospital mortality among
patients admitted with acute ischemic. Stroke. J Am Heart Assoc; 2(3).
Atanassova PA, Angelova E, Tzvetanov P, Semerdjieva M, Dimitrov B. 2007. Modelling of increased homocysteine ischemic stroke. Arq
Neuropsiquiatr. 65(1):24-31.
Daroff R, Fenichel GM, Jankovic J, Mazziotta JC. 2012. Bradley's Neurology in Clinical Practice. 6 th edn. Elsevier pub, Netherlands.
Davies MJ. 1995. Stability and instability: tow faces of cinronary atherosclerosis. The Paul Dudley white Lecture. 94:2013-20.
Fischer U, Arnold M, Nedeltchev K, Brekenfeld C, Ballinari P, Remonda L, Schroth G, Mattle HP. 2005. NIHSS score and arteriographic
findings in acute ischemic stroke. Stroke. 36(10):2121-5.
Greenberg D, Aminoff MJ, Simon R. 2012. Clinical neurology, 8th edn. McGraw Hill Professional.
Li ZH, Sun L, Zhang H, Liao Y, Wang D, Zhao B. 2003. Elevated plasma homocysteine was associated with hemorrhagic and ischemic
stroke, but methylenetetrahydrofolate reductase gene C677T polymorphism was a risk factor for thrombotic stroke: a multicenter
case-control study in china. Stroke.34:2085-2090.
Masoud SA, Koochaki E, Mousavi Gh. 2009. Appointment of correlation between stroke and serum level of homocysteine,folic acid and
vitamin B12. J Army Univ Med Sci I.R. Iran. 7(3): 169-173.

1956
Tech J Engin & App Sci., 3 (17): 1954-1957, 2013

Mazdeh M, Monsef AR, Mani Kashani Kh. 2006. Study of relationship between homocysteine and stroke. Sci J Hamdan Univ Med Sci.
12(38):16-11.
Meiklejohn DJ, Vickers MA, Dijkhuisen R, Greaves M. 2001. Plasma homocysteine concentrations in the acute and convalescent periods of
atherothrombotic. Stroke. 32(1):57-62.
Moini L, Mousavi AJ. 2008. Study of frequency distribution of Homocysteinemia in patients admitted to ICU of Rasoul-Akram hospital 2005.
J Arak Univ Med Sci. 4 (41):50-56.
Monshi Karimi A, Mohtadi Nia J, Farhoodi M, Aref Hosseini SR. 2011. Relationship between smoking status, vitamin B12 and folic acid,
with homocysteine in patients with ischemic. Stroke. 33(2):81-86.
NIH Stroke Scale Training, Part 2. Basic Instruction. Department of Health and Human Services, National Institute of Neurological
Disorders and Stroke. The National Institute of Neurological Disorders and Stroke (NINDS) Version 2.0
Schlegel D, Kolb SJ, Luciano JM, Tovar JM, Cucchiara BL, Liebeskind DS, Kasner SE. 2003. Utility of the NIH Stroke Scale as a predictor
of hospital disposition. Stroke. 34(1):134-7.
Simon R, Greenberg D, Aminoff MJ. 2009. Clinical neurology (A Lange Medical Book), 7th edn. McGraw-Hill, Philadelphia.
Stöllberger C, Exner I, Finsterer J, Slany J, Steger C. 2005. Stroke in diabetic and non-diabetic patients: course and prognostic value of
admission serum glucose. Ann Med. 37(5):357-64.
Ver Hage. 2011. The NIH stroke scale: a window into neurological status. Nursing Spectrum (Greater Chicago). 24(15):44-49.
Zongte Z, Shaini L, Debbarma A, Bhimo Singh TH, Devi S. 2008. Serum homocysteine levels in cerebrovascular accidents. Ind. J. of
Clinical Biochemistry. 23(2) 154-157.

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