Ischemic Stroke Prognosis in Adults

19/9/2019 Ischemic stroke prognosis in adults - UpToDate
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Ischemic stroke prognosis in adults

Author: Matthew A Edwardson, MD
Section Editor: Scott E Kasner, MD
Deputy Editor: John F Dashe, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2019. | This topic last updated: Jun 10, 2019.
INTRODUCTION
Stroke is the third most common cause of disability and second most common cause of death
worldwide (see "Etiology, classification, and epidemiology of stroke", section on 'Epidemiology').
Clinicians are often asked to predict outcome after stroke by the patient, family, other healthcare
workers, and insurance providers. A wide variety of factors influence stroke prognosis, including age,
stroke severity, stroke mechanism, infarct location, comorbid conditions, clinical findings, and related
complications. In addition, interventions such as thrombolysis, stroke unit care, and rehabilitation can
play a major role in the outcome of ischemic stroke. Knowledge of the important factors that affect
prognosis is necessary for the clinician to make a reasonable prediction for individual patients, to
provide a rational approach to patient management, and to help patient and family understand the
course of the disease.
This topic will review the factors that affect stroke prognosis, with a focus on the acute phase of
ischemic stroke. The prognosis of intracerebral hemorrhage and subarachnoid hemorrhage is reviewed
separately. (See "Aneurysmal subarachnoid hemorrhage: Treatment and prognosis", section on
'Prognosis' and "Spontaneous intracerebral hemorrhage: Treatment and prognosis", section on
'Prognosis'.)
MAJOR PREDICTORS
In the acute phase of stroke, the strongest predictors of outcome are stroke severity and patient age.
Stroke severity can be judged clinically, based upon the degree of neurologic impairment (eg, altered
mentation, language, behavior, visual field deficit, motor deficit) and the size and location of the
infarction on neuroimaging with magnetic resonance imaging (MRI) or computed tomography (CT).
Other important influences on stroke outcome include ischemic stroke mechanism, comorbid conditions,
epidemiologic factors, and complications of stroke.
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Neurologic severity — The severity of stroke on neurologic exam is probably the most important factor
affecting short- and long-term outcome [1-14]. As a general rule, large strokes with severe initial clinical
deficits have poor outcomes compared with smaller strokes.
Neurologic impairment is measured quantitatively in many research studies, and increasingly in clinical
practice, by use of the National Institutes of Health Stroke Scale (NIHSS), which measures neurologic
impairment using a 15-item scale (table 1) or less often by use of the Canadian Neurological Scale
(table 2). As an example, the combination of neurologic findings in patients with a large infarction
involving the middle cerebral artery vascular territory typically includes forced gaze deviation, visual field
deficit, hemiplegia, and aphasia or neglect, depending on the hemisphere involved, and yields a NIHSS
score >15 for a right hemisphere infarction and >20 for a left hemisphere infarction.
Several studies have demonstrated that the NIHSS is a good predictor of stroke outcome [2,15-17].
One report analyzed NIHSS scores obtained within 24 hours of acute ischemic stroke symptom onset
from over 1200 patients enrolled in a clinical trial [2]. Each additional point on the NIHSS decreased the
odds of an excellent outcome at three months by 17 percent. At three months, the proportion of patients
with excellent outcomes for NIHSS scores of 7 to 10 and 11 to 15 was approximately 46 and 23
percent, respectively. An NIHSS score of ≤6 predicted a good recovery (able to live independently,
whether or not able to return to work or school), while a score ≥16 was associated with a high
probability of death or severe disability. In many such studies, descriptors such as "good recovery" are
based upon discharge location to home or independence in activities of daily living such as mobility.
However, the NIHSS does not evaluate more complex goals such as return to prior level of
employment, participation in leisure activities, or social participation. In general, recovery of these areas
is less than those measured by the NIHSS.
The relationship of NIHSS score with final outcome varies according to the time elapsed from stroke
onset [9,15], in part because early stroke-related deficits tend to be unstable, and because many
patients experience gradual recovery. Thus, the NIHSS score associated with a specific disability
outcome shifts to lower values over time [9]. One study found that the best predictor of poor prognosis
at 24 hours was an NIHSS of >22, and the best predictor at 7 to 10 days was an NIHSS score of >16
[15]. In addition, the correlation of the NIHSS score with final disability outcome increases with time [9].
The Canadian Neurological Scale (CNS) is also useful for predicting outcome after acute ischemic
stroke. A CNS score of <6.5 on admission is associated with increased 30-day mortality and a poor
outcome at six months [17,18]. Although comparative data are limited, the results of one study suggest
that the NIHSS is more accurate than the CNS for predicting outcome at three months [16].
An important limitation of both the NIHSS and the CNS scales is that they do not capture all stroke-
related impairments. (See "Use and utility of stroke scales and grading systems", section on 'Stroke
impairment scales'.)
Patients with acute ischemic stroke who are treated with intravenous thrombolysis and/or mechanical
thrombectomy according to recommended guidelines may have a dramatic reduction in neurologic
impairment. In the case of mechanical thrombectomy, a meta-analysis found that the rate of functional
independence (ie, a 90-day modified Rankin scale [mRS] score of 0 to 2) was significantly greater for
the intervention group compared with the control group (46 versus 27 percent, odds ratio [OR] 2.35,
95% CI 1.85-2.98) [19]. Thus, impairment scales performed after the intervention are a more accurate
gauge of prognosis than those performed at initial presentation [20].
Age — Advancing age has a major negative impact on stroke morbidity, mortality, and long-term
outcome [1,5,7,10,12,21-25]. The influence of age in stroke outcome is seen in both minor and major
strokes. Older adults (over 65 years) have increased chance of dying in two months after stroke and
being discharged to the skilled nursing facility if they survive [26,27]. Advancing age is used in several
predictive models. (See 'Global prognostic scales' below.)
Neuroimaging — Findings on neuroimaging including stroke size and location are an important adjunct
to the neurologic exam when gauging prognosis. Early after stroke, the neurologic exam alone can
suggest a falsely grim or favorable prognosis. For example, a patient may have a small stroke on
neuroimaging and present with stupor or coma caused by seizure or metabolic derangement that is
reversible. Conversely, a patient presenting with mild stroke and a low NIHSS score on examination
may have large vessel occlusion and a large perfusion deficit on neuroimaging, suggesting the
possibility of stroke progression and worse outcome.
Infarct volume — The volume of acute infarction on neuroimaging studies may be used to estimate
stroke outcome [28]. In one small study, the volume of ischemic tissue determined by diffusion-weighted
MRI within 36 hours of stroke onset combined with the NIHSS score and time from stroke onset to
imaging predicted the functional outcome at three months better than any of the individual factors alone
[11]. A much larger study analyzed data from over 1800 patients who had CT or MRI within 72 hours of
ischemic stroke onset and found that initial infarct volume was an independent predictor of stroke
outcome at 90 days, along with age and NIHSS score [8]. In these and most other reports [8,11,28], the
vast majority of infarcts analyzed were supratentorial (eg, anterior circulation, middle cerebral artery
territory) and the results may not apply to posterior circulation or infratentorial infarcts, in which an
infarct of small volume can result in severe disability.
Infarct location — The prognosis for stroke recovery may vary by the affected vascular territory and
site of ischemic brain injury.
● Acute occlusion of the cervical internal carotid artery [29,30], basilar artery [31], or a large
intracranial artery is associated with an increased risk of poor outcome [32-34]. It follows that
involvement of total anterior circulation or posterior circulation also portends poor prognosis [18,35-
37].
● Strokes in the insular region (supplied by the insular branch of the middle cerebral artery) have
been associated with increased mortality, which is often attributed to autonomic dysregulation
[38,39]. However, this association may be confounded by infarct size [40]. Insular infarcts may
undergo early expansion due to associated large vessel occlusion and progression of infarction in
surrounding areas of initially viable but ischemic brain tissue [41].
● Anterior choroidal artery infarctions may be more likely to progress in the first few days after stroke
than other subtypes [42,43]. In a prospective study of over 1300 patients with acute ischemic

stroke, anterior choroidal territory infarcts had intermediate long-term prognosis between lacunar
infarcts and large artery territory hemispheric infarcts [42].
● A retrospective report of 75 survivors of ischemic stroke in the middle cerebral artery territory found
that strokes located in the internal capsule demonstrated a worse prognosis for recovery of hand
motor function at one year than strokes in the corona radiata or motor cortex after controlling for
infarct size [44].
● There are limited and conflicting data regarding borderzone infarcts (ie, infarcts that occur along the
boundaries of adjacent arterial territories, such as the middle cerebral and anterior cerebral artery
territories) and outcome; some studies suggest a lower severity at onset and a good prognosis in
most cases [45], while others describe severe impairment and poor recovery in a substantial
proportion [46,47].
Other imaging findings — In addition to stroke volume and location, there are other features
identifiable on neuroimaging that may suggest poor prognosis:
● Diffusion-perfusion mismatch (ie, an ischemic brain lesion characterized by a core of infarcted

tissue on MRI diffusion imaging that is embedded within a still viable but ischemic penumbral
region on MRI perfusion imaging), which may be a risk factor for lesion enlargement. (See
"Neuroimaging of acute ischemic stroke", section on 'Magnetic resonance imaging'.)
● Poor collateral blood flow [48,49].
● Development of cerebral edema in nonlacunar ischemic stroke [50].
Ischemic stroke mechanism — The etiology or mechanism of ischemic stroke influences prognosis
for recovery [51].
● Patients with lacunar infarcts have a better prognosis up to one year after onset than those with
infarcts due to other stroke mechanisms. However, the longer-term prognosis after lacunar stroke
may not differ greatly from nonlacunar stroke. (See "Lacunar infarcts", section on 'Prognosis'.)
● Compared with other ischemic stroke subtypes, cryptogenic stroke, where no mechanism of stroke
is identified, tends to have a better prognosis up to one year following onset. (See "Cryptogenic
stroke", section on 'Prognosis'.)
● Patients with strokes of cardioembolic or large artery etiology tend to have worse prognosis for
recovery compared with other ischemic stroke subtypes [51-54].
Comorbidities — A host of prestroke comorbid conditions are associated with an increased risk of poor
outcome following ischemic stroke, including the following:
● Anemia [55]
● Atrial fibrillation [4,7,15,56,57]
● Cancer [4,56]
● Coronary artery disease [4]

● Dementia [4,10,58]
● Dependency [4,23,25,56]
● Diabetes mellitus [14,59,60]
● Hyperglycemia (eg, blood glucose >6.1 mmol/L [>110 mg/dL]) on admission [60,61]
● Heart failure [4,56]
● Myocardial infarction [62,63]
● Periventricular white matter disease or leukoaraiosis [64-66]
● Renal dysfunction or dialysis [4,67-71]
● Poor nutritional status [72]
● Low hemoglobin level [73]
The relationship between blood pressure in the acute phase of ischemic stroke and outcome is complex
and is discussed separately. (See "Initial assessment and management of acute stroke", section on
'Blood pressure management'.)
Body mass index appears to be inversely related to stroke prognosis, such that patients who are
underweight or normal weight have paradoxically higher mortality rates and worse functional outcomes
than patients who are overweight or obese [74-76].
Finally, ischemic stroke that occurs in the postoperative period has a high short-term morbidity [77].
Epidemiologic factors — Differences in sex, race, and socioeconomic status may affect stroke
recovery. Most studies have found that women are more likely than men to have poor outcomes after
stroke [78-80]. However, the difference is mostly related to age, stroke severity, and pre-stroke
dependency [81].
There are racial and ethnic differences in outcome after stroke. In studies from the United States, black
or nonwhite race is associated with a higher risk for poor outcome [64,82,83]. Lower levels of
educational attainment [84,85], socioeconomic status [85-87], and lesser degrees of social support have
been correlated with poor outcome following ischemic stroke, and a lower socioeconomic status has
been associated with a worse health-related quality of life at five years [88,89]. However, it is unclear if
these are independent prognostic factors, since lower socioeconomic status may also be associated
with increased comorbidities and greater stroke severity [90,91].
Complications of stroke — Medical complications of acute ischemic stroke are common and influence
outcome after ischemic stroke. The most frequent serious medical complications include pneumonia,
the need for intubation and mechanical ventilation, gastrointestinal bleeding, congestive heart failure,
cardiac arrest, deep vein thrombosis, pulmonary embolism, and urinary tract infection. (See
"Complications of stroke: An overview".)
Early neurologic deterioration during the acute phase of ischemic stroke affects a significant minority
and is associated with an increased risk of morbidity and mortality [92-97]. The mechanisms of early
neurologic deterioration are heterogeneous and include extension of the infarct into surrounding areas
of hypoperfused brain tissue, progressive edema, increased intracranial pressure, seizure, and

hemorrhagic conversion of the infarct. Delirium, characterized by a disturbance of consciousness with

decreased attention and disorganized thinking, is another potential complication of acute stroke.
Poststroke depression has a high prevalence and a negative impact on stroke outcome [58]. Stroke
severity with subsequent disability and cognitive impairment are likely risk factors. (See "Complications
of stroke: An overview", section on 'Depression'.)
PREDICTING RECOVERY
In the period from 12 hours to seven days after ischemic stroke onset, many patients who are without
complications experience moderate but steady improvement in neurologic impairments [98].
The greatest proportion of recovery after stroke occurs in the first three to six months [3,6,99,100],
though some patients experience further improvement up to 18 months [6]. In a prospective study that
evaluated more than 1100 patients from Denmark with acute stroke, those who had mild disability
tended to recover within two months and those who had moderate disability recovered within three
months [3,100]. Patients with severe disability who recovered did so within four months, and those with
the most severe disability within five months from onset (figure 1). Functional recovery was preceded by
neurologic recovery by two weeks on average.
Accumulating data suggest that integrity of the ipsilesional corticospinal tract is necessary to allow for
motor recovery, and that excessive corticospinal tract injury is a predictor of poor recovery [101-104].
The functional integrity of the corticospinal tract can be assessed by a variety of specialized techniques,
including motor evoked potentials elicited by transcranial magnetic stimulation, and magnetic resonance
imaging (MRI) methods such as diffusion-weighted imaging maps and diffusion tensor tractography.
Despite the emerging importance of corticospinal tract integrity for motor recovery, none of these
measures are in widespread clinical use.
Other data suggest that functional outcome at three months after stroke predicts survival at four years
[64], and functional status at six months predicts long-term survival [105].
Specific neurologic deficits — Attempting to predict recovery from specific neurologic deficits is
challenging and best provided by an experienced neurologist or physiatrist after careful clinical
examination and review of pertinent neuroimaging. The time course and degree of improvement may
vary for specific deficits, but as a general rule, mild deficits improve more rapidly and more completely
than severe deficits [99].
● Arm and hand weakness – An early study found that in patients with hemiplegic stroke, the first
voluntary movements were observed between 6 to 33 days after onset [106]. In a prospective
report of patients with arm disability, the maximum degree of functional recovery was reached
within three weeks from stroke onset by 80 percent of patients, and within nine weeks by 95
percent [107]. Complete functional arm recovery was achieved by patients with initial mild and
severe arm paresis in 79 and 18 percent, respectively.

The return of arm and hand function after stroke is particularly important to a good functional
recovery. The flexor synergy seen after stroke limits the ability to isolate joint movements, so the
ability to extend the fingers and release grasp is a significant component of a good motor outcome.
Several studies have found that early active finger extension, grasp release, shoulder shrug,
shoulder abduction, and active range of motion are associated with a favorable prognosis for arm
and hand recovery at six months [108-111]. As an example, in a prospective cohort study of 188
patients with monoparesis or hemiparesis from anterior circulation ischemic stroke observed,
patients with some voluntary finger extension and shoulder abduction of the hemiplegic limb on day
2 after stroke onset had a high probability (0.98) to regain some dexterity by six months [112]. In
contrast, the probability for patients without these voluntary movements at two and nine days was
0.25 and 0.14, respectively.
● Leg weakness and ambulation – In a study of 154 patients who were unable to walk after first
ischemic stroke, multivariate modeling showed that patients who could maintain sitting balance for
30 seconds and perform muscle contraction (with or without actual limb movement) in the paretic
leg within the first 72 hours after stroke had a probability for ambulating independently at six
months of 98 percent [113]. For those who did not reach either functional level within 72 hours, the
probability for ambulating independently at six months was only 27 percent.
● Aphasia – Patients with poststroke aphasia are likely to experience some improvement from the
initial impairment. Not surprisingly, the prognosis for full recovery is greatest when patients have
milder degrees of aphasia at onset. The time course for recovery from aphasia is similar to that of
motor function. One prospective study included over 300 patients with aphasia at admission; the
time to maximal language recovery in 95 percent of patients with initially mild, moderate, and
severe aphasia was 2, 6, and 10 weeks, respectively [114]. (See "Aphasia: Prognosis and
treatment".)
● Dysphagia – Early after stroke, approximately 50 percent of patients have difficulty swallowing,
placing them at risk for aspiration [115]. Swallowing impairments commonly improve over time. A
large multicenter trial found no benefit to early enteral feeding via a percutaneous endoscopic
gastrostomy (PEG) tube compared with no tube feeding [116]. Risk factors for more longstanding
dysphagia eventually requiring PEG tube placement include high National Institutes of Health
Stroke Scale (NIHSS) score and bihemispheric infarcts [117,118]. In a retrospective cohort study of
563 patients admitted for stroke rehabilitation, feeding tubes were placed in 6 percent [119]. Of
these, approximately one-third of feeding tubes were discontinued before patients were discharged
from rehabilitation, and almost all of the rest were discontinued by one year. Persons with stroke
lesions that were bilateral or in the posterior fossa were least likely to return to oral feeding. (See
"Complications of stroke: An overview", section on 'Dysphagia'.)
● Sensory loss – Sensory impairment is found in 65 to 94 percent of stroke survivors; the reported
incidence depends greatly on the method of assessment, with formal quantitative testing being the
most sensitive [120]. Sensory loss is also common on the apparently unaffected side. Sensory
impairment is associated with reduced mobility and less independence in activities of daily living
[121]. However, there are currently no reliable predictors of recovery from sensory loss. Patients
with infarcts involving the spinothalamic or trigeminothalamic pathways sometimes develop a

debilitating central poststroke pain syndrome [122]. (See "Approach to the patient with sensory
loss", section on 'Thalamic lesions'.)
● Visuospatial neglect – Limited data suggest that full recovery from visuospatial neglect occurs in
70 to 80 percent of affected patients within three months of stroke onset [123,124].
● Hemianopia – A study of 99 patients with acute stroke and homonymous hemianopia (HH) found
that 17 percent of those with complete HH had full recovery at one month, whereas 72 percent with
partial HH had full recovery [125]. It is important to counsel patients with hemianopia after stroke
not to drive until they are cleared by an ophthalmologist or pass a formal driver rehabilitation
program (offered at select rehabilitation centers). (See "Homonymous hemianopia", section on
'Driving'.)
Global prognostic scales — In stroke rehabilitation venues, the Orpington Prognostic Scale (OPS)
[126,127] and the Reding three-factor approach [128] are in wide clinical use.
● The OPS (table 3) includes assessments of arm motor function, proprioception, balance, and
cognition, making it easier to perform than the NIHSS. The OPS is better at predicting return of
function than NIHSS in those with mild to moderate stroke [126], possibly because balance is so
critical to carrying out activities of daily living.
● The Reding three-factor approach provides a useful way to gauge the speed and degree of
recovery for an individual patient [128]. Patients are divided into one of three groups:
• Motor deficit only

• Motor deficit plus somatic sensory deficit
• Motor deficit plus somatic sensory deficit plus homonymous visual field deficit
Once the group is determined for the individual patient, their recovery can be compared with a
cohort of similar patients (figure 2) to estimate the probability of return to Barthel Index (table 4)
score of ≥60. This level of function is a useful benchmark because most patients with a Barthel
Index score ≥60 are able to walk with assistance and contribute to their activities of daily living; in
addition, the likelihood of a supported discharge to the community rises substantially. With a
Barthel Index score of 100, a discharge to the community at a level of independence becomes
plausible, but requires adequate cognitive function.
A number of other prognostic models may be useful for predicting global outcome from acute ischemic
stroke; however, none of the current models is established as generally valid, and none is widely used
in clinical practice. These models include the ASTRAL score [129,130], DRAGON score [131], iScore
[132,133], and PLAN score [56]. These stroke prognostic models are intended to be easy to calculate
from data available on admission. However, they disregard information available from follow-up and
testing, such as stroke etiology, treatment, and complications, that has an important impact on outcome
[64,134]. The course of stroke often changes in the first days after onset, and assessment at later times
(eg, from 1 to 10 days after stroke onset) is likely to provide a more reliable prognosis [9].

MORBIDITY AND MORTALITY
The estimated worldwide 30-day case fatality rate after first ischemic stroke ranges from 16 to 23
percent, though there is wide variation in reports from different countries [135,136]. A cohort study of
adults 18 to 49 years of age who were 30-day survivors of first stroke found that, compared with the
general population, mortality risk remained elevated up to 15 years after stroke [137]. Even minor
ischemic strokes portend a diminished long-term prognosis. In a 10-year follow-up study of 322 patients
with minor ischemic stroke, the cumulative mortality rate was 32 percent, almost twice that of the
general population [138].
Intracerebral hemorrhage and subarachnoid hemorrhage are associated with higher morbidity and
mortality than ischemic stroke [5,22,25,139-142]. (See "Spontaneous intracerebral hemorrhage:
Treatment and prognosis", section on 'Prognosis' and "Aneurysmal subarachnoid hemorrhage:
Treatment and prognosis", section on 'Prognosis'.)
In a community-based study from the United States that evaluated 220 ischemic stroke survivors (age
≥65 years), the following neurologic deficits were observed at six months after stroke [143]:
● Hemiparesis, 50 percent
● Cognitive deficits, 46 percent
● Hemianopia, 20 percent
● Aphasia, 19 percent
● Sensory deficits, 15 percent
Disability measures at six months after stroke were as follows [143]:
● Depression symptoms, 35 percent

● Unable to walk unassisted, 31 percent
● Social disability, 30 percent
● Institutionalization, 26 percent
● Bladder incontinence, 22 percent
A systematic review from 2009 identified only three studies that specifically evaluated work status after
stroke and used appropriate analytic methods [144]. In these reports, the proportion of patients at 6 to
12 months after stroke who had returned to paid employment was just over 50 percent [145-147]. A
subsequent report evaluated a hospital-based cohort of 694 working-age (18 to 50 years) patients with
transient ischemic attack (TIA), ischemic stroke, or hemorrhagic stroke and found that the risk of
unemployment after eight years of follow-up was two- to threefold higher compared with the general
population of vocational age [148].
Outcome from ischemic stroke can be assessed with the modified Rankin Scale and the Barthel Index.
The modified Rankin Scale (table 5) measures functional independence on a seven-grade scale. The
Barthel Index (table 4) measures ten basic aspects of self-care and physical dependency. These indices
are reviewed in greater detail elsewhere. (See "Use and utility of stroke scales and grading systems",

section on 'Modified Rankin Scale' and "Use and utility of stroke scales and grading systems", section
on 'Barthel Index'.)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of subjects
by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Recovery after stroke (The Basics)")
SUMMARY AND RECOMMENDATIONS
● In the acute phase of stroke, the strongest predictors of outcome are stroke severity and patient
age. Stroke severity can be judged clinically, based upon the degree of neurologic impairment (eg,
altered mentation, language, behavior, visual field deficit, motor deficit), and the size and location of
the infarction on neuroimaging with magnetic resonance imaging (MRI) or (CT). Other important
influences on stroke outcome include infarct location, ischemic stroke mechanism, comorbid
conditions, epidemiologic factors, and complications of stroke. (See 'Major predictors' above.)
● In the period from 12 hours to seven days after ischemic stroke onset, many patients who are
without complications experience moderate but steady improvement in neurologic impairments.
The greatest proportion of recovery occurs in the first three to six months after stroke, with lesser
improvements thereafter. (See 'Predicting recovery' above.)
● The return of arm and hand function after stroke is particularly important to a good functional
recovery. Early active finger extension, grasp release, shoulder shrug, shoulder abduction, and
active range of motion are associated with a favorable prognosis for arm and hand recovery at six
months. (See 'Specific neurologic deficits' above.)
● The estimated 30-day case fatality rate after first ischemic stroke ranges from 16 to 23 percent.
Available data suggest that persistent neurologic deficits observed at six months after stroke
include hemiparesis and cognitive deficits in 40 to 50 percent of patients, and hemianopia, aphasia,
or sensory deficits in 15 to 20 percent. Disability outcomes at six months after stroke include
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depression, inability to walk unassisted, and social impairments in approximately 30 percent, and
institutional care in approximately 25 percent. (See 'Morbidity and mortality' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Alexander Dromerick, MD, who contributed to
an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 14086 Version 18.0

GRAPHICS
National Institutes of Health Stroke Scale (NIHSS)
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not
go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient
does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam
and work quickly. Except where indicated, the patient should not be coached (ie, repeated requests to patient to make a
special effort).
Instructions Scale definition Score
1a. Level of consciousness: The investigator must 0 = Alert; keenly responsive.

choose a response if a full evaluation is prevented by 1 = Not alert; but arousable by minor stimulation to
such obstacles as an endotracheal tube, language obey, answer, or respond.
barrier, orotracheal trauma/bandages. A 3 is scored
2 = Not alert; requires repeated stimulation to
only if the patient makes no movement (other than _____
attend, or is obtunded and requires strong or painful
reflexive posturing) in response to noxious
stimulation to make movements (not stereotyped).
stimulation.
3 = Responds only with reflex motor or autonomic
effects or totally unresponsive, flaccid, and areflexic.
1b. Level of consciousness questions: The patient 0 = Answers both questions correctly.
is asked the month and his/her age. The answer must 1 = Answers one question correctly.
be correct - there is no partial credit for being close.
2 = Answers neither question correctly.
Aphasic and stuporous patients who do not
comprehend the questions will score 2. Patients
unable to speak because of endotracheal intubation,
_____
orotracheal trauma, severe dysarthria from any
cause, language barrier, or any other problem not
secondary to aphasia are given a 1. It is important
that only the initial answer be graded and that the
examiner not "help" the patient with verbal or non-
verbal cues.
1c. Level of consciousness commands: The 0 = Performs both tasks correctly.

patient is asked to open and close the eyes and then 1 = Performs one task correctly.
to grip and release the non-paretic hand. Substitute
2 = Performs neither task correctly.
another one step command if the hands cannot be
used. Credit is given if an unequivocal attempt is
made but not completed due to weakness. If the
_____
patient does not respond to command, the task
should be demonstrated to him or her (pantomime),
and the result scored (ie, follows none, one or two
commands). Patients with trauma, amputation, or
other physical impediments should be given suitable
one-step commands. Only the first attempt is scored.
2. Best gaze: Only horizontal eye movements will be 0 = Normal.

tested. Voluntary or reflexive (oculocephalic) eye 1 = Partial gaze palsy; gaze is abnormal in one or
movements will be scored, but caloric testing is not both eyes, but forced deviation or total gaze paresis
done. If the patient has a conjugate deviation of the is not present.
eyes that can be overcome by voluntary or reflexive
2 = Forced deviation, or total gaze paresis not
activity, the score will be 1. If a patient has an
overcome by the oculocephalic maneuver.
isolated peripheral nerve paresis (cranial nerves III,
IV or VI), score a 1. Gaze is testable in all aphasic _____
patients. Patients with ocular trauma, bandages, pre-
existing blindness, or other disorder of visual acuity
or fields should be tested with reflexive movements,
and a choice made by the investigator. Establishing
eye contact and then moving about the patient from
side to side will occasionally clarify the presence of a
partial gaze palsy.
3. Visual: Visual fields (upper and lower quadrants) 0 = No visual loss. _____
are tested by confrontation, using finger counting or 1 = Partial hemianopia.
visual threat, as appropriate. Patients may be
2 = Complete hemianopia.
encouraged, but if they look at the side of the moving
fingers appropriately, this can be scored as normal. If 3 = Bilateral hemianopia (blind including cortical
there is unilateral blindness or enucleation, visual blindness).

fields in the remaining eye are scored. Score 1 only if
a clear-cut asymmetry, including quadrantanopia, is
found. If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this
point. If there is extinction, patient receives a 1, and
the results are used to respond to item 11.
4. Facial palsy: Ask - or use pantomime to 0 = Normal symmetrical movements.

encourage - the patient to show teeth or raise 1 = Minor paralysis (flattened nasolabial fold,
eyebrows and close eyes. Score symmetry of grimace asymmetry on smiling).
in response to noxious stimuli in the poorly
2 = Partial paralysis (total or near-total paralysis of
responsive or non-comprehending patient. If facial _____
lower face).
trauma/bandages, orotracheal tube, tape or other
physical barriers obscure the face, these should be 3 = Complete paralysis of one or both sides
removed to the extent possible. (absence of facial movement in the upper and lower
face).
5. Motor arm: The limb is placed in the appropriate 0 = No drift; limb holds 90 (or 45) degrees for full
position: extend the arms (palms down) 90 degrees 10 seconds.
(if sitting) or 45 degrees (if supine). Drift is scored if 1 = Drift; limb holds 90 (or 45) degrees, but drifts
the arm falls before 10 seconds. The aphasic patient down before full 10 seconds; does not hit bed or
is encouraged using urgency in the voice and other support.
pantomime, but not noxious stimulation. Each limb is
2 = Some effort against gravity; limb cannot get
tested in turn, beginning with the non-paretic arm.
to or maintain (if cued) 90 (or 45) degrees, drifts
Only in the case of amputation or joint fusion at the
down to bed, but has some effort against gravity. _____
shoulder, the examiner should record the score as
untestable (UN), and clearly write the explanation for 3 = No effort against gravity; limb falls.
this choice. 4 = No movement.
UN = Amputation or joint fusion,
explain:________________
5a. Left arm
5b. Right arm
6. Motor leg: The limb is placed in the appropriate 0 = No drift; leg holds 30-degree position for full 5
position: hold the leg at 30 degrees (always tested seconds.
supine). Drift is scored if the leg falls before 5 1 = Drift; leg falls by the end of the 5-second period
seconds. The aphasic patient is encouraged using but does not hit bed.
urgency in the voice and pantomime, but not noxious
2 = Some effort against gravity; leg falls to bed by
stimulation. Each limb is tested in turn, beginning
5 seconds, but has some effort against gravity.
with the non-paretic leg. Only in the case of
amputation or joint fusion at the hip, the examiner 3 = No effort against gravity; leg falls to bed _____
should record the score as untestable (UN), and immediately.
clearly write the explanation for this choice. 4 = No movement.
UN = Amputation or joint fusion,
explain:________________
6a. Left leg
6b. Right leg
7. Limb ataxia: This item is aimed at finding 0 = Absent.

evidence of a unilateral cerebellar lesion. Test with 1 = Present in one limb.
eyes open. In case of visual defect, ensure testing is
2 = Present in two limbs.
done in intact visual field. The finger-nose-finger and
heel-shin tests are performed on both sides, and UN = Amputation or joint fusion,
ataxia is scored only if present out of proportion to explain:________________
weakness. Ataxia is absent in the patient who cannot _____
understand or is paralyzed. Only in the case of
amputation or joint fusion, the examiner should
record the score as untestable (UN), and clearly write
the explanation for this choice. In case of blindness,
test by having the patient touch nose from extended
arm position.
8. Sensory: Sensation or grimace to pinprick when 0 = Normal; no sensory loss. _____

tested, or withdrawal from noxious stimulus in the 1 = Mild-to-moderate sensory loss; patient feels
obtunded or aphasic patient. Only sensory loss pinprick is less sharp or is dull on the affected side; or
attributed to stroke is scored as abnormal and the there is a loss of superficial pain with pinprick, but
examiner should test as many body areas (arms [not patient is aware of being touched.
hands], legs, trunk, face) as needed to accurately
check for hemisensory loss. A score of 2, "severe or

total sensory loss," should only be given when a 2 = Severe to total sensory loss; patient is not
severe or total loss of sensation can be clearly aware of being touched in the face, arm, and leg.
demonstrated. Stuporous and aphasic patients will,
therefore, probably score 1 or 0. The patient with
brainstem stroke who has bilateral loss of sensation is
scored 2. If the patient does not respond and is
quadriplegic, score 2. Patients in a coma (item 1a=3)
are automatically given a 2 on this item.
9. Best language: A great deal of information about 0 = No aphasia; normal.

comprehension will be obtained during the preceding 1 = Mild-to-moderate aphasia; some obvious loss
sections of the examination. For this scale item, the of fluency or facility of comprehension, without
patient is asked to describe what is happening in the significant limitation on ideas expressed or form of
attached picture, to name the items on the attached expression. Reduction of speech and/or
naming sheet and to read from the attached list of comprehension, however, makes conversation about
sentences. Comprehension is judged from responses provided materials difficult or impossible. For
here, as well as to all of the commands in the example, in conversation about provided materials,
preceding general neurological exam. If visual loss examiner can identify picture or naming card content
interferes with the tests, ask the patient to identify _____
from patient's response.
objects placed in the hand, repeat, and produce
2 = Severe aphasia; all communication is through
speech. The intubated patient should be asked to
fragmentary expression; great need for inference,
write. The patient in a coma (item 1a=3) will
questioning, and guessing by the listener. Range of
automatically score 3 on this item. The examiner
information that can be exchanged is limited; listener
must choose a score for the patient with stupor or
carries burden of communication. Examiner cannot
limited cooperation, but a score of 3 should be used
identify materials provided from patient response.
only if the patient is mute and follows no one-step
commands. 3 = Mute, global aphasia; no usable speech or
auditory comprehension.
10. Dysarthria: If patient is thought to be normal, 0 = Normal.

an adequate sample of speech must be obtained by 1 = Mild-to-moderate dysarthria; patient slurs at
asking patient to read or repeat words from the least some words and, at worst, can be understood
attached list. If the patient has severe aphasia, the with some difficulty.
clarity of articulation of spontaneous speech can be
2 = Severe dysarthria; patient's speech is so _____
rated. Only if the patient is intubated or has other
slurred as to be unintelligible in the absence of or out
physical barriers to producing speech, the examiner
of proportion to any dysphasia, or is mute/anarthric.
should record the score as untestable (UN), and
clearly write an explanation for this choice. Do not tell UN = Intubated or other physical barrier,
the patient why he or she is being tested. explain:________________
11. Extinction and inattention (formerly 0 = No abnormality.

neglect): Sufficient information to identify neglect 1 = Visual, tactile, auditory, spatial, or personal
may be obtained during the prior testing. If the inattention or extinction to bilateral simultaneous
patient has a severe visual loss preventing visual stimulation in one of the sensory modalities.
double simultaneous stimulation, and the cutaneous
2 = Profound hemi-inattention or extinction to
stimuli are normal, the score is normal. If the patient _____
more than one modality; does not recognize own
has aphasia but does appear to attend to both sides,
hand or orients to only one side of space.
the score is normal. The presence of visual spatial
neglect or anosognosia may also be taken as
evidence of abnormality. Since the abnormality is
scored only if present, the item is never untestable.
_____
Adapted from: Goldstein LB, Samsa GP, Stroke 1997; 28:307.
Graphic 61698 Version 7.0

Canadian Neurological Scale
Patient Name:
Rater Name:
Date:
Time:
Mentation Score
Level consciousness Alert 3.0
Drowsy 1.5
Orientation Oriented 1.0
Disoriented/NA 0.0
Speech Normal 1.0
Expressive deficit 0.5
Receptive deficit 0.0
TOTAL:
Motor functions (no comprehension deficit) Weakness Score

Face None 0.5
Present 0.0
Arm: proximal None 1.5
Mild 1.0
Significant 0.5
Total 0
Arm: distal None 1.5
Mild 1.0
Significant 0.5
Total 0
Leg None 1.5
Mild 1.0
Significant 0.5
Total 0
TOTAL:
Motor response (comprehension deficit) Score

Face Symmetrical .5
Asymmetrical 0
Arms Equal 1.5
Unequal 0
Legs Equal 1.5
Unequal 0
TOTAL:
Reproduced with permission from: Côté R, Hachinski VC, Shurvell BL, et al. The Canadian Neurological Scale: a preliminary study
in acute stroke. Stroke 1986; 17:731. Copyright © 1986 Lippincott Williams & Wilkins.

Time course of neurologic recovery after stroke
The time course of recovery in survivors shown as the cumulated rate of patients having reached their best neurological
outcome. Rates are given for all patients, §; for patients with initial mild stroke severity, ◊; for patients with initial
moderate stroke severity, Δ; for patients with initial severe stroke severity, *; for patients with initial very severe stroke
severity, •. The ANOVA test showed an overall difference in the time course of recovery between the groups, p<0.0001.
Further analyses showed that the time course of recovery differed significantly between patients with initially mild strokes
versus moderate strokes, p<0.0001, and between patients with moderate strokes versus severe strokes, p<0.03. No
difference was found between patients with severe versus very severe strokes, p = 0.19.
ANOVA: analysis of variance.
Reproduced from: Jørgensen HS1, Nakayama H, Raaschou HO, et al. Outcome and time course of recovery in stroke. Part II: Time
course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76:406. Illustration used with the permission of
Elsevier Inc. All rights reserved.

Orpington Prognostic Scale
A. Motor deficit in arm
Lying supine, patient flexes shoulder to 90° and is given resistance.
0.0 = MRC grade 5 (normal power)
0.4 = MRC grade 4 (diminished power)
0.8 = MRC grade 3 (movement against gravity)
1.2 = MRC grade 1 to 2 (movement with gravity eliminated or trace)
1.6 = MRC grade 0 (no movement)
B. Proprioception (eyes closed)
Locates affected thumb:
0.0 = Accurately
0.4 = Slight difficulty
0.8 = Finds thumb via arm
1.2 = Unable to find thumb
C. Balance
0.0 = Walks 10 feet without help
0.4 = Maintains standing position (unsupported for one minute)
0.8 = Maintains sitting position
1.2 = No sitting balance
D. Cognition
Hodkinson's Mental Test: Score one point for each correct answer.
_____ 1. Age of patient
_____ 2. Time (to the nearest hour)
I am going to give you an address, please remember it and I will ask you later: 42 West Street.
_____ 3. Name of hospital
_____ 4. Year
_____ 5. Date of birth of patient
_____ 6. Month
_____ 7. Years of the Second World War
_____ 8. Name of the President
_____ 9. Count backwards (20 to 1)
_____ 10. What is the address I asked you to remember: 42 West Street.
0.0 = Mental test score of 10
0.4 = Mental test score of 8 to 9
TOTAL SCORE: 1.6 + Motor + Proprioception + Balance + Cognition.
MRC: Medical Research Council.
From: Lai SM, Duncan PW, Keighley J. Prediction of functional outcome after stroke: comparison of the Orpington Prognostic
Scale and the NIH Stroke Scale. Stroke 1998; 29:1838. Reproduced with permission from Lippincott Williams & Wilkins.
Copyright © 1998 American Heart Association. Unauthorized reproduction of this material is prohibited.

Reding prognostic subgroups for outcome after stroke
Life table curves for probability of reaching the goal of walking with assistance and assisted self-care function, defined as a
Barthel Index score of ≥60.
From: Reding MJ, Potes E. Rehabilitation outcome following initial unilateral hemispheric stroke. Life table analysis approach. Stroke
1988; 19:1354. Reproduced with permission from Lippincott Williams & Wilkins. Copyright © 1998 American Heart Association.
Unauthorized reproduction of this material is prohibited.

Barthel Index
Activity Score
Feeding
0 = Unable
5 = Needs help cutting, spreading butter, etc, or requires modified diet
10 = Independent
Bathing
0 = Dependent
5 = Independent (or in shower)
Grooming
0 = Needs to help with personal care
5 = Independent face/hair/teeth/shaving (implements provided)
Dressing
0 = Dependent
5 = Needs help but can do about half unaided
10 = Independent (including buttons, zips, laces, etc)
Bowels
0 = Incontinent (or needs to be given enemas)
5 = Occasional accident
10 = Continent
Bladder
0 = Incontinent, or catheterized and unable to manage alone
5 = Occasional accident
10 = Continent
Toilet use
0 = Dependent
5 = Needs some help, but can do something alone
10 = Independent (on and off, dressing, wiping)
Transfers (bed to chair and back)
0 = Unable, no sitting balance
5 = Major help (one or two people, physical), can sit
10 = Minor help (verbal or physical)
15 = Independent
Mobility (on level surfaces)
0 = Immobile or <50 yards
5 = Wheelchair independent, including corners, >50 yards
10 = Walks with help of one person (verbal or physical) >50 yards
15 = Independent (but may use any aid; for example, stick) >50 yards
Stairs
0 = Unable
5 = Needs help (verbal, physical, carrying aid)
10 = Independent
Total (0-100):
The Barthel ADL Index: Guidelines

The index should be used as a record of what a patient does, not as a record of what a patient could do
The main aim is to establish degree of independence from any help, physical or verbal, however minor and for
whatever reason
The need for supervision renders the patient not independent

Patient performance should be established using the best available evidence provided by the patient, family, friends
and caregivers; direct observation and common sense are also important, but direct testing is not needed
Usually the patient's performance over the preceding 24 to 48 hours is important, but occasionally longer periods will
be relevant
Middle categories imply that the patient supplies over 50 percent of the effort
Use of aids to be independent is allowed
ADL: activities of daily living.
References:
1. Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965; 14:56. Used with
permission.
2. Loewen SC, Anderson BA. Predictors of stroke outcome using objective measurement scales. Stroke 1990; 21:78.
3. Gresham GE, Phillips TF, Labi ML. ADL status in stroke: Relative merits of three standard indexes. Arch Phys Med Rehabil
1980; 61:355.
4. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: A reliability study. Int Disability Study 1988; 10:61.

Modified Rankin Scale
Score Description
0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all usual duties and activities
2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
3 Moderate disability; requiring some help, but able to walk without assistance
4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without
assistance
5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention
6 Dead
Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of
handicap in stroke patients. Stroke 1988; 19:604. Copyright © 1988 Lippincott Williams & Wilkins.

Contributor Disclosures
Matthew A Edwardson, MD Nothing to disclose Scott E Kasner, MD Grant/Research/Clinical Trial Support: WL
Gore and Associates [Stroke (PFO closure)]; Bayer [Stroke (rivaroxaban)]; Bristol Meyers Squibb [Stroke];
Medtronic [Stroke]. Consultant/Advisory Boards: Bayer; BMS; Merck; Boehringer Ingelheim; Abbvie; J&J;
Medtronic; Urovant; Janssen [Stroke]. John F Dashe, MD, PhD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be provided
to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate
standards of evidence.
Conflict of interest policy

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● Diffusion-perfusion mismatch (ie, an ischemic brain lesion characterized by a core of infarcted

● Poor collateral blood flow [48,49].

● Development of cerebral edema in nonlacunar ischemic stroke [50].

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hemorrhagic conversion of the infarct. Delirium, characterized by a disturbance of consciousness with

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with infarcts involving the spinothalamic or trigeminothalamic pathways sometimes develop a

• Motor deficit only

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MORBIDITY AND MORTALITY

Disability measures at six months after stroke were as follows [143]:

● Depression symptoms, 35 percent

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INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

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Use of UpToDate is subject to the Subscription and License Agreement.

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39. Colivicchi F, Bassi A, Santini M, Caltagirone C. Prognostic implications of right-sided insular

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134. Caplan LR. Scores of scores. JAMA Neurol 2013; 70:252.

Topic 14086 Version 18.0

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National Institutes of Health Stroke Scale (NIHSS)

Instructions Scale definition Score

1a. Level of consciousness: The investigator must 0 = Alert; keenly responsive.

1c. Level of consciousness commands: The 0 = Performs both tasks correctly.

2. Best gaze: Only horizontal eye movements will be 0 = Normal.

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4. Facial palsy: Ask - or use pantomime to 0 = Normal symmetrical movements.

7. Limb ataxia: This item is aimed at finding 0 = Absent.

8. Sensory: Sensation or grimace to pinprick when 0 = Normal; no sensory loss. _____

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9. Best language: A great deal of information about 0 = No aphasia; normal.

10. Dysarthria: If patient is thought to be normal, 0 = Normal.

11. Extinction and inattention (formerly 0 = No abnormality.

Adapted from: Goldstein LB, Samsa GP, Stroke 1997; 28:307.

Graphic 61698 Version 7.0

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Canadian Neurological Scale

Orientation Oriented 1.0

Speech Normal 1.0

Expressive deficit 0.5

Receptive deficit 0.0

Motor functions (no comprehension deficit) Weakness Score

Arm: proximal None 1.5

Arm: distal None 1.5

Leg None 1.5

Motor response (comprehension deficit) Score

Arms Equal 1.5