title: External Validation of the ASTRAL and DRAGON Scores for Prediction of Functional Outcome in Stroke.
abstract: ASTRAL (Acute Stroke Registry and Analysis of Lausanne) and DRAGON (includes dense middle cerebral artery sign, prestroke modified Rankin Scale score, age, glucose, onset to treatment, National Institutes of Health Stroke Scale score) are 2 recently developed scores for predicting functional outcome after acute stroke in unselected acute ischemic stroke patients and in patients treated with intravenous thrombolysis, respectively. We aimed to perform external validation of these scores to assess their predictive performance in the large multicentre Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register.
  
  
  
  We calculated the ASTRAL and DRAGON scores in 36 131 and 33 716 patients, respectively, registered in Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register between 2003 and 2013. The proportion of patients with 3-month modified Rankin Scale scores of 3 to 6 was observed for each score point and compared with the predicted proportion according to the risk scores. Calibration was assessed using calibration plots, and predictive performance was assessed using area under the curve of the receiver operating characteristic. Multivariate logistic regression coefficients for the variables in the 2 scores were compared with the original derivation cohorts.
  
  
  
  The ASTRAL showed an area under the curve of 0.790 (95% confidence interval, 0.786-0.795) and the DRAGON an area under the curve of 0.774 (95% confidence interval, 0.769-0.779). All ASTRAL parameters except range of visual fields and all DRAGON parameters were significantly associated with functional outcome in multivariate analysis.
  
  
  
  The ASTRAL and DRAGON scores show an acceptable predictive performance. ASTRAL does not require imaging-data and therefore may have an advantage for the use in prehospital patient assessment. Prospective studies of both scores evaluating the impact of their use on patient outcomes after intravenous thrombolysis and endovascular therapy are needed.
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.). charith.cooray@karolinska.se.
authors.forename: Charith
authors.initials: C
authors.lastname: Cooray
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Michael
authors.initials: M
authors.lastname: Mazya
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Matteo
authors.initials: M
authors.lastname: Bottai
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Laura
authors.initials: L
authors.lastname: Dorado
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Ondrej
authors.initials: O
authors.lastname: Skoda
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Danilo
authors.initials: D
authors.lastname: Toni
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Gary A
authors.initials: GA
authors.lastname: Ford
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Nils
authors.initials: N
authors.lastname: Wahlgren
authors.affiliation: From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.W., N.A.); Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (M.B.); Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (L.D.); Department of Neurology, 3rd Medical Faculty, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (O.S.); Stroke Unit, Neurological Department, Regional Hospital, Jihlava, Czech Republic (O.S.); Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.); and Department of Medicine, Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, United Kingdom (G.A.F.).
authors.forename: Niaz
authors.initials: N
authors.lastname: Ahmed
mesh_terms: D000368:Aged; D000465:Algorithms; D019540:Area Under Curve; D002545:Brain Ischemia / Q000503:physiopathology / Q000628:therapy*; D002138:Calibration; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D020127:Recovery of Function; D012016:Reference Values; D012042:Registries; D015203:Reproducibility of Results; D020521:Stroke / Q000503:physiopathology / Q000628:therapy*; D015912:Thrombolytic Therapy; D016896:Treatment Outcome
keywords: ROC curve; calibration; prognosis; registries; stroke