title: Accuracy of National Institutes of Health Stroke Scale Score in Predicting the Site of Arterial Occlusion in Acute Stroke: A Transcranial Doppler Study.
abstract: BACKGROUND
  In acute stroke, it is crucial to assess for intracranial large-vessel occlusion and site of occlusion. The National Institutes of Health Stroke Scale score (NIHSSS) is the frequently used clinical tool to predict the site of arterial occlusion. In this study we aimed to determine the following: (1) if there is a correlation between the site of occlusion and the NIHSSS at presentation (bNIHSSS); and (2) if there is a bNIHSSS cutoff which can distinguish proximal occlusions (PO) from distal occlusions (DO).
  
  
  METHODS
  Up to 313 patients from CLOTBUST data bank with demonstrable intracranial arterial occlusion and having received intravenous recombinant tissue plasminogen activator (rt-PA) were included. Occlusions were classified as PO (terminal internal carotid artery, M1 segment of middle cerebral artery [M1 MCA], and basilar artery) or DO (M2 MCA, anterior cerebral artery, posterior cerebral artery, and vertebral artery).
  
  
  RESULTS
  By univariate analysis, bNIHSSS, thrombolysis in brain ischemia (TIBI) flow grade before rt-PA, degree of recanalization after rt-PA, and modified Rankin Scale score at 3 months were significantly different between various sites of occlusion. By univariate analysis, a higher bNIHSSS, lower TIBI flow grade, and lower ASPECTS (Alberta Stroke Program Early CT Score) differentiated PO from DO. Lower TIBI flow grade and higher bNIHSSS differentiated PO from DO by logistic regression analysis. No single NIHSSS cutoff with acceptable sensitivity and specificity could be derived to differentiate PO from DO.
  
  
  CONCLUSIONS
  Although NIHSSS are higher in PO, there is no satisfactory NIHSSS cutoff which differentiates PO from DO. A vascular imaging or transcranial doppler should be obtained to determine the site of arterial occlusion in acute stroke.
authors.affiliation: Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Deepak
authors.initials: D
authors.lastname: Gupta
authors.affiliation: Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Arvind
authors.initials: A
authors.lastname: Sharma
authors.affiliation: Cerebrovascular Center, Cleveland Clinic Main Campus, Cleveland, Ohio.
authors.forename: Ken
authors.initials: K
authors.lastname: Uchino
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
authors.forename: Andrei V
authors.initials: AV
authors.lastname: Alexandrov
authors.affiliation: Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Khurshid
authors.initials: K
authors.lastname: Khan
authors.affiliation: Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Ashfaq
authors.initials: A
authors.lastname: Shuaib
authors.affiliation: Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Electronic address: maher.saqqur@ualberta.ca.
authors.forename: Maher
authors.initials: M
authors.lastname: Saqqur
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000209:etiology*; D000072226:Computed Tomography Angiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D009316:National Institutes of Health (U.S.) / Q000592:standards; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D017585:Ultrasonography, Doppler, Transcranial / Q000379:methods*; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: NIHSSS; occlusion; stroke; transcranial Doppler