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ABSTRACT

Objectives:

Age and stroke severity are major determinants of stroke outcomes, but systematically incorporating these prognosticators in the routine practice of acute ischemic stroke can be challenging. We evaluated the effect of an index combining age and stroke severity on response to IV tissue plasminogen activator (tPA) among patients in the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke trials.

Methods:

We created the Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index by combining age in years plus NIH Stroke Scale (NIHSS) ≥100. We applied the SPAN-100 index to patients in the NINDS tPA stroke trials (parts I and II) to evaluate its ability to predict clinical response and risk of intracerebral hemorrhage (ICH) after thrombolysis. The main outcome measures included ICH (any type) and a composite favorable outcome (defined as a modified Rankin Scale score of 0 or 1, NIHSS ≤1, Barthel index ≥95, and Glasgow Outcome Scale score of 1) at 3 months. Bivariate and multivariable logistic regression analyses were used to determine the association between SPAN-100 and outcomes of interest.

Results:

Among 624 patients in the NINDS trials, 62 (9.9%) participants were SPAN-100 positive. Among those receiving tPA, ICH rates were higher for SPAN-100–positive patients (42% vs 12% in SPAN-100–negative patients; p < 0.001); similarly, ICH rates were higher in SPAN-100–positive patients (19% vs 5%; p = 0.005) among those not receiving tPA. SPAN-100 was associated with worse outcomes. The benefit of tPA, defined as favorable composite outcome at 3 months, was present in SPAN-100–negative patients (55.4% vs 40.2%; p < 0.001), but not in SPAN-100–positive patients (5.6% tPA vs 3.9%; p = 0.76). Similar trends were found for secondary outcomes (e.g., symptomatic ICH, catastrophic outcome, discharge home).

Conclusion:

The SPAN-100 index could be a simple method for estimating the clinical response and risk of hemorrhagic complications after tPA for acute ischemic stroke. These results need further confirmation in larger contemporary datasets.

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Supplementary Material

File (stroke_prognostication_using_age.pdf)
File (wnl204547.pdf)

STUDY FUNDING

Dr. Saposnik is supported by the Distinguished Clinician-Scientist Award from the Heart and Stroke Foundation of Canada (HSFC).

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Letters to the Editor
11 January 2013
Response to Dr. Yufe
Gustavo Saposnik, Directo, Stroke Outcomes Research Center

We thank Dr. Yufe for his comments regarding our article. [1] Regarding the control group for the SPAN-100, figures 1 and 2 and table 2 provide a comparison of multiple outcomes between SPAN-100 patients receiving tPA and placebo. SPAN-100 patients receiving tPA had higher risk of intracerebral hemorrhage compared to SPAN-100 in the placebo group. No significant benefit was observed in functional clinical outcomes allowing for a small sample size. The combination of age and stroke severity are the two major predictors of stroke outcomes. Although these results need to be validated in a larger dataset, we believe are useful when counseling ischemic stroke patients and their families.

1. Saposnik G, Guzik AK, Reeves M, Ovbiagele B, Johnston SC. Stroke Prognostication using Age and NIH Stroke Scale: SPAN-100. Neurology 2013; 80: 21-28.

For disclosures, please contact the editorial office at [email protected].

10 January 2013
Stroke Prognostication using Age and NIH Stroke Scale: SPAN-100
Robert Yufe, Physician

I read the article by Saposnik et al. with interest. [1] Without a control group with a Positive SPAN 100, it is difficult to know if giving tPA is of benefit. Studies have shown that the elderly do benefit from Tpa so that leaves the severity of the stroke as measured by the NIHSS Score as the main determinant of a good outcome.

Nevertheless, the paper is a useful tool with which to counsel families and substitute decision makers who must often decide for the aphasic patient on whether to give or not to give tpa in SPAN 100 patients.

1. Saposnik G, Guzik AK, Reeves M, Ovbiagele B, Johnston SC. Stroke Prognostication using Age and NIH Stroke Scale: SPAN-100. Neurology 2013; 80: 21-28.

For disclosures, contact the editorial office. .

Information & Authors

Information

Published In

Neurology®
Volume 80Number 1January 1, 2013
Pages: 21-28
PubMed: 23175723

Publication History

Received: May 24, 2012
Accepted: August 15, 2012
Published online: November 21, 2012
Published in print: January 1, 2013

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Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Authors

Affiliations & Disclosures

Gustavo Saposnik, MD, MSc, FAHA
From the Stroke Outcomes Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; University of San Diego (A.K.G.), San Diego, CA; Department of Epidemiology and Biostatistics (M.R.), Michigan State University, East Lansing; Department of Neurosciences (B.O.), Medical University of South Carolina, Charleston; Clinical and Translational Science Institute and Department of Neurology (S.C.J.), University of California, San Francisco; Institute for Clinical Evaluative Sciences (ICES) (G.S.), Toronto; and Institute of Health Policy, Management and Evaluation (iHPME) 9G.S.0, University of Toronto, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Served as a member of the STROKE and Journal of Strokeand Cerebrovascular Diseases Editorial Advisory boards
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Distinguished Clinician Scientist Award from Heart andStroke Foundation of Canada (2012-2017)
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Amy K. Guzik, MD
From the Stroke Outcomes Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; University of San Diego (A.K.G.), San Diego, CA; Department of Epidemiology and Biostatistics (M.R.), Michigan State University, East Lansing; Department of Neurosciences (B.O.), Medical University of South Carolina, Charleston; Clinical and Translational Science Institute and Department of Neurology (S.C.J.), University of California, San Francisco; Institute for Clinical Evaluative Sciences (ICES) (G.S.), Toronto; and Institute of Health Policy, Management and Evaluation (iHPME) 9G.S.0, University of Toronto, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Mathew Reeves, PhD, FAHA
From the Stroke Outcomes Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; University of San Diego (A.K.G.), San Diego, CA; Department of Epidemiology and Biostatistics (M.R.), Michigan State University, East Lansing; Department of Neurosciences (B.O.), Medical University of South Carolina, Charleston; Clinical and Translational Science Institute and Department of Neurology (S.C.J.), University of California, San Francisco; Institute for Clinical Evaluative Sciences (ICES) (G.S.), Toronto; and Institute of Health Policy, Management and Evaluation (iHPME) 9G.S.0, University of Toronto, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Receive consulting fees from Michigan Peer Review Organization (MPRO), Farmington Hills, Michigan.
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Grant support from the Blue Cross Blue Shield Foundation, Michigan (PASSS pre-hospital Stroke Surveillance Project)
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Bruce Ovbiagele, MD, MSc
From the Stroke Outcomes Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; University of San Diego (A.K.G.), San Diego, CA; Department of Epidemiology and Biostatistics (M.R.), Michigan State University, East Lansing; Department of Neurosciences (B.O.), Medical University of South Carolina, Charleston; Clinical and Translational Science Institute and Department of Neurology (S.C.J.), University of California, San Francisco; Institute for Clinical Evaluative Sciences (ICES) (G.S.), Toronto; and Institute of Health Policy, Management and Evaluation (iHPME) 9G.S.0, University of Toronto, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
1) Assistant Editor: Stroke 2) Editorial Board: Journal of Stroke and Cerebrovascular Diseases
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NIH-NINDS, U01 NS079179, Principal Investigator
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
S. Claiborne Johnston, MD, PhD, FAHA
From the Stroke Outcomes Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; University of San Diego (A.K.G.), San Diego, CA; Department of Epidemiology and Biostatistics (M.R.), Michigan State University, East Lansing; Department of Neurosciences (B.O.), Medical University of South Carolina, Charleston; Clinical and Translational Science Institute and Department of Neurology (S.C.J.), University of California, San Francisco; Institute for Clinical Evaluative Sciences (ICES) (G.S.), Toronto; and Institute of Health Policy, Management and Evaluation (iHPME) 9G.S.0, University of Toronto, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Journal Watch Neurology, Co-Editor-in-Chief Annals of Neurology, Vice Editor
Patents:
1.
Co-holder of patent on the RNA panel to identify TIA and risk stratify.
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Sanofi-Aventis (drug and placebo for an NIH-sponsored trial); Stryker Neurovascular; Boston Scientific
Research Support, Government Entities:
1.
(1) NCRR/NCATS, CTSA, PI 2008-current; (2) NINDS/U01, POINT Trial, PI, 2009-current
Research Support, Academic Entities:
1.
Kaiser-Permanente Adjunct Investigator
Research Support, Foundations and Societies:
1.
AHA/ASA, Bugher Award, Project PI, 2007-2011
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
Glaxo Smith Kline, expert witness, 2011

Notes

Correspondence to Dr. Saposnik: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

G. Saposnik: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, contribution of vital reagents/tools/patients, acquisition of data, statistical analysis, study supervision, obtaining funding. A. Guzik: drafting/revising the manuscript. B. Ovbiagele: drafting/revising the manuscript, study concept or design, analysis or interpretation of data. M. Reeves: drafting/revising the manuscript, analysis or interpretation of data, statistical analysis. S.C. Johnston: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, study supervision.

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