The risk of incomplete functional recovery and sustained disability in patients treated in an integrated stroke unit

Abstract

Objective – to identify factors that are associated with incomplete functional recovery or sustained disability in patients managed at a Comprehensive Stroke Unit (CSU).
Materials and methods. We included 764 patients (41.7 % of women) aged from 20 to 95 years (median – 66 years, interquartile interval 57–75 years), who were in period from 2010 to 2018 admitted to our Stroke Center (SC) operating as a CSU. Upon admission all participants were examined by a Neurologist. Work-up and treatment were in line with recommendations of clinical guidelines. Ischemic stroke was diagnosed in 80.5 % of the patients, hemorrhagic stroke – in 19.5 %. Univariate and multivariate analyses were performed. The functional state was assessed using a modified Rankin scale (MRS). We The considered that the desired outcome was achieved if, at the time of discharge from the hospital, the initial MRS score decreased by ≥ 2 or reached ≤ 2.
Results. The baseline NIHSS score ranged from 0 to 39 (median – 10, interquartile interval 6–17). 17.5 % of patients were admitted to our SC in the 1st day, 19.0 % – between 2 and 7 days, 7.5 % –
between 8 and 14 days, 14.7 % – between 15 and 30 days, 10.3 % – between 31 and 60 days,
13.0 % – between 61 and 180 days, and 18.0 % – later than 180 days after the stroke onset. According to the univariate analysis, the risk of not achieving the desired outcome was associated with many factors: stroke type and subtype, the patient’s age, time delay before SC admission, the initial severity of stroke, cognitive impairment, limitations of mobility and ADLs, the presence and severity of certain types of neurological deficit, in addition to certain vascular risk factors (atrial fibrillation, smo-
king) and signs of inflammation (increased erythrocyte sedimentation rate and C-reactive protein) on admission. Multivariate analysis revealed 4 independent predictors that are strongly associated with the lack of the desired functional outcome: patient age (odds ratio (OR) – 1.03, on average, for each additional year), initial stroke severity (after adjustment to the rest of factors, OR – 1.05, on average, for each additional point of the baseline NIHSS score), global disability on admission (OR – 2.3, on average for each point of the initial MRS score) and the time from stroke onset to the SC admission (compared with a shorter delay, OR – 3.3–4.2, if the patient was hospitalized between 15 and 180 days from the onset, OR – 9.2 if admitted later than 6 months after the onset). The area under the curve of operational characteristics – 0.92 (95 % CI 0.89–0.94) proved the excellent quality of the prediction model and the strong link of this set of factors to the risk of incomplete functional recovery at the time of discharge.
Conclusions. According to the results of univariate analysis, the risk of incomplete functional recovery and sustained disability after treatment is associated with a wide range of factors, such as stroke type and subtype, severity of neurological and cognitive deficit, activities limitations, certain risk factors and laboratory abnormalities. Multivariate analysis identified 4 independent predictors of sustained disability, which may help us better predict the length of stay and the outcome of treatment.