Clinical Prediction of Functional Outcome After Ischemic Stroke: The Surprising Importance of Periventricular White Matter Disease and Race

• Published in: Stroke (1970) Vol. 40; no. 2; pp. 530 - 536
• Main Authors: Kissela, Brett, Lindsell, Christopher J., Kleindorfer, Dawn, Alwell, Kathleen, Moomaw, Charles J., Woo, Daniel, Flaherty, Matthew L., Air, Ellen, Broderick, Joseph, Tsevat, Joel
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD American Heart Association, Inc 01.02.2009; Lippincott Williams & Wilkins
• Subjects: Aged; Algorithms; Biological and medical sciences; Black People; Brain - pathology; Brain Diseases - pathology; Cohort Studies; Comorbidity; Ethnicity; Female; Follow-Up Studies; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Humans; Logistic Models; Male; Medical sciences; Middle Aged; Models, Statistical; Nervous system (semeiology, syndromes); Neurology; Prospective Studies; Socioeconomic Factors; Stroke - mortality; Stroke - pathology; Stroke Rehabilitation; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; White People; predicted models; Cerebral infarction; models; Stroke; Nervous system diseases; Prognosis; Cardiovascular disease; White matter; Cerebral disorder; Vascular disease; white matter disease; outcomes; Central nervous system disease; Race; Brain ischemia; Cerebrovascular disease; ischemic stroke
• ISSN: 0039-2499; 1524-4628; 1524-4628
• DOI: 10.1161/STROKEAHA.108.521906

BACKGROUND AND PURPOSE—We sought to build models that address questions of interest to patients and families by predicting short- and long-term mortality and functional outcome after ischemic stroke, while allowing for risk restratification as comorbid events accumulate. METHODS—A cohort of 451 ischemic stroke subjects in 1999 were interviewed during hospitalization, at 3 months, and at approximately 4 years. Medical records from the acute hospitalization were abstracted. All hospitalizations for 3 months poststroke were reviewed to ascertain medical and psychiatric comorbidities, which were categorized for analysis. Multivariable models were derived to predict mortality and functional outcome (modified Rankin Scale) at 3 months and 4 years. Comorbidities were included as modifiers of the 3-month models, and included in 4-year predictions. RESULTS—Poststroke medical and psychiatric comorbidities significantly increased short-term poststroke mortality and morbidity. Severe periventricular white matter disease (PVWMD) was significantly associated with poor functional outcome at 3 months, independent of other factors, such as diabetes and age; inclusion of this imaging variable eliminated other traditional risk factors often found in stroke outcomes models. Outcome at 3 months was a significant predictor of long-term mortality and functional outcome. Black race was a predictor of 4-year mortality. CONCLUSIONS—We propose that predictive models for stroke outcome, as well as analysis of clinical trials, should include adjustment for comorbid conditions. The effects of PVWMD on short-term functional outcomes and black race on long-term mortality are findings that require confirmation.