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Late Improvements Lead to Long-Term Benefits in Stroke

PHILADELPHIA—Improvements in function three to 12 months after ischemic stroke are associated with long-term benefits, researchers said here at the AAN Annual Meeting.

One-year survivors of ischemic stroke who experienced improvements from three months to a year after the stroke had a higher five-year survival rate, a lower rate of being institutionalized at five years, and lower associated costs, researchers at the University of Calgary and the University of Oxford reported.

 The findings underscore the importance of earlier findings by the group that late functional improvement, past the three-month mark, occurs more commonly than previously thought—in about a quarter of patients—more often in those with lacunar stroke.

 "'Does it really matter?' was kind of the big question," said Aravind Ganesh, MD, DPhil, a neurology resident at the University of Calgary and associate fellow at the University of Oxford, who presented the report. "In the end, that's what dictates whether patients get access to treatments that promote this type of improvement, or whether research into such treatments or therapies gets funded."

Researchers looked at outcomes from all of the one-year survivors of ischemic stroke—a total of 1,135 patients—in the Oxford Vascular Study, a prospective population study of transient ischemic attack and stroke. Stroke had occurred between 2002 to 2014, and patients were followed until May of 2017.

Late functional improvement, as observed in 319 patients, at three to 12 month was determined based on least 1 modified Rankin Scale grade, at least 1 point on the Rivermead Mobility Index (RMI), and/or at least 2 points on the Barthel Index (BI), a measure of independent function and mobility.

The associations between late improvement and the five-year outcomes were adjusted for age, lacunar stroke vs. non-lacunar, and three-month disability. Researchers looked only at improvement after three months, so the longer-term benefits were those associated only with functional improvements between three months and a year, and not with functional improvement that had already taken place.

Approximately 20 percent of patients who experienced these late improvements measured by mRS were dead at five years, compared with more than 30 percent who did not have the improvements (p=.001). About 10 percent who had had the improvements on mRS were in an institution at five years, compared with about 20 percent who had not improved (p<.001). Similarly significant differences were seen between patients who had late functional improvements as measured by RMI.

Researchers found that those with late improvements incurred lower five-year costs, about $17,500 less per patient than those who did not see these improvements (p<.001).

Dr. Ganesh said that the data should motivate clinicians and patients to work harder to continue to achieve functional improvements after three months of rehabilitation.

"It's quite easy in practice for a focus on additional rehab to take a bit of a back seat because we've traditionally accepted that this is where the patients ended up," he said. "Findings like this can function as a bit of a boost to say, 'Hey, we might not be done yet. There might still be additional salvageable function for this patient in their daily life.' I think that's good news for both the provider and the patient here."

James C. Grotta, MD, FAAN, director of stroke research at Memorial Hermann-Texas Medical Center in Houston, said: "These findings should remind clinicians and patients that the game isn't over at three months," he said. "Patients hate to hear that from their doctors. What patients need to hear, and what this study shows, is that improvement can continue after three months, and that it can result in better long-term outcomes."

He noted that the study looked only at activity and disability measures, and not measures such as quality of life, happiness, or cognition. "The latter parameters are what matter most to patients," he said, "and it would be important to determine if they improve in parallel with the outcomes measured in this study."

Dr. Ganesh has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Adkins Research Group. Dr. Ganesh has received compensation for serving on the board of directors of SnapDx and AHA Health Ltd. Dr. Grotta disclosed no competing interests.

Link Up for Related Information:

AAN Abstract S47.003: Ganesh A, Luengo-Fernandez R, Rothwell P. Association of late functional improvement with 5-year post-stroke outcomes: A population-based cohort study.