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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 1  |  Page : 57-60

Functional outcome of ischemic stroke in relation to site of lesion: A prospective cohort study


1 Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Radiodiagnosis, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication18-Jun-2018

Correspondence Address:
Dr. Bimol Naorem
Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_58_17

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  Abstract 

Background: Accurate prediction of motor recovery and functional outcome is difficult, but it is important for proper rehabilitative planning and poststroke care. Infarct location may be more important for some patients in determining eventual clinical outcome.
Objectives: To study the functional outcome of ischemic stroke in relation to the site of lesion.
Materials and Methods: A prospective cohort study was conducted in the Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur. All computed tomography confirmed ischemic stroke patients attending the outpatient department within 7 days of stroke onset were included in the study. Functional Independence Measure (FIM) scoring was done on 7, 30, and 90 days poststroke. Site was categorized as cortical (C), subcortical (S), combined cortical and subcortical (CS), basal ganglia (BG), or combined cortical, subcortical, and BG.
Results: Ninety patients with mean age of 58.26 ± 7.021 years in the range of 45–70 years were studied. Males constituted 55.6% of the total participants. The site of lesion was in BG in majority of cases 37 (41.1%), subcortical in 31 (34.4%) cases, and cortical in 20 (22.2%) cases. Mean FIM score was highest 53.70 (±13.2) when the site of lesion was in BG. The mean FIM scores differed significantly between the different sites of lesion (P = 0.000) at subsequent follow-up examinations. Post hoc test further revealed that there was statistically significant differences in the FIM scores between BG and all the other sites of lesion at baseline and at subsequent follow-up.
Conclusion: Site of lesion influenced the functional outcome significantly early on and at 30 days and 90 days after stroke, and the most favorable outcome was observed when the site of lesion was in BG.

Keywords: Computed tomography scan, functional independence measure score, ischemic stroke, lesion site


How to cite this article:
Khuraijam T, Soibam S, Naorem B, Sareo T, Yumnam N, Yumnam NS. Functional outcome of ischemic stroke in relation to site of lesion: A prospective cohort study. J Med Soc 2018;32:57-60

How to cite this URL:
Khuraijam T, Soibam S, Naorem B, Sareo T, Yumnam N, Yumnam NS. Functional outcome of ischemic stroke in relation to site of lesion: A prospective cohort study. J Med Soc [serial online] 2018 [cited 2020 May 25];32:57-60. Available from: http://www.jmedsoc.org/text.asp?2018/32/1/57/234653


  Introduction Top


Worldwide, stroke is increasing along with modernization. It is anticipated that by 2020, stroke will have moved from the 6th leading cause of disability-adjusted life years lost to 4th leading cause.[1] Globally, there are 15 million new acute stroke cases every year.[2] In India, the prevalence of stroke was estimated to be 55.6/100,000 for all ages.[3]

Accurate prediction of motor recovery and functional outcome is difficult, but it is important for proper rehabilitative planning and poststroke care. Neuroimaging parameters may improve the predictive value of clinical measures such as National Institutes of Health Stroke Scale, Mini-Mental Status, Functional Independence Measure (FIM) score, and Barthel Index.[4] An emergent noncontrast head computed tomography (CT) scan is the mandatory initial imaging workup for a presumed stroke. Infarct location may be more important for some patients in determining eventual clinical outcome.[5] Certain brain regions have classically being thought more important than others.[6] The effect of location reflects human brain organization into regionally distributed, large scale neural networks subserving specialized functions, including motor control and language, with disparate impact on clinical outcome.[7]

This study was undertaken to study the influence of lesion site according to the initial CT scan in ischemic stroke patients on functional outcome of the patients as measured by the FIM score.


  Materials and Methods Top


The study was a prospective cohort study conducted in the Department of Physical Medicine and Rehabilitation (PMR), Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, for a period of 2 years from September 2012 to October 2014.

All CT confirmed ischemic stroke patients attending Department of PMR OPD, RIMS within 7 days of stroke onset fulfilling the inclusion criteria were included in the study. All the patients were treated with neuro-developmental exercises.

Inclusion criteria

  • First attack of ischemic stroke confirmed by CT
  • CT taken from patients within 7 days of onset of symptoms
  • No other neurological disease
  • Sufficient cooperation for clinical and neurologic testing
  • Age 45–70 years.


Exclusion criteria

  • Severely moribund patients
  • Those who suffer from intracerebral hemorrhage.


Outcome measure

Functional outcome was the outcome measure. It was assessed by FIM Score (FIMS).

The FIMS consists of 18 items grouped into 6 subscales measuring self-care, sphincter control, transfer, locomotion, communication, and social cognition ability. Each item is rated from 1 to 7 (score range: 18–126) based on the required level of assistance to perform the tasks (1 - complete assistance, 2 - maximal assistance, 3 - moderate assistance, 4 - minimal assistance, 5 - supervision, 6 - modified independence, and 7 - complete independence). A low score on any subscale indicates a more severe disability. Evaluation of the reliability, validity, and responsiveness of the FIM has been reported extensively.[8]

Initial assessment was done on 7th day of stroke. Follow-up assessment was done on the 30th and 90th day poststroke.

Independent variable

Site of lesion was the independent variable. Site was determined by noncontrast computerized tomography (NCCT). It is the first-line diagnostic test for emergency evaluation of acute stroke due to its speed of imaging, widespread availability, and low cost. The sites were categorized as cortical (C), subcortical (S), combined cortical and subcortical (CS), basal ganglia (BG), or combined cortical, subcortical, and BG. We do not give emphasis on the size of the lesion in our study.

Ethical approval

All the participants were informed about the nature of the study, and those who agreed to participate were asked to sign the informed consent form. Participants were assured that they could withdraw from the study at any time. The prior approval of the Institutional Ethics Committee was taken.

Data management and statistical analysis

The data so collected were analyzed using SPSS for Windows, Version 16.0 (Chicago, SPSS Inc). Descriptive statistics such as percentage, mean, and standard deviation were used. For analytical statistics, ANOVA test and post hoc test were used.


  Results Top


A total of ninety patients were studied. The mean age of the patients was 58.26 ± 7.021 years in the range of 45–70 years. The site of lesion was in BG in the majority of cases 37 (41.1%) followed by subcortical 31 (34.4%) and cortical 20 (22.2%). The mean FIM score was observed to be the highest when the site of lesion was in BG and mean FIM score was lowest when the site of lesion was combined cortical and subcortical. [Figure 1] shows the mean FIM scores at baseline, first, and second follow-up by different sites of lesion.
Figure 1: Bar charts showing mean functional independence measure scores at baseline, first, and second follow-up by different sites of lesion

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[Table 1] shows that at baseline, the mean FIM score was observed to be the highest 53.70 (±13.2) when the site of lesion was in BG. ANOVA test revealed that the mean FIM scores differed significantly among the different sites of lesion (P = 0.000). However, post hoc test revealed that there was a statistically significant difference in the FIM scores between BG and all the other sites of lesion. However, there were no significant differences in the FIM scores between cortical, subcortical, and combined cortical and subcortical lesions.
Table 1: Distribution of mean Functional Independence Measure Score of the study population at baseline by site of lesion

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[Table 2] shows that at first follow-up, the mean FIM score was observed to be the highest 74.97 (±14.4) when the site of lesion was in BG. The mean FIM scores differed significantly among the different sites of lesion (P = 0.000). Post hoc test further revealed that there was statistically significant differences in the FIM scores between BG and all the other sites of lesion. However, no significant difference in the FIM scores between cortical, subcortical, and combined cortical and subcortical lesions was observed.
Table 2: Distribution of mean Functional Independence Measure Score at first follow-up (30th day poststroke) by site of lesion

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[Table 3] shows that at second follow-up, the mean FIM score was observed to be the highest 89.24 (+13.0) when the site of lesion was in BG. The mean FIM scores differed significantly among the different sites of lesion (P = 0.000). Post hoc test further revealed that the differences were significant between cortical and BG (P = 0.000) as well as between cortical and combined cortical and subcortical sites of lesion (P = 0.001). There was no significant difference between cortical and subcortical lesions (P = 0.118). The FIM score was observed to be the highest when the lesion was in BG at all follow-ups, and the finding was statistically significant.
Table 3: Distribution of mean Functional Independence Measure Scores at second follow-up (90th day poststoke) by site of lesion

Click here to view



  Discussion Top


This study was conducted to find out if there was any association between CT scan findings taken in ischemic stroke <7 days' duration and functional outcome in terms of FIM score at 30 and 90 days. All 90 patients who were enrolled completed the study. Variables studied included age, sex, and site of lesion. NCCT scan is the initial mandatory investigation done in stroke patients; it was thus important to know the predictive value of CT findings. In this study, it was found that site of lesion influenced the functional outcome significantly early on and at 30 and 90 days after stroke. BG lesion had the most favorable outcome having a maximum mean FIM score at 1st and 2nd follow-up. A study by Ring et al.[9] has shown that cortical damage leads to more impairment in terms of functional score. They found that patient with cortical lesion had a significantly lower FIM score at admission and discharge compared to the subcortical group. This finding was not in agreement with other studies which linked cortical stroke as having better outcome.[10],[11] The rationale behind their findings was that although subcortical strokes are smaller than cortical strokes, they are more likely to involve both primary and secondary motor pathways. The descending axon from primary motor area and secondary motor area must converge as they reach the internal capsule thus making even small lesions devastating. However, as already mentioned, subcortical lesion and BG lesion are mostly smaller in size. Most of the subcortical lesion and BG lesion in this study come under the definition of lacunar infarct, and it is well known that lacunar infarcts have much better functional recovery. Lacunar infarct patients usually present with a pure motor or pure sensory stroke or sensory motor stroke or ataxic hemiparesis without any higher cerebral dysfunction. A study conducted by Osmani et al.[12] also found that a large portion (67.7%) of lacunar stroke were significantly independent functionally at 1 and 3 months after stroke. They had used the modified Rankin scale as an outcome measure.

Moreover, stroke patients cannot be homogenized by site alone. Specific syndromes such as neglect and aphasias resulting from the right and left brain damage, respectively, have a profound effect on patient's activities of daily living which has not been taken into account. Saver et al[7] failed to yield significant correlation according to localization as pure cortical, pure subcortical, and mix subcortical-cortical group.

There are many limitations in our study: one is the small sample size, older age above 70 was not included in our study although the incidence of ischemic stroke was more common in above 65 years.


  Conclusion Top


This study aimed to find if lesion site in ischemic stroke patients influences the functional outcome. We concluded that lesion site do influence functional outcome to some extent, and BG lesion has the most favorable outcome even though there are many other clinical variables as confounding factor which needs to be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kollen B, Kwakkel G, Lindeman E. Functional recovery after stroke: A review of current developments in stroke rehabilitation research. Rev Recent Clin Trials 2006;1:75-80.  Back to cited text no. 1
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2.
Taylor FC. Stroke in India; 2012. p. 1-13. Available from: http://sancd.org/uploads/pdf/factsheet_Stroke.pdf. [Last accessed on 2012 Aug 08].  Back to cited text no. 2
    
3.
Dalal P, Bhattacharjee M, Variale J, Bhat P. U N millineum development goals: Can we halt the stroke epidemic in India? Ann Indian Acad Neurol 2007;10:130-6.  Back to cited text no. 3
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Wardlaw JM, West TM, Sandercock PA, Lewis SC, Mielke O; International Stroke Trials Collaborative Group. Visible infarction on computed tomography is an independent predictor of poor functional outcome after stroke, and not of haemorrhagic transformation. J Neurol Neurosurg Psychiatry 2003;74:452-8.  Back to cited text no. 4
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Hedegard WC. Neurology Case of the Week. Available from: http://www.urme.rochester_edu/smd/Rad/neurocases/neurocase323.htm. [Last accessed on 2012 Jul 30].  Back to cited text no. 5
    
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Brammer CM, Herring GM. Stroke rehabilitation. In: Brammer CM, Spires MC, editors. Manual of Physical Medicine and Rehabilitation. Philadelphia: Hanley & Belfus; 2002. p. 139-65.  Back to cited text no. 6
    
7.
Saver JL, Johnston KC, Homer D, Wityk R, Koroshetz W, Truskowski LL, et al. Infarct volume as a surrogate or auxiliary outcome measure in ischemic stroke clinical trials. The RANTTAS Investigators. Stroke 1999;30:293-8.  Back to cited text no. 7
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Hsieh YW, Wu CY, Lin KC, Chang YF, Chen CL, Liu JS. Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation. Stroke 2009;40:1386-91.  Back to cited text no. 8
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Ring H, Feder M, Schwartz J, Samuels G. Functional measures of first-stroke rehabilitation inpatients: Usefulness of the Functional Independence Measure total score with a clinical rationale. Arch Phys Med Rehabil 1997;78:630-5.  Back to cited text no. 9
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Abdelsalam M, Belal T, Hazen M, Saad M. Role of early CT in predicting recovery of ischemic stroke. Egypt J Neurol Psychiatry Neurolsurg 2010;47:407-12.  Back to cited text no. 10
    
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Shelton FN, Reding MJ. Effect of lesion location on upper limb motor recovery after stroke. Stroke 2001;32:107-12.  Back to cited text no. 11
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Osmani AH, Durrani RK, Ara J. Comparison of outcome in different types of stroke due to cerebral ischemia. J Coll Physicians Surg Pak 2010;20:42-6.  Back to cited text no. 12
[PUBMED]    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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