A Simple 3-Item Stroke Scale Comparison With the National Institutes of Health Stroke Scale and Prediction of Middle Cerebral Artery Occlusion Oliver C. Singer, MD; Florian Dvorak, MD; Richard du Mesnil de Rochemont, MD; Heiner Lanfermann, MD; Matthias Sitzer, MD; Tobias Neumann-Haefelin, MD Background and Purpose—The purpose of the study was to design a simple stroke scale that requires minimal training but reflects initial stroke severity and is predictive of middle cerebral artery (MCA) occlusion. Methods—The new stroke scale assessed 3 parameters: (1) level of consciousness, (2) gaze, and (3) motor function. Each item was graded 0 to 2, where 0 indicated normal findings and 2 severe abnormalities (ie, profound drowsiness or worse, forced gaze deviation, and severe hemiparesis, respectively). During a study period of 11 months, patients presenting with acute stroke symptoms (onset 6 hours) were examined by a stroke neurologist assessing the new scale as well as the National Institutes of Health Stroke Scale (NIHSS). In addition, 83 patients received acute magnetic resonance angiography (MRA; as part of an acute stroke protocol). Results—The new stroke scale was strongly associated with the NIHSS. Interobserver reliability of the new scale was high (intraclass correlation coefficient 0.947). Using post hoc analysis, a score of 4 predicted proximal vessel occlusion (T-segment or M1-segment occlusion of the MCA on MRA) almost as accurately (overall accuracy 0.86) as an NIHSS score of 14 (overall accuracy 0.93). Conclusions—The new stroke scale reflects acute stroke severity well and predicts proximal MCA occlusion with reasonable accuracy. However, the clinical scale needs further evaluation before it can be recommended as a tool for the triage of acute stroke patients. (Stroke. 2005;36:773-776.) Key Words: magnetic resonance imaging  stroke assessment  stroke, acute M odern imaging techniques allow the rapid assessment of vessel status in acute ischemic stroke and can be used for the triage of patients for (invasive) recanalization strategies. However, computed tomography (CT) and mag- netic resonance angiography (MRA) as well as transcranial Duplex ultrasound are not yet broadly available 24 hours per day. In addition, for some severely ill patients, MRI is not an ideal imaging modality because of limitations concerning patient monitoring. 1 Particularly for hospitals with limited imaging resources, surrogate markers of vessel occlusion would be helpful. Recently, a relatively strong relationship between the neurological deficit as measured by the National Institutes of Health Stroke Scale (NIHSS) and vessel status has been established. 2,3 However, although the NIHSS has proven useful in the context of clinical trials, it remains a complex scoring system necessitating regular training for accurate application. Furthermore, there is evidence that the NIHSS is performed rarely in clinical routine. 4 Recent studies investi- gated the utility of shorter stroke scales to assess stroke severity and to differentiate stroke from other conditions. 5–9 However, their predictive value as to large vessel status has not been investigated yet. The purpose of this study was to design a simple scale that: (1) reflects acute stroke severity, and (2) may serve as a predictor of middle cerebral artery (MCA) occlusion. Materials and Methods The 3-Item Stroke Scale Table 1 displays the scoring sheet of the new 3-item stroke scale (3I-SS), assessing the items: (1) level of consciousness, (2) gaze, and (3) motor function. Each item was graded 0 to 2, where 0 indicated normal, 1 mild, and 2 severe abnormalities. Consciousness was classified as being mildly disturbed if the patient was drowsy. If vigorous (painful) stimuli were necessary for arousal, or the patient was unarousable, consciousness was classified as being severely disturbed. Gaze deviation was classified as being incomplete if crossing of the midline was possible by visual or acoustic stimuli; otherwise it was classified as being fixed. Hemiparesis was classified as moderate if the patient was able to elevate both upper and lower extremities but with a drift in 10 seconds in either or both extremities of one side. Hemiparesis was rated as severe if no or only Received November 1, 2004; final revision received December 9, 2004; accepted December 15, 2004. From the Departments of Neurology (O.C.S., F.D., M.S., T.N.-H.) and Neuroradiology (R.d.M.d.R., H.L.), J.W. Goethe University, Frankfurt am Main, Germany. Correspondence to Dr Oliver C. Singer, MD, Department of Neurology, J.W. Goethe University, Schleusenweg 2-16, D-60528 Frankfurt/Main, Germany. E-mail o.singer@em.uni-frankfurt.de © 2005 American Heart Association, Inc. Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000157591.61322.df 773 by guest on August 10, 2015 http://stroke.ahajournals.org/ Downloaded from