Long-term functional outcome after ischemic stroke: : Prognostic value of early identification of neglect and aphasia

Abstract: Early symptoms of neglect and aphasia are often observed after ischemic stroke and have been associated with unfavorable short-term functional outcomes within one year post-stroke. However, there is a lack of studies with inclusion of both neglect and aphasia as potential predictors that have studied long-term functional outcomes exceeding one year after stroke. In the current licentiate thesis, a consecutive cohort of 375 stroke patients was assessed early after stroke by a basic screening for the occurrence of visuospatial inattention (VSI) using the Star Cancellation Test (SCT) and for language impairment (LI) using the language item from the Scandinavian Stroke Scale (SSS). Neurological deficits were also investigated. At the 7 year follow-up, functional outcomes i.e. disability and levels of participation in instrumental activities of daily living were measured by the modified Rankin Scale (mRS) and the Frenchay Activities Index (FAI). In study I, 235 stroke survivors without a recurrent stroke were included at the follow-up. The aim was to examine if a basic screening of VSI and LI at the early stage post-stroke could provide prognostic information about functional outcomes 7 years post-stroke. Multiple regression analyses identified VSI and neurological deficits (the SSS score without the language item) as the significant independent predictors of unfavorable outcomes in mRS and FAI. The early screening of LI did not provide any further prognostic information beyond the information provided by VSI and neurological deficits. In study II, 105 individuals with left and 77 with right hemisphere stroke without a recurrent stroke were included at the 7 year follow-up. The aim was the same as for study I but in this study the possible prognostic information about long-term functional outcomes provided by neglect and aphasia was investigated separately for left and right hemispheric group. It was found that the presence of VSI following a left hemisphere stroke was as frequent as after a right hemisphere stroke. For the left hemisphere group the multiple regression identified VSI and neurological deficits as the independent predictors of unfavorable outcomes in mRS, and for the outcome in FAI, VSI and LI were the independent predictors. Interestingly, for this group with a left hemisphere stroke, VSI was identified as the strongest significant independent predictor of the unfavorable outcomes. Language impairments (LI) were significantly related with unfavorable long-term outcomes but only in combination with symptoms of VSI. Individuals with such combination of symptoms were those with the most unfavorable outcomes. For the right hemispheric group, the multiple regression identified VSI and neurological deficits as the independent predictors of unfavorable outcome in mRS, and for the outcome in FAI, neurological deficits and age were the independent predictors. Study I and II emphasize the importance of identifying early symptoms of VSI not only after right hemisphere stroke but also after left hemisphere stroke and particularly for individuals with severe symptoms of LI. Identification of these individuals is important since a combination of attention and language deficits seems to be rather common for patients with severe aphasia at the acute phase and indicates an increased risk of unfavorable outcomes.