Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : TC21 - TC25 Full Version

Correlation of Diffusion-Weighted Magnetic Resonance Imaging Determined Infarct Volume with Clinically Assessed National Institutes of Health Stroke Scale in Patients of Acute Stroke: A Cross-sectional Study


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49862.15309
Bhavya Kataria, Shibani Mehra

1. Senior Resident, Department of Radiodiagnosis, RML Hospital, New Delhi, India. 2. Professor, Department of Radiodiagnosis, RML Hospital, New Delhi, India.

Correspondence Address :
Bhavya Kataria,
D-12, Tower-1, Type-4, East Kidwai Nagar, New Delhi, India.
E-mail: nono_5333@yahoo.co.in

Abstract

Introduction: Infarct volume is an essential factor in predicting patient prognosis. National Institutes of Health Stroke Scale (NIHS) allows consistent reporting of neurological deficits in stroke patients. Limited studies have been done in the Indian population correlating the volume of infarct and the NIHS Scale.

Aim: To correlate the Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) assessed infarct volume with the clinically assessed NIHS to prognosticate clinical outcomes in patients of acute stroke.

Materials and Methods: This was a cross-sectional study comprising 36 patients of acute stroke with a study duration from November 2017 to April 2019. Diffusion-Weighted MRI was obtained on Siemens Magnetom 3 Tesla, and diffusion restriction on b=1000 image was measured with a Region of Interest (ROI) tool using manual contouring in each slice. Assessment of the neurological deficit was done by NIHS scale at the time of admission and 7 days post admission for each patient. Correlation of the infarct volume with NIHS Scale was done with p<0.05 considered statistically significant. Receiver Operating Characteristic Curve (ROC) was used to predict cut-off of the volume of infarct and NIHS Scale to predict adverse patient outcome.

Results: Present study consisted of 36 patients of acute stroke with a mean age of 52.05±18.53 years. The minimum age of the patient was one year, and the maximum age was 78 years. There was a statistically significant correlation between the volume of infarct and NIHS Scale at time of admission admission (p=0.001; r=0.807) and the NIHS Scale at one week (p=0.002; r=0.602).The Area Under the Curve (AUC) for a cut-off of 115 cc of the volume of infarct in predicting adverse patient outcomes was 0.931, whereas that for the NIHS scale of 20 was 0.998.

Conclusion: Volume of infarct of 115 cc and NIHS Scale of 20 are excellent as prognostic tools in predicting patient outcome and have comparable efficacy.

Keywords

Barthel index of daily living, Fluid attenuated inversion recovery sequence, Prognostic tools

Stroke is a universal health problem with 20 million people in India suffering from stroke each year, out of which 5 million people do not survive (1). DW-MRI sequences have a higher sensitivity than conventional MRI sequences in the detection of cerebral ischaemia in the hyperacute and acute phase of stroke and have become indispensable in stroke imaging protocols (2).

Diffusion-Weighted Imaging (DWI) analyses the molecular architecture of the cell by recognising cytotoxic oedema as early as 30 minutes of stroke onset which demonstrates as areas of diffusion restriction in the affected brain tissue on DWI and corresponding Apparent Diffusion Coefficient (ADC) maps. Diffusion-weighted MRI has a sensitivity and specificity of 88-100% and 86-100%, respectively, for demonstrating the cytotoxic oedema (3).

Diffusion-weighted MRI is also useful in the measurement of the size of the volume of the infarct and plays a significant role in predicting the utility of thrombolysis in acute stroke patients by characterising the ischaemia core (non salvageable brain tissue) and the penumbra (salvageable brain tissue) accurately. Patients with a small core and large penumbra form ideal candidates for reperfusion therapy (4).

Universal stroke assessment tools are essential in clinical practice and provide an objective insight into stroke progress and predict potential outcomes. The commonly used neurological assessment scales, particularly for stroke, are the Scandinavian Stroke Scale (SSS), NIHS scale, Barthel Index of Daily Living (BI), and modified Rankin Scale (mRS) (5). The NIHS scale is an 11-item scale that standardises and quantifies the basic neurological examination, paying particular attention to those neurological aspects that are most pertinent to stroke. It is a straightforward clinical tool and takes around six minutes to perform. The scale includes an assessment of language, motor function, sensory loss, consciousness, visual fields, extraocular movements, coordination, neglect, and speech. It is scored from 0 (no impairment) to a maximum of 42. Baseline neurological status is classified as standard with a score of 0, minor stroke with a Score of 1-4, moderate stroke with a score of 5-15, moderately severe stroke with a score of 16-20 and severe stroke with a score of >20 (5).

A study have been done in the Indian population assessing the prognostic significance of volume of infarct and the NIHS scale; lacunae in the cited study being absence of follow-up for the patient outcome and merely establishing a statistical correlation between the variables (6). Hence, present study aimed to establish correlation between the DW-MRI assessed infarct volume and the clinically assessed NIHS as well as prognosticate clinical outcomes in patients of acute stroke.

Material and Methods

A cross-sectional study was conducted in the Department of Radiodiagnosis at PGIMER and Dr. RML Hospital for a duration of two years from November 2017 to April 2019 in a total of 36 patients of acute stroke referred from all Clinical Departments. Informed consent was taken from all patients in the study; parental consent was taken for minor subjects in the study. The Institutional Ethics Committee (IEC) approval for the study was obtained in 2018. (F.No.TP(MD/MS (103/2017)/IEC/PGIMER/RMLH/311/18).

Acute stroke was defined as patients presenting with neurological deficit within seven days of symptom onset.

Inclusion criteria: Acute stroke patients irrespective of the vascular territory involved and lacunar strokes were included in the study.

Exclusion criteria: The patients with general contradictions to MRI scanning and those with haemorrhagic stroke without an obvious infarct were excluded from the study.

Sample size calculation: The sample size was calculated using the statistical formula:

N=Zα2×p(1-p) / d2

where Zα is 1.96 at a confidence level of 95%; d=(1-p/2) and p is the prevalence. The average prevalence was taken to be 70% according to a study taken into consideration (7). The minimum sample size thus calculated was approximately 35.8 (~36).

All 36 patients were taken up for Diffusion-weighted MRI within 48 hours of admission. MRI was acquired using the Siemens 3 Tesla Magnetom Skyra machine at b values of 0,500 and 1000 along with routine T1, T2, and Fluid Attenuated Inversion Recovery (FLAIR) sequences. A Time of Flight (TOF) MR Angiography sequence was performed in all patients to detect additional information about the aetiology of stroke.

The infarct was identified as an area of bright signal intensity on DWI with a corresponding dark region on the ADC map (Table/Fig 1), (Table/Fig 2). The area of infarct was measured with a free hand ROI tool using commercial automatic software Syngo MR D13A by manual contouring in each DWI slice with a b value of 1000, and the sum of the value so obtained was multiplied by the total slice thickness (Table/Fig 3).

The formula used for infarct volume was: Volume (cm3)=(Area×slice thickness).

In each patient, the degree of neurological deficit related to the stroke was assessed by calculating the NIHS scale by the neurologist at the time of admission. The patients were followed-up to 1 week (discharge), and amongst those who survived at the end of 1 week, NIHS scale was assessed again to evaluate a change in the scale calculated at the time of admission (5).

The volume of infarct was correlated with the NIHS scale at admission and discharge. The prognostic efficacy of the two was also calculated in predicting patient outcome.

Statistical Analysis

For statistical analysis, a categorical variable was presented in number and percentage (%), and continuous variables were presented as mean±Standard Deviation (SD) and median. The normality of data was tested by the Kolmogorov-Smirnov test. A diagnostic test was used to find out sensitivity, specificity, negative predictive value, and positive predictive value. The ROC curve was used to find cut off points of the NIHS scale and volume of infarct for predicting patient outcome. Quantitative variables were compared using the Independent Student t-test between the two groups. Qualitative variables like patient outcome were assessed using the Chi-square test. Analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0, with a p-value <0.05 considered statistically significant.

Results

Present study consisted of 36 patients of acute stroke with a mean age of 52.05±18.53 years. The minimum age of the patient was one year, and the maximum age was 78 years. Two patients were below 21 years, three patients between 21-30 years, four patients between 31-40 years age group, eight patients between 41-50 years age group, eight patients between 51-60 years age group, eight patients between 61-70 years and three patients were more than 71 years.

Out of 36 patients, 24 patients were males (66.7%) while 12 patients were females (33.3%). Hemiparesis was found in 27 patients amongst which 14 patients (38.88%) had right-sided hemiparesis and 13 patients (36.11%) had left-sided hemiparesis.

Infarcts were seen involving a single vascular territory in 27 (75%) patients and multiple vascular territories in 9 (25%) patients. Out of these, 29 (80.55%) patients had involvement of MCA territory, 5 (15.1%) patients were involved of PCA territory, 3 (8.3%) patients had involvement of ACA territory and 8 (22.22%) patients involved vertebrobasilar territory of which two patients had brainstem infarcts and six patients had cerebellar infarcts (Table/Fig 4)a,b.

Of the total 36 patients included in the study, 27 presented with hemiparesis (75%), 28 with altered sensorium (77.77%) (Table/Fig 5). The maximum volume of infarct was 487 cc, whereas the minimum volume of infarct was 1.68 cc. It was found that infarct volume was less than 5 cc in six patients, 6-25 cc in one patient, 25-50 cc in seven patients, 50-70 cc in five patients, 70-110 cc in four patients, 110-140 cc in three patients and more than 140 cc in 10 patients (Table/Fig 6).

Total 14 patients (38.89%) had a NIHS scale between 5 to 15 at the time of admission (moderate stroke), nine patients (25%) had a NIHS scale between 16 to 20 at admission (moderately severe stroke), and 13 patients (36.11%) had a NIHS scale of more than 20 at admission (severe stroke).

All 36 patients of acute stroke in this study were evaluated for the outcome at the end of one-week (at discharge). Out of these, 12 (33.3%) patients died within a week of onset of a stroke while 24 (66.7%) survived. Amongst the 24 patients who survived, 17 patients (70.83%) had a NIHS scale between 5 to 15 (moderate stroke), and seven patients (29.17%) had a NIHS scale between 16 to 20 (moderately severe stroke). None of the patients who survived had a NIHS scale of more than 20.

On statistical analysis by student t-test, the volume of infarcts measured was found to correlate positively with NIHS scale evaluated at the time of admission with a correlation coefficient of 0.807. The p-value was found to be statistically significant for this correlation and was less than 0.001 (Table/Fig 7)a.

Further, the results of this study also show that diffusion-Weighted MRI calculated infarct volume correlates positively with the NIHS scale evaluated at one week after onset of stroke (time of discharge) with a correlation coefficient of 0.602. The correlation was statistically significant, with a p-value of 0.002 (Table/Fig 7)b.

The statistical analysis by student t-test revealed that the diffusion-weighted MRI calculated infarct volume was highly significant in predicting the clinical outcome in all the patients with a p-value of less than 0.001 (Table/Fig 8).

In this study, DWI measured infarct volume greater than 115 cc was associated with a higher NIHS scale and an adverse clinical outcome in the form of death whereas DW measured infarct volume less than 115 cc was associated with a better clinical outcome in terms of survival or functional improvement (Table/Fig 9).

Using the ROC curve, the Area Under the Curve (AUC) for cut-off 115 cc as infarct volume to predict patient outcome was 0.931 {CI:95% (0.805-1.056), sensitivity: 91.7%, specificity: 95.8%, PPV: 91.7%, NPV: 95.8%, accuracy: 94.4%} (Table/Fig 10), (Table/Fig 11).

Using the ROC curve, the AUC for a cut-off value of 20 of NIHS scale at the time of hospital admission to predict patient outcome in this study population was 0.998 {CI:95% (0.991-1.005), sensitivity: 100%, specificity: 95.8%, PPV: 92.3%, NPV: 100%, accuracy: 97.2%} (Table/Fig 12), (Table/Fig 13).

Discussion

Diffusion sequences help characterise penumbra and ischaemic core for identifying patients for reperfusion therapy. Patients showing large penumbras and small core infarct volumes are good candidates for reperfusion therapy even beyond the 4.5 hour therapeutic window (8),(9).

Greater the infarct volume, the greater is the neurological deficit in the patient, and worse is the prognosis. The NIHS scale can also be used to prognosticate the patient outcome (10). Zaidi SF et al., found a significant correlation between infarct volume and patient outcome and concluded that infarct volume more than 111.8 cc was associated with unfavourable outcomes (p<0.01) (11).Saunders DE et al., found that patients with an initial infarct volume of fewer than 80 cm3 were found to have a better outcome than those with larger infarct volumes (12).

Sablot D et al., found that NIHS scale <5 was predictive of functional outcome whereas NIHS scale >22 was predictive of physical dependency or death, thus concluding that low and high NIHS scale cut-off points are effective positive predictive values for good and poor outcomes (13). Yaghi S et al., concluded that the NIHS scale on admission is associated with stroke severity and functional outcome. The accuracy of the NIHS scale in predicting the outcome is most reliable in the first nine days after stroke for determining patient prognosis. A score of more than or equal to 16 predicted a high probability of death or severe disability, and the score below six predicted good recovery (14). Thijs VN et al., found that the NIHSS score at admission and the volume of infarct measured on DW-MRI correlated significantly with a spearman rank correlation coefficient of 0.454 and a p-value of less than 0.01 (15). The findings of present study were in agreement with the above mentioned studies (11),(12),(13),(14),(15).

The results of present study show that all patients who had lower than 15 NIHS scale at admission survived and showed some amount of functional improvement at one week with the improvement of NIHS scale. Out of the seven patients who had a moderately severe stroke and NIHS scale of 16 to 20 at the time of admission, three patients showed an improved NIHS scale at one week corresponding to improvement in clinical symptoms. The NIHS scale improved from 21 to 17 in one patient, whereas the other two patients with significant improvement showed a change of NIHSS at one week from 16 to 10 and 19 to 13, respectively. The significant improvement was noted in the level of sensorium.

The statistical analysis showed that the volume of infarct correlates positively in a statistically significant manner with NIHS scale at discharge (one week) with a correlation coefficient of 0.602 and a p-value of 0.002. The NIHS scale at discharge was less than 20 in all patients, along with a lower volume of infarct as measured on DW MR (less than 115 cc). Schiemanck SK et al., in a study also concluded that there was a strong correlation between the volume of infarct measured on DWI and NIHS scale measured at two weeks of symptom onset with a correlation coefficient of 0.61 and a p-value of 0.001 (16).

Laredo C et al., found that the AUC of the volume of infarct in predicting mortality was 0.89, whereas the AUC of NIHS scale at admission was 0.73. The results of their study showed the MR assessed volume of the infarct is a better diagnostic tool in predicting patient outcome than the NIHS scale (17). The results of present study are similar to those conducted by Laredo C et al., as the AUC of the volume of infarct was seen to be (0.931), whereas that for NIHS scale at admission was (0.998), indicating that the two have comparable efficacy as a prognostic tool in predicting the outcome (17).

One patient in present study with multiple infarcts in bilateral deep gray matter distribution (bilateral thalami and left side of the midbrain) with a maximum volume of infarct 4 cc had a poor prognosis and died within one week of onset of stroke. There was non visualisation of the proximal left vertebral artery on 3D TOF MR angiography, indicating the possibility of thrombotic occlusion. The NIHS scale in this patient calculated at the time of admission was 21 (severe stroke category). Author feel that the reason for the poor NIHS scale at admission and the poor outcome seems to be the presence of multiple infarcts involving the thalamus and midbrain, both of which contain important decussation pathways for motor tracts. Moreover, acute total thrombotic occlusion of the left vertebral artery, as shown by 3D TOF MR angiography, could have precipitated death in this patient.

One patient who had an infarct volume greater than 115 cc survived. The NIHS scale at the time of admission was 18 and at one week (time of discharge) was 17. The infarct was found involving the ipsilateral MCA and PCA territory. The cortical grey and white matter were involved without the involvement of the deep grey matter. Author feel that the better prognosis in this patient could be explained by the involvement of two vascular territories and the border zone with a likelihood of more effective collateralisation. One patient with NIHS scale at the admission of 21 (severe stroke) survived. The NIHS scale at discharge was 17. The improvement in patient outcome could be explained by the smaller volume of infarct (71.9 cc) in this patient.

The patients with symptom onset less than 4.5 hours in duration and those without haemorrhagic transformation were taken for thrombolysis irrespective of the infarct volume. However, amongst those in which intervention was performed, no change in outcome was seen. Patients with infarct volume >115 cc had succumbed to death, whereas those with infarct volume <115 cc showed improvement in symptoms.

Limitation(s)

Small sample size and the usage of manual contouring for measuring volume of infarct with existence of the possibility of human error for the same are few limitations.

Conclusion

Clinical outcomes in stroke patients can be predicted from initial infarct volume quantified by DW-MRI and NIHS scale. The cut-off value of 115 cc of infarct volume and NIHS scale of 20 suggest the two being comparable and excellent as prognostic tools in predicting the patient outcome. Both the parameters have high sensitivity and specificity in predicting the clinical outcome. It is thus recommended that the infarct volume ought to be measured using Diffusion-Weighted MRI in all patients of acute stroke. The infarct volume obtained on Diffusion-Weighted MR must be correlated with the NIHS scale at admission and at the time of discharge (one week) in order to predict patient outcome.

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DOI and Others

10.7860/JCDR/2021/49862.15309

Date of Submission: Apr 11, 2021
Date of Peer Review: May 15, 2021
Date of Acceptance: Jun 26, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 14, 2021
• Manual Googling: Jun 26, 2021
• iThenticate Software: Jul 16, 2021 (13%)

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