After stroke, neurological deficits improve in most patients over the subsequent several months, and the improvements are faster early on [1, 2]. However, individual neurological deficit improvements have rarely been reported [3, 4]. We studied improvements on each National Institutes of Health Stroke Scale (NIHSS) item in the acute stroke clinical trial TOAST (Trial of ORG10172 in Acute Stroke Treatment) [5]. The TOAST trial was a randomized, placebo-controlled trial of anticoagulation therapy in patients with mild to moderate stroke severity, starting within 24 h after symptom onset. No significant treatment effect was found.


The TOAST Data Management Center in Iowa City, Iowa, kindly provided the data. We analyzed the NIHSS scores at baseline, seven-days, and three-months. Percent NIHSS change was (baseline score − subsequent score) / baseline score times 100.


Of 1275 enrolled patients, 1269 had the data needed for this analysis. Table 1 shows the proportions of patients with individual NIHSS deficits and those with improvements at seven-days and at three-months. The majority of patients who improved began to do so during the first week. A smaller proportion of patients improved between seven-days and three-months. This improvement pattern was similar in patients with lacunar (small subcortical, n = 305) and nonlacunar (n = 957) stroke subtypes. The total NIHSS in all patients decreased from baseline by a median 36% at seven-days and by 60% at three-months.

Table 1. Baseline neurological deficits and improvements at seven-days and three-months by at least one point in 1269 patients in the TOAST trial
NIHSS itemDeficit present at baseline, n (%)Percent of patients improved at seven-days/three-months
  1. NIHSS, National Institutes of Health Stroke Scale; LOC, level of consciousness; L, left; R, right.

LOC207 (16.3)76.5/82.0
LOC questions225 (18.4)62.0/67.6
LOC commands126 (10.1)62.6/68.6
Gaze deviation234 (18.4)66.4/76.7
Visual fields298 (24.0)46.7/63.4
Facial palsy990 (78.0)45.1/64.3
Motor L-arm524 (41.3)46.3/60.6
Motor R-arm531 (41.8)48.1/65.1
Motor L-leg468 (36.9)47.3/63.4
Motor R-leg449 (35.5)52.6/65.7
Limb ataxia469 (41.5)52.3/73.1
Sensation635 (51.2)47.3/60.1
Aphasia326 (25.9)48.7/69.0
Dysarthria741 (61.6)46.2/66.9
Neglect311 (25.2)56.5/71.0


Although the mechanisms of recovery of neurological function after stroke in different brain regions may vary, all neurological deficits on the NIHSS appear to follow a similar pattern of improvement. Improvements are considerably faster during the first week than later. Future studies could further evaluate the relative contribution of each neurological deficit or a combination of deficits to favorable clinical outcome.


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  2. References
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    Jorgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Stoier M, Olsen TS. Outcome and time course of recovery in stroke. Part II: time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76:406412.
  • 2
    Verheyden G, Nieuwboer A, De Wit L et al. Time course of trunk, arm, leg, and functional recovery after ischemic stroke. Neurorehabil Neural Repair 2008; 22:173179.
  • 3
    Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis 2004; 17:2127.
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    Mikulik R, Dusek L, Hill MD et al. Pattern of response of national institutes of health stroke scale components to early recanalization in the CLOTBUST trial. Stroke 2010; 41:466470.
  • 5
    The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Low molecular weight heparinoid, org 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. JAMA 1998; 279:12651272.