ORIGINAL RESEARCH| Volume 103, ISSUE 5, P964-969, May 2022

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Accurate Prediction of Persistent Upper Extremity Impairment in Patients With Ischemic Stroke

Published:November 20, 2021DOI:



      To develop a simple and effective risk score for predicting which stroke patients will have persistent impairment of upper extremity motor function at 90 days.


      Post hoc analysis of clinical trial patients hospitalized with acute ischemic stroke who were followed for 90 days to determine functional outcome.


      Patient were hospitalized at facilities across the United States.


      We created a harmonized cohort of individual patients (N=1653) from the NINDS tPA, ALIAS part 2, IMS-III, DEFUSE 3, and FAST-MAG trials. We split the cohort into balanced derivation and validation samples.


      Not applicable.

      Main Outcome Measures

      The primary outcome was persistent arm impairment, defined as a National Institutes of Health Stroke Scale (NIHSS) arm domain score of 2 to 4 at 90 days in patients who had a 24-hour NIHSS arm score of 1 or more. We used least absolute shrinkage and selection operator regression to determine the elements of the persistent upper extremity impairment (PUPPI) index, which we validated as a predictive tool.


      We included 1653 patients (827 derivation, 826 validation), of whom 803 (48.6%) had persistent arm impairment. The PUPPI index gives 1 point each for age 55 years or older and NIHSS values of worse arm (4), worse leg (>2), facial palsy (3), and total NIHSS (≥10). The optimal cutpoint for the PUPPI index was 3 or greater, at which the area under the curve was greater than 0.75 for the derivation and validation cohorts and when using NIHSS values from either 24 hours or in a subacute or discharge time window. Results were similar across different levels of stroke severity.


      The PUPPI index uses readily available information to accurately predict persistent upper extremity motor impairment at 90 days poststroke. The PUPPI index can be administered in minutes and could be used as inclusion criterion in recovery-related clinical trials or, with additional development, as a prognostic tool for patients, caregivers, and clinicians.


      List of abbreviations:

      AIS (acute ischemic stroke), AUC (area under the receiver operating characteristic curve), LASSO (least absolute shrinkage and selection operator), NIHSS (National Institutes of Health Stroke Scale), NPV (negative predicative value), PPV (positive predictive value), PUPPI (persistent upper extremity impairment), UE (upper extremity)
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