Adverse nonmotor outcomes are prevalent in younger adults up to 6 months after stroke — even in those with favorable functional recovery scores on standard scales.

In a prospective trial of about 500 patients younger than 55 years, poststroke fatigue was reported by 55% of participants at 6 months, with reduced social participation and sleep disturbance reported by 47% and 46%, respectively.

In addition, 91% of the cohort had at least one adverse poststroke outcome and nearly 30% had at least four adverse outcomes.

However, outcome prevalence rates did not differ between those with favorable vs unfavorable recovery scores on the modified Rankin Scale (mRS), a clinical tool that is “widely used as the sole outcome measure after stroke,” the researchers reported.

“Traditional scores that we use for stroke as a whole don’t adequately capture nonmotor outcomes, particularly in a young-stroke age group but probably across the board,” co-investigator Arvind Chandratheva, DPhil, consultant neurologist and clinical director for stroke at the National Hospital of Neurology and Neurosurgery, London, England, told Medscape Medical News.

“I think this could have genuine clinical impact on our day-to-day work,” Chandratheva added.

The findings were published online recently in the Journal of Neurology, Neurosurgery, & Psychiatry.

mRS Limitations Exposed

The investigators noted that while nonmotor outcomes are increasingly recognized as an important consequence of stroke, research in younger populations and in those with intracerebral hemorrhage (ICH) is limited.

Previous studies that have examined nonmotor outcomes mostly measured only one or two individual outcomes “in isolation,” the researchers noted.

For the current analysis, investigators assessed 493 participants from the prospective cohort trial ULYSSES. All were younger than 55 years (mean age, 48 years; 82% women) when admitted to one hospital in London between 2017 and 2020 with acute ischemic stroke (82%) or ICH (18%).

At 6-month follow-up, data were collected on the following six nonmotor domains from the Patient-Reported Outcome Measurement Information System-29 (PROMIS-29): anxiety, depression, fatigue, sleep disturbance, pain interference, and social participation ability. In addition, information was collected on bowel and bladder control using the Barthel Index.

Investigators also compared the prevalence of outcomes between those with favorable mRS scores of 0-1 and unfavorable scores of 2-5.

At 6 months poststroke, fatigue, reduced participation in social activities, and sleep disturbance were the most common nonmotor outcomes, each affecting about half of the participants. Other frequently reported outcomes included anxiety (35%), depression (32%), and pain interference (18%).

At least one adverse nonmotor outcome was reported by 91% of participants and 27% reported having at least four poststroke outcomes.

The prevalence of any of the measured nonmotor outcomes did not differ significantly between patients with favorable mRS scores compared with those with unfavorable scores.

At 6 months, anxiety was significantly more likely among patients with ICH (odds ratio [OR], 1.9; P = .02) and those with higher education levels (OR, 1.12; P = .01).

Stroke severity at admission, measured with the National Institutes of Health Stroke Scale, was a significant predictor of pain interference (OR per 10-point increase, 1.5; P = .025).

The investigators noted that the results show there is a real need for early recognition and management of these outcomes in a younger population.

“Despite appearing to be fully recovered by their families, carers, or clinical teams, this group may struggle with ‘hidden’ nonmotor outcomes, which may have a major adverse impact on their quality of life,” they wrote.

They added that the findings also highlighted limitations of the mRS.

“Instead, a comprehensive, domain-specific approach may be needed to accurately assess nonmotor aspects of recovery,” the researchers wrote.

Striking Findings

In an accompanying editorial, Jukka Putaala, MD, professor in the Department of Neurology at Helsinki University Hospital Neurocenter, Helsinki, Finland, and Karoliina Aarnio, MD, Department of Neurology at University of Helsinki, Helsinki, Finland, said the research “makes an important contribution” to the literature and showed striking results, especially that more than 90% of respondents had at least one of these outcomes.

The findings also highlight “the limitations of conventional functional measures in capturing the true burden of stroke recovery,” the editorialists wrote.

They added that the results “echo recent findings from our multicenter long-term follow-up study,” which showed that nearly one third of young participants with stroke reported having fatigue, anxiety, or cognitive impairment 10 years later.

The current findings “underscore the need to rethink how we measure recovery after stroke in younger adults,” Putaala and Aarnio wrote. They added that the recently developed Young Stroke Questionnaire may be one candidate for better assessments in this population.

Chandratheva agreed that other measures are needed, and suggested that the PROMIS-29 questionnaire, Barthel Index, and Stroke Impact Scale are other possible considerations. “The area of most importance is that we’re using something that is beyond just a score directed at motor function,” he said.

“I think the editorial is quite right that there are other scores that can be used,” Chandratheva added.

Putaala told Medscape Medical News that this was one of only a few studies to assess nonmotor outcomes of stroke.

He noted that outcome measures focusing on abilities such as walking have traditionally been considered sufficient.

“But often, while young patients cope very well with their motor functions after stroke, they’re having many other problems, including with their mood, memory, attention, and so forth,” he said.

Putaala added that such outcomes are not well captured by the broad measures that have been used for many years.

Overall, he said, “clinicians should follow their younger patients more carefully. There are so many dimensions in [patients’] lives that a stroke can affect, and that’s becoming part of the emerging evidence,” Putaala said.

This study was funded by the National Institute for Health and Care Research and the University College London Hospitals Biomedical Research Center. The investigators and the editorialists reported no relevant financial relationships.