ASTRAL Score for Ischemic Stroke

George Ntaios, MD, PhD, is an assistant professor of internal medicine at the University of Thessaly in Larissa, Greece. He is co-chair of the Guidelines Committee of the European Stroke Organization and Secretary General of the Hellenic Stroke Organization. Dr. Ntaios is an active researcher, focusing mainly on secondary stroke prevention and stroke prognosis.

Why did you develop the ASTRAL Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

Our daily work with acute stroke patients taught us that our gut feeling about which patient would recover well was wrong in about a third of patients.

What pearls, pitfalls and/or tips do you have for users of the ASTRAL Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

Like with every score, it is not perfect and surprisingly short for a complex problem, which is long-term prognosis after stroke. Our two pieces of advice:

1. Always use it together with other information that may not be in the score, and
2. Use the score only for patients with pre-stroke independence (Modified Rankin Scale 0-2 points). Patients who were already dependent before the stroke will in general remain so after three months.

What recommendations do you have for doctors once they have applied the ASTRAL Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?

The information of the calculated score should add to, not replace, the estimation of prognosis.

We have already shown that adding basic imaging information adds little to the score. However, we feel that adding subacute clinical information, such as the NIHSS or temperature at 24 hours, could add further precision to the score.

How do you use the ASTRAL Score in your own clinical practice? Can you give an example of a scenario in which you use it?

We use it in the acute phase when discussing difficult situations with the next of kin. For example, "Your mother, who was still at home, now had a moderately severe stroke; from our estimation, she has an approximately 60% chance of being dependent (or dead) in three months. Does this help you in your wish for how aggressive we should be in our management in the next few days in the stroke unit?"

Any other research in the pipeline that you’re particularly excited about?

We are currently nearly finished with:

1. A new score predicting stroke recurrence in the first 12 months after an ischemic stroke.
2. A new clinical prehospital score which predicts not only which patients have a large (proximal) vessel occlusion for possible thrombectomy, but also does so up to 24 hours, and predicts who has a good chance of responding to thrombectomy. 

Patrik Michel, MD, is a professor in the department of neurology at the University of Lausanne in Switzerland. He is chief of the Cerebrovascular Center there, which he also established. Dr. Michel is active in many professional organizations, including the European Stroke Organization and the World Stroke Organization.