ASTRAL Score for Ischemic Stroke

ASTRAL Score
Age
NIHSS Score
Time from Onset to Admission
Visual Field Defect
Acute Glucose >7.3 mmol/L (>131 mg/dL)
Level of Consciousness (NIHSS 1a)
ASTRAL Score:0
–
–
Predicts 90-day poor outcome in patients with acute ischemic stroke.

Why Use

Can provide additional information on medium-term functional outcome in patients that have suffered acute ischemic stroke, in addition to clinical judgment based on relevant clinical and laboratory variables. Does not need neuroimaging data to calculate. Can be used to adjust for functional outcome in multivariate models in acute stroke-related research studies. Can serve as a selection criterion for cohorts in acute stroke-related research studies.

When to Use

Patients with acute ischemic stroke admitted within 24 hours of stroke onset.

Formula

Addition of the selected points: A ge 1 point for every 5 years -- S everity 1 point for every admission NIHSS point -- T ime delay between symptom onset or last proof of good health and admission 2 points if >3 hours 0 points if ≤3 hours R ange of visual fields (new visual field defect) 2 points if yes 0 points if no Glucose at a dmission 1 point if >7.3 or <3.7 mmol/L 0 points if 3.7-7.3 mmol L evel of consciousness 3 points if impaired 0 points if normal

Pearls / Pitfalls

The ASTRAL Score uses clinical characteristics and laboratory testing to predict the likelihood that a given patient with acute ischemic stroke will have a Modified Rankin Scale result of 3–6 at 90 days after stroke. Developed to predict a dichotomous outcome, not a discrete Modified Rankin Scale score at 90 days. Does not predict mortality or degree of improvement from any form of rehabilitation. Should not be used as a surrogate for stroke severity.

Management

In cases of suspected ischemic stroke, the following is recommended: STAT neurological consultation. STAT CT head without contrast. STAT laboratory testing (complete blood count, PT/INR/aPTT, basic metabolic panel, type & screen, troponin-I). Consider STAT CT angiogram of the head & neck in cases of suspected large-vessel occlusion (LVO) presenting in the acute setting.

Critical Actions

Intravenous tissue plasminogen activator (IV tPA) is the standard-of-care treatment for adult patients presenting with acute ischemic stroke within 4.5 hours of symptom onset, if no exclusion criteria are met. Mechanical thrombectomy is the standard-of-care treatment for selected adult patients presenting with acute ischemic stroke due to LVO presenting in the acute setting. Note that the appropriateness of patient for endovascular intervention depends on multiple factors, such as time since onset, neuroimaging, baseline functional status, and others. Appropriateness for intravenous thrombolysis or mechanical thrombectomy should be determined by neurological/neurosurgical consultant whenever available.

Advice

Acute ischemic stroke is a neurological emergency that is amenable to time-sensitive treatments (e.g. tPA, mechanical thrombectomy) if certain clinical conditions are met. Neurological consultation should be obtained immediately in suspected cases of acute ischemic stroke. Should not be used as a substitute for clinical judgment and is intended for use as an adjunct to medical decision-making.

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