The crossed leg sign indicates a favorable
outcome after severe stroke
J. Re ´mi, MD
T. Pfefferkorn, MD
R.L. Owens, MD
C. Schankin, MD
S. Dehning, MD
T. Birnbaum, MD
A. Bender, MD
M. Klein, MD
J. Adamec, PhD
H.-W. Pfister, MD
A. Straube, MD
B. Feddersen, MD, PhD
Objective: We investigated whether crossed legs are a prognostic marker in patients with severe
Methods: In this controlled prospective observational study, we observed patients with severe
stroke who crossed their legs during their hospital stay and matched them with randomly selected
severe stroke patients who did not cross their legs. The patients were evaluated upon admission,
on the day of leg crossing, upon discharge, and at 1 year after discharge. The Glasgow Coma
Scale, the NIH Stroke Scale (NIHSS), the modified Rankin Scale (mRS), and the Barthel Index (BI)
Results: Patients who crossed their legs (n ? 34) and matched controls (n ? 34) did not differ in
any scale upon admission. At the time of discharge, the GCS did not differ, but the NIHSS was
better in crossed legs patients (6.5 vs 10.6; p ? 0.0026), as was the mRS (3.4 vs 5.1, p ?
0.001), and the BI (34.0 vs 21.1; p ? 0.0073). At 1-year follow-up, mRS (2.9 vs 5.1, p ? 0.001)
and the BI (71.3 vs 49.2; p ? 0.045) were also better in the crossed leg group. The mortality
between the groups differed grossly; only 1 patient died in the crossing group compared to 18 in
the noncrossing group (p ? 0.001).
Conclusion: Leg crossing is an easily obtained clinical sign and is independent of additional tech-
nical examinations. Leg crossing within the first 15 days after severe stroke indicates a favorable
outcome which includes less neurologic deficits, better independence in daily life, and lower rates
of death. Neurology®2011;77:1453–1456
BI ? Barthel Index; GCS ? Glasgow Coma Scale; mRS ? modified Rankin Scale; NICU ? neurologic intensive care unit;
NIHSS ? NIH Stroke Scale.
Stroke is the third most frequent cause of death and the most frequent cause of permanent
disability in developed countries.1Several prognostic models have been developed to predict
functional recovery and survival.2–4However, the contributing factors for these models are
difficult to assess and may not be applicable in patients with severe stroke who require ventila-
tion or circulatory support.5
In our neurologic intensive care unit (NICU) early crossing of legs was observed in patients
with severe stroke despite markedly reduced consciousness, paresis of the crossed leg, need of
ventilation, or need of circulatory support. To evaluate the prognostic significance of this sign
we performed a prospective study in patients with severe stroke.
METHODS Patients. We included patients with severe stroke (intracranial CNS infarction or bleeding) who were admitted to
our NICU from May 2005 to September 2006. We arbitrarily defined “severe stroke” as a cerebral infarction or bleeding where the
patient had to be referred to our NICU because of severely impaired consciousness, need of mechanical ventilation, need of circula-
tory support, need of extraventricular drainage, or need for a high level of neurologic monitoring. All medical staff (physicians, nurses)
were instructed to report leg crossing, which was then noted in the patient chart.
The control group consisted of patients after severe stroke that did not cross their legs during their stay at the NICU. They were
matched based on age, Glasgow Coma Scale (GCS) score, and severity of neurologic impairment (NIH Stroke Scale [NIHSS]) upon
From the Departments of Neurology (J.R., T.P., C.S., S.D., T.B., A.B., M.K., H.-W.P., A.S., B.F.) and Forensic Medicine (J.A.), University of
Munich, Munich, Germany; and Pulmonary and Critical Care Medicine (R.L.O.), Brigham and Women’s Hospital, Boston, MA.
Disclosure: Author disclosures are provided at the end of the article.
Address correspondence and
reprint requests to Dr. Berend
Feddersen, Department of
Neurology, University of Munich,
Marchioninistr. 15, 81377
Copyright © 2011 by AAN Enterprises, Inc.
admission. Matching was performed without knowledge of the
scales at discharge. Patients were only included in the study
when the rating scales at admission and discharge were obtained
without the influence of sedative medications. Sedation was al-
lowed on the crossing day. In the crossing group, 8 patients were
lost to 1-year follow-up, compared to 6 controls.
Standard protocol approvals, registrations, and patient
consents. The ethics committee of the University of Munich
approved this study, and patients or next of kin gave informed
consent to the use of their data. One patient withdrew consent at
the time of 1-year follow-up; those data were omitted.
Rating scales. At admission, crossing day, discharge, and
follow-up, the Glasgow Coma Scale (GCS6), Barthel index (BI,7
ranking a patient’s level of independence in daily activities from
0 [fully dependent] to 100 [fully independent]), NIHSS8(evalu-
ating severity of neurologic impairment from 0 [no impairment]
to 42 [severe impairment]), and modified Rankin scale (mRS,9
disability score, ranging from 0 [full health] to 6 [death]) were
documented. Furthermore, the mRS before onset of symptoms
was documented. The 1-year follow-up was performed by a
phone interview. Therefore, the NIHSS was not assessed because
it requires clinical examination.
Statistical analysis. The differences between the 2 groups
were compared using the Mann-Whitney U test. Differences in
categorical data were tested with Fisher exact test. Results were
considered statistically significant when p ? 0.05.
RESULTS Patients. Of 120 patients with severe
stroke, the crossing leg sign was observed in 34 pa-
tients. They were matched to 34 patients who did not
cross their legs. The underlying syndromes and comor-
site at www.neurology.org). The first time of leg
crossing was observed after an average of 10.5 days
(median 7 days, SD 12.6 days, minimum 0 days,
maximum 59 days) after intensive care unit admis-
sion. Twenty patients crossed their right leg over
their left (58.8%), 13 crossed their left over the right
(38.2%), and 1 patient crossed both ways (2.9%).
Six patients crossed with the leg contralateral to their
Outcome results. At admission, no differences be-
tween “crossers” or “noncrossers” were observed for
the GCS, the NIHSS, the mRS, or the BI (table 1).
However, over time, the other scores demonstrated
significant differences between the 2 groups. Upon
discharge, the NIHSS was lower for crossers, indicat-
ing less severe neurologic deficits, and the BI was
higher, demonstrating higher functional indepen-
dence of the patient (figure 1). These results im-
proved even further at the 1-year follow-up. The
mRS was lower in the crossing group at discharge
and follow-up, indicating less disability (figure 2).
The OR for attaining a mRS of at least 2 (able to
look after own affairs without assistance) at the
1-year follow-up was 8.1 for crossers (10/26) com-
pared to noncrossers (2/28).
When patients crossed their legs after day 15, no
BI outcome over 15 was attained (figure e-1). The 6
patients who crossed the leg contralateral to the CNS
lesion showed no difference in outcome. The mortal-
ity rate between the 2 groups differed grossly: in the
crossed leg group only 1 patient died compared to 18
fatalities in the control group (odds ratio 37.1; p ?
DISCUSSION Consistent with our hypothesis, we
found that leg crossing early after severe stroke was a
favorable prognostic indicator of outcome both at
hospital discharge and up to 1 year after admission.
Moreover, this marker conveyed not only statistical
relevance but also substantial clinical improvement.
For example, based on the modified mRS at 1 year
after discharge, the average leg crosser was moder-
ately disabled, but could walk unassisted, while aver-
age noncrossers were severely disabled and required
constant attention.9Next to this gradual outcome
scale, the difference in mortality between the leg-
crossing group (8.8%) and the noncrossers (52.9%)
was striking. Compared with commonly used predic-
tive metrics, which require neurologic assessment by
a trained health care provider and may only provide
information about recovery up to 3 months,2–4leg
crossing is easily assessed, and provides prognostic
information up to 1 year. From an epistemologic
view, leg-crossing translates a gradual improvement
of state of health into a categorical marker. That al-
lows easier categorization compared to judging from
Table 1Rating score resultsa
Day of first
8.1 ? 4.4 12.2 ? 2.813.8 ? 2.614.4 ? 1.2
8.8 ? 4.3NA 12.3 ? 3.514.5 ? 1.3
16.9 ? 8.8 9.6 ? 6.6 5.8 ? 4.3c
16.6 ? 6.9NA 10.9 ? 5.7
0.74 ? 1.264.5 ? 0.64.1 ? 0.83.4 ? 1.2d
2.9 ? 1.2d
0.62 ? 0.824.6 ? 0.7NA5.1 ? 1.0 5.1 ? 1.1
8.1 ? 16.115.9 ? 20.134.0 ? 24.0b
70.8 ? 32.9b
7.6 ? 20.2NA21.9 ? 26.9 49.2 ? 32.8
Abbreviations: GCS ? Glasgow Coma Scale; NA ? not applicable; NICU ? neurologic inten-
sive care unit; NIHSS ? NIH Stroke Scale.
aTime course of evaluation parameters in the leg crossing group (“cross”) as compared to
controls. Values are mean ? SD.
bp ? 0.05.
cp ? 0.01.
dp ? 0.001.
Neurology 77 October 11, 2011
gradual parameters like size of lesion or amount of
paresis2–4where a threshold has to be defined rather
than being observed.
In general, people have preferences of which leg to
cross over which, which refers to the asymmetric use
of bilateral limbs or sense organs, like handedness.
Similar to the preference of handedness, right over
left leg crossing is more common (62.4%) than left
over right leg crossing (25.7%).10In stroke pa-
tients, these preferences may become important
because of the accompanying hemiparesis, consid-
ering that more than 50 N of force have to be
applied for leg crossing (appendix e-1). On our
patients, though, the side of leg crossing did not
differ from the literature.10
The limitations of our study may be that leg
crossing was missed by the staff, but that would bias
toward the null hypothesis. Additionally, as this
study could not be blinded, a selection bias may be
present. We believe this bias to be small, because on
one hand this was a pilot study and it was unknown
whether crossed legs indicate a favorable outcome.
Conversely, we lack prognostic factors that are easily
obtained from clinical observation, so we believe that
the expectations of the medical staff did not severely
impact the outcome of this study.
Leg crossing is an inexpensive, easily obtained
clinical sign. Therefore, it can be used widely in daily
practice by an intensive care unit team; possibly it
may be used even by families or other nonmedical
caregivers, which should be evaluated in future stud-
ies. Leg crossing within the first 15 days after severe
stroke indicates a favorable outcome which includes
less neurologic deficits, better independence in daily
life, and lower rates of death. Based on this small
study, larger future studies could confirm the prog-
nostic value of leg crossing in general stroke, or eval-
uate its prognostic value in other intensive care unit
settings like septic or metabolic coma.
Dr. Re ´mi: data and statistical analysis, figure production, manuscript
draft and revision. Dr. Pfefferkorn: study design, follow-up, manuscript
revision. Dr. Owens: critical manuscript revisions. Dr. Schankin: data
collection, manuscript revision. Dr. Dehning: follow-up, manuscript revi-
sion. Dr. Birnbaum: data collection, manuscript revision. Dr. Bender:
data collection, manuscript revision. Dr. Klein: data collection, manu-
script revision. Dr. Adamec: force calculations, manuscript revision. Dr.
Pfister: critical manuscript revisions. Dr. Straube: study design, manu-
script revision. Dr. Feddersen: study idea, study design, data collection,
follow-up, manuscript draft and revision.
The authors thank Professor Jenni Carbaugh Cook and Eric Cook of
Nottingham, NH, for copyediting the manuscript and all nurses and doc-
tors of the Neurological Intensive Care Unit of the University of Munich
for careful observation of crossed legs.
Dr. Re ´mi has received speaker honoraria from UCB and Pfizer Inc. Dr.
Pfefferkorn reports no disclosures. Dr. Owens receives research support
from the NIH/NHBLI. Dr. Schankin received research support from
Merck Sharp & Dohme and Deutsche Forschungsgemeinschaft (German
Research Council). Dr. Dehning, Dr. Birnbaum, Dr. Bender, Dr. Klein,
and Dr. Adamec report no disclosures. Dr. Pfister received speaker hono-
raria from Novartis; serves on the editorial board of Journal of Neurology;
and has received research support from Deutsche Forschungsgemeinschaft
(German Research Council). Dr. Straube serves on the scientific advisory
boards for Desitin Pharmaceuticals, GmbH, Allergan, Inc., and Merck
Sharp & Dohme; has received speaker honoraria from Desitin Pharma-
ceuticals, GmbH, Allergan, Inc., Pfizer Inc, and Merck Sharp & Dohme;
serves on the editorial board of the Journal of Headache and Pain; and
receives research support from Deutsche Forschungsgemeinschaft (Ger-
Figure 1 Barthel Index
Barthel Index scores of level of independence in the crossed leg (“crossers,” full circles) and
control groups (empty circles). High values represent high level of independence. Error bars
indicate the SD. *p ? 0.05.
Figure 2 Modified Rankin Scale
circles) and control groups (empty circles). High values represent high disability. Error bars
indicate the SD. *p ? 0.001.
Neurology 77 October 11, 2011
man Research Council). and University of Munich. Dr. Feddersen re- Download full-text
ceived speaker honoraria from UCB and Pfizer Inc.
Received April 15, 2011. Accepted in final form June 27, 2011.
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