Hernan Altman

Publications (2)11.46 Total impact

• Article: Relationship between neurologic deficit severity and final functional outcome shifts and strengthens during first hours after onset.

  Jeffrey L Saver, Hernan Altman
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  ABSTRACT: Early neurological deficit severity is the most important determinant of final functional outcome in acute ischemic stroke. However, deficit severity frequently changes during the first hours and days postonset. Analysis of control group patients enrolled in the 2 National Institute of Neurological Disorders and Stroke tissue-type plasminogen activator trials. Neurological deficit severity was measured serially using the National Institutes of Health Stroke Scale (NIHSS) at 1 to 3 hours postonset, 3 to 5 hours, 24 hours, 7 to 10 days, and 90 days. Final global disability outcome was assessed at 90 days using the modified Rankin Scale. Among the 312 patients, median neurological deficit severity on the NIHSS improved throughout the 90-day observation period, from 15 (interquartile range, 9.5-20) at 1 to 3 hours, to 12 (interquartile range, 6-19) at 24 hours, to 7 (interquartile range, 2-19) at 90 days. Between 1-to-3-hours to 24 hours, more patients spontaneously improved than worsened: 39.1% versus 17.6% (P<0.001). NIHSS scores associated with individual final modified Rankin Scale global disability ranks shifted to lower values over time; eg, patients with a final modified Rankin Scale of 2 had the following median NIHSS scores: 12 at 1 to 3 hours, 10 at 3 to 5 hours, 9 at 24 hours, and 3 at 90 days. Correlation coefficients between NIHSS and the final modified Rankin Scale increased over time, from 0.51 at 1 to 3 hours, to 0.72 at 24 hours, to 0.87 at 90 days. During the first 24 hours after onset, spontaneous improvement occurs in 2 of 5 acute ischemic stroke patients. The NIHSS scores associated with individual global disability ranks decrease over time. Neurological deficit severity increasingly predicts final disability outcome, accounting for one quarter of the variance at 1 to 3 hours, one half at 24 hours, and three quarters at 90 days.
  Stroke 04/2012; 43(6):1537-41. · 5.73 Impact Factor
• Article: Statistical analysis of the primary outcome in acute stroke trials.

  Philip M W Bath, Kennedy R Lees, Peter D Schellinger, Hernan Altman, Martin Bland, Cheryl Hogg, George Howard, Jeffrey L Saver
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  ABSTRACT: Common outcome scales in acute stroke trials are ordered categorical or pseudocontinuous in structure but most have been analyzed as binary measures. The use of fixed dichotomous analysis of ordered categorical outcomes after stroke (such as the modified Rankin Scale) is rarely the most statistically efficient approach and usually requires a larger sample size to demonstrate efficacy than other approaches. Preferred statistical approaches include sliding dichotomous, ordinal, or continuous analyses. Because there is no best approach that will work for all acute stroke trials, it is vital that studies are designed with a full understanding of the type of patients to be enrolled (in particular their case mix, which will be critically dependent on their age and severity), the potential mechanism by which the intervention works (ie, will it tend to move all patients somewhat, or some patients a lot, and is a common hazard present), a realistic assessment of the likely effect size, and therefore the necessary sample size, and an understanding of what the intervention will cost if implemented in clinical practice. If these approaches are followed, then the risk of missing useful treatment effects for acute stroke will diminish.
  Stroke 03/2012; 43(4):1171-8. · 5.73 Impact Factor