Beyond the Rankin Scale: A Patient-Centered Score for Meaningful Recovery After Mechanical Thrombectomy in Older Adults With Pre-Stroke Disability.

Abstract

Aim: The benefit of mechanical thrombectomy (MT) for acute ischemic stroke in patients with pre-stroke moderate-to-severe disability is difficult to evaluate using the modified Rankin Scale (mRS) alone. We developed and evaluated the SMILE-Stroke score as a patient-centered outcome measure.

Methods: We conducted a retrospective cohort study of 31 patients with pre-stroke mRS scores of 3-5 who underwent MT. The 10-point SMILE-Stroke score, comprising Speech, Mobility, Ingestion, Lavatory, and Engagement domains, was assessed at discharge; a score ≥ 4 was prespecified as favorable. Interrater reliability, convergent validity with the Barthel Index, associations with discharge disposition and mRS, and pre-stroke SMILE-Stroke scores were evaluated.

Results: Twelve patients (38.7%) achieved a favorable SMILE-Stroke outcome. Interrater reliability was excellent for the total score (single-rater intraclass correlation coefficient = 0.957) and dichotomized outcome (Fleiss' κ = 0.863). The score correlated strongly with the discharge Barthel Index (Spearman's ρ = 0.86, p < 0.001) and showed a graded association with discharge disposition (Kruskal-Wallis p = 0.0012). For distinguishing discharge to home/original residence or rehabilitation hospital from long-term care hospital or death, the SMILE-Stroke score yielded an AUC of 0.82. Notably, 6 of 19 patients (31.6%) with 90-day mRS scores of 4-5 achieved a favorable SMILE-Stroke outcome.

Conclusions: The SMILE-Stroke score was feasible, reproducible, and associated with established functional and discharge outcomes in selected MT-treated patients with pre-stroke disability. It may complement the mRS by identifying preserved or regained patient-centered functional domains within poor mRS categories.