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Peer-reviewedCC BY 4.0Frontiers in Neurology

Rethinking favorable outcomes: “return to baseline” as an additional outcome in ischemic stroke

  • Julia-Laura Schulz1
  • Arno Reich2
  • Charlotte S. Weyland1
  • Hani Ridwan1
  • Dimah Hasan1
  • Rebecca May1
  • Martin Wiesmann1
  • Omid Nikoubashman1,3
  • João Pinho2
  1. 1Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen
  2. 2Department of Neurology, University Hospital RWTH Aachen
  3. 3Department of Neuroradiology, University Hospital Bielefeld
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Abstract

Background: Stroke outcomes are commonly assessed using the modified Rankin Scale (mRS), dichotomized into “favorable” (0–2) and “unfavorable” (3–6). Many elderly patients present with pre-stroke mRS scores of 3–5, making “favorable” outcomes unattainable and complicating treatment evaluation.

Methods: This is a monocentric, retrospective analysis of ischemic stroke patients in our prospective registry (2010–2022). Outcomes include mRS scores at discharge and 90 days post-stroke. Descriptive and inferential statistics were applied with appropriate tests for categorical and ordinal variables. Multivariable logistic regression was used to model return to pre-stroke mRS and death by 90 days, adjusted for pre-stroke mRS group, age, sex, NIHSS on admission, treatment modality and vascular territory. Statistical significance was defined as p < 0.05.

Results: Of 3,724 ischemic stroke patients admitted, 2,070 met inclusion criteria (median age 75.7). Among those with favorable pre-stroke mRS (0–2, n = 1,827), 47.6% achieved favorable outcomes at discharge and 47.5% at 90 days. By definition, none with unfavorable pre-stroke mRS achieved favorable outcomes. At discharge, return to baseline mRS occurred in 16.2% with favorable pre-stroke mRS, compared to 19.3% with unfavorable ( p = 0.216). 90 days post-stroke, return to baseline occurred in 21.8% with favorable pre-stroke mRS, compared to 11.9% with unfavorable ( p < 0.001). Redefining favorable outcome to include return to pre-stroke mRS increased rates from 42.0 to 44.3% at discharge and from 41.9 to 43.3% 90 days post-stroke ( p < 0.001). In multivariable analysis a pre-stroke mRS of 3–5 was associated with death by 90 days (OR 4.40, 95% CI 3.18–6.10) but not with return to baseline in all patients (OR 1.02, 95% CI 0.65–1.58); among survivors it was associated with a higher probability of return to baseline (OR 2.34, 95% CI 1.40–3.91).

Conclusion: The traditional dichotomization of mRS does not reflect the wide range of pre-stroke status. Incorporating “return to pre-stroke mRS score” as a favorable outcome metric alongside the conventional dichotomy provides a more individualized measure, improving treatment evaluation and supporting tailored care strategies, particularly for patients with higher pre-stroke mRS scores.

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Cite

BibTeXRIS
BibTeX
@article{schulz2026rethinking,
  title = {{Rethinking favorable outcomes: “return to baseline” as an additional outcome in ischemic stroke}},
  author = {Julia-Laura Schulz and Arno Reich and Charlotte S. Weyland and Hani Ridwan and Dimah Hasan and Rebecca May and Martin Wiesmann and Omid Nikoubashman and João Pinho},
  journal = {Frontiers in Neurology},
  year = {2026},
  month = oct,
  doi = {10.3389/fneur.2026.1866829},
  url = {https://www.frontiersin.org/articles/10.3389/fneur.2026.1866829/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Rethinking favorable outcomes: “return to baseline” as an additional outcome in ischemic stroke
AU  - Julia-Laura Schulz
AU  - Arno Reich
AU  - Charlotte S. Weyland
AU  - Hani Ridwan
AU  - Dimah Hasan
AU  - Rebecca May
AU  - Martin Wiesmann
AU  - Omid Nikoubashman
AU  - João Pinho
PY  - 2026
DA  - 2026/10/19
JO  - Frontiers in Neurology
DO  - 10.3389/fneur.2026.1866829
UR  - https://www.frontiersin.org/articles/10.3389/fneur.2026.1866829/full
AB  - Background: Stroke outcomes are commonly assessed using the modified Rankin Scale (mRS), dichotomized into “favorable” (0–2) and “unfavorable” (3–6). Many elderly patients present with pre-stroke mRS scores of 3–5, making “favorable” outcomes unattainable and complicating treatment evaluation.  Methods: This is a monocentric, retrospective analysis of ischemic stroke patients in our prospective registry (2010–2022). Outcomes include mRS scores at discharge and 90 days post-stroke. Descriptive and inferential statistics were applied with appropriate tests for categorical and ordinal variables. Multivariable logistic regression was used to model return to pre-stroke mRS and death by 90 days, adjusted for pre-stroke mRS group, age, sex, NIHSS on admission, treatment modality and vascular territory. Statistical significance was defined as p < 0.05.  Results: Of 3,724 ischemic stroke patients admitted, 2,070 met inclusion criteria (median age 75.7). Among those with favorable pre-stroke mRS (0–2, n = 1,827), 47.6% achieved favorable outcomes at discharge and 47.5% at 90 days. By definition, none with unfavorable pre-stroke mRS achieved favorable outcomes. At discharge, return to baseline mRS occurred in 16.2% with favorable pre-stroke mRS, compared to 19.3% with unfavorable ( p = 0.216). 90 days post-stroke, return to baseline occurred in 21.8% with favorable pre-stroke mRS, compared to 11.9% with unfavorable ( p < 0.001). Redefining favorable outcome to include return to pre-stroke mRS increased rates from 42.0 to 44.3% at discharge and from 41.9 to 43.3% 90 days post-stroke ( p < 0.001). In multivariable analysis a pre-stroke mRS of 3–5 was associated with death by 90 days (OR 4.40, 95% CI 3.18–6.10) but not with return to baseline in all patients (OR 1.02, 95% CI 0.65–1.58); among survivors it was associated with a higher probability of return to baseline (OR 2.34, 95% CI 1.40–3.91).  Conclusion: The traditional dichotomization of mRS does not reflect the wide range of pre-stroke status. Incorporating “return to pre-stroke mRS score” as a favorable outcome metric alongside the conventional dichotomy provides a more individualized measure, improving treatment evaluation and supporting tailored care strategies, particularly for patients with higher pre-stroke mRS scores.
SN  - 1664-2295
ER  -