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    Modified SOAR Score for Stroke

    Predicts short-term mortality in acute ischemic stroke.
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    INSTRUCTIONS

    Use admission data for calculation. Do not use in patients with transient ischemic attack, subarachnoid hemorrhage, or subdural hemorrhage.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients admitted with acute ischemic or hemorrhagic stroke that have mRS and NIH Stroke Scale assessments.

    • No single universally accepted stroke mortality prediction score exists.
    • Score is based on data present on admission and is static.
    • Does not apply to patients with transient ischemic attack, subarachnoid hemorrhage, or subdural hemorrhage.
    • Can be applied for both ischemic and hemorrhagic stroke.
    • Component variables are familiar to most clinicians.
    • Can be calculated quickly.
    • Does not necessitate a weighting algorithm.
    • Can be administered by non-MD personnel.
    • Component variables are static over a given hospitalization.

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • The mSOAR Score may be considered in patients with acute stroke, as a predictor of short-term mortality.
    • The score should not be used as a substitute for clinical judgment, or as a sole predictive tool for mortality.

    Management

    Acute ischemic stroke and intracerebral hemorrhage (ICH) are both neurological emergencies. Patients with acute ischemic stroke, in particular, can benefit from time-sensitive treatments (e.g. tPA, mechanical thrombectomy) that can be administered if certain clinical conditions are met.

    In cases of suspected acute ischemic stroke, the following is recommended:

    • STAT neurological consultation.
    • STAT CT head without contrast.
    • STAT laboratory testing (CBC, PT/INR/aPTT, basic metabolic panel, type & screen, troponin-I).
    • Consider STAT CT angiogram of the head & neck in cases of suspected acute stroke due to large-vessel occlusion (LVO).

    In cases of confirmed acute intracerebral hemorrhage, the following is recommended:

    • Airway, breathing and circulation monitoring.
    • Immediate neurological and neurosurgical consultation.
    • Thorough medication history to identify anticoagulant and antiplatelet-associated hemorrhage.
    • Hypertensive patients with ICH should undergo blood pressure reduction with intravenous agents. The target blood pressure should be discussed with neurological or neurosurgical consultants if available.
    • Similarly, the decision to administer reversal agents (e.g. desmopressin, vitamin K), blood products (e.g. prothrombin complex concentrates, fresh frozen plasma), or anti-epileptic medications should not be made without discussion with the neurological or neurosurgical consultant if available.

    Critical Actions

    It is crucial to identify anticoagulant-associated ICH with careful medication history, and reverse with agents specifically tailored to the offending anticoagulant. 

    Platelet transfusion is not recommended in cases of spontaneous antiplatelet-related ICH.

    Formula

    Addition of the selected points:

     

    0 points

    1 point

    2 points

    Stroke type

    Infarct

    Hemorrhage

    --

    Oxford Community Stroke Project classification

    LACS/PACS

    POCS

    TACS

    Age (years)

    ≤65

    66–85

    >85

    Pre-stroke disability (Modified Rankin Score)

    0–2

    3–4

    5

    NIH Stroke Scale Score

    0–4

    5–10

    ≥11

    LACS, lacunar circulation stroke. PACS, partial anterior circulation stroke. POCS, posterior circulation stroke. TACS, total anterior circulation stroke.

    Facts & Figures

    Interpretation:

    mSOAR Score

    Inpatient mortality

    0

    1.0%

    1

    1.0%

    2

    1.5%

    3

    6.5%

    4

    9.2%

    5

    19.5%

    6

    26.2%

    7

    49.2%

    From Abdul-Rahim 2016. Scores >7 were not reported.

    Evidence Appraisal

    The SOAR Score was originally derived by Myint et al in a UK-based prospectively-collected analysis from 2013 that investigated whether 4 static variables at presentation (stroke type, age, premorbid functional status, and Oxfordshire Community Stroke Project (OCSP) classification) accurately predicted early mortality in a multi-center cohort of approximately 12,000, mainly elderly inpatients, who were mostly functionally independent (60%), and had suffered mostly ischemic (91%) and partial anterior-circulation stroke. The AUC for predicting either inpatient or 7-day mortality was 0.79 (95% CI 0.78-0.80). Importantly, this analysis was restricted to inpatient mortality only; stroke severity as measured by the NIH Stroke Scale (NIHSS) was unknown, and functional status was based on medical documentation rather than interview.

    The SOAR Score was then externally validated by Kwok et al in 2013 in an analysis of approximately 3,500 patients, also from a multi-center UK population, with the addition of investigating the predictive ability for 7-day mortality. The SOAR AUC (cut-point of ≥3) for inpatient mortality was 0.80 (95% CI 0.78–0.82) and 7-day mortality was 0.82 (95% CI 0.79-0.84).

    While the derivation and validation cohort populations were relatively similar in terms of the underlying SOAR component variables, approximately 20% of patients in the validation cohort (that had substantially higher rates of hemorrhagic stroke and overall mortality) were excluded due to incomplete data.

    Abdul-Rahim et al derived the mSOAR Score in a retrospective study from 2016 that incorporated baseline NIHSS scores into the SOAR Scores of approximately 1,000 inpatients from two UK-based stroke registries. The study compared both SOAR and mSOAR in their ability to predict mortality within 90 days of admission (rather than during admission). This study also externally validated both the SOAR and mSOAR Scores in an independent 1,000-patient stroke cohort also based in the UK.

    For SOAR, AUC for mortality ≤90 days in the derivation and validation cohorts was 0.79 (95% CI 0.75-0.84) and 0.81 (95% CI 0.77-0.85), respectively. For mSOAR, AUC in the same cohorts were 0.83 (95%CI, 0.79-0.86) and 0.84 (95% CI 0.82-0.88), respectively. The AUCs of SOAR and mSOAR in derivation cohorts were statistically significantly different (p <0.0001), suggesting that the addition of the NIHSS score significantly improved the predictive accuracy of the original SOAR. While quite similar to the original SOAR derivation cohort, both mSOAR derivation and validation cohorts were more functional at baseline (mRS 0-1 84.8% vs 69%), and the comparative stroke severity of the cohort from Myint et al was unknown.

    Dr. Phyo Kyaw Myint

    About the Creator

    Phyo Kyaw Myint, MBBS, MD, FRCP, is the clinical chair in old age medicine at the University of Aberdeen. He is also on the Council of the Scottish Intercollegiate Guidelines Network (SIGN) and a member of the NIHR Dementias Clinical Studies Portfolio Development Group. Dr. Myint’s research interests include cardiovascular and cerebrovascular diseases, physical and mental aging, and clinical geriatrics.

    To view Dr. Phyo Kyaw Myint's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. Phyo Kyaw Myint
    Content Contributors