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DRAGON Score for Post-TPA Stroke Outcome

Calculators  Neurology
The DRAGON Score for Post-TPA Stroke Outcome is a tool utilized to help predict 90 day clinical outcomes in patients with ischemic stroke receiving intravenous thrombolysis (tPA), using only data that is available shortly after hospital arrival.
Early Infarct on CT/Hyperdense Cerebral Artery
No 0
Either 1
Both 2
Age
<65 0
65-79 1
>=80 2
Glucose at Baseline>144 mg/dL (8 mmol/L)
No 0
Yes 1
Treatment time >90 minutes
No 0
Yes 1
Baseline National Institutes of Health Stroke Scale
0-4 0
5-9 1
10-15 2
>=16 3
Result:

Background

Measured Factor
The DRAGON Score
Measured Factor Disease
  • Good clinical outcomes even if given intravenous thrombolysis (tPA)
  • Miserable clinical outcomes even if given intravenous thrombolysis (tPA)
Measured Factor Detail
The DRAGON Score is utilized to predict 90 day clinical outcomes for ischemic stroke patients using only information that is available shortly after they arrive at the hospital. It can help predict which patients are likely to have good clinical outcomes and those who are likely to have miserable clinical outcomes even if given intravenous thrombolysis (tPA), which can help when weighing the risks and benefits of administering tPA. A DRAGON Score of 0 - 10, along with an mRS Score of 0 - 2, indicates good clinical outcomes. A DRAGON Score of 0 - 10, along with an mRS Score of 5 - 6, indicates miserable clinical outcomes.
Speciality
Multi-Speciality
Body System
Neurology
Measured Factor Low Impact
  • A patient with a DRAGON score of 0, along with an mRS score of 0 - 2, is likely to have good clinical outcomes even if given intravenous thrombolysis (tPA).
Measured Factor High Impact
  • A patient with a DRAGON score of 10, along with an mRS score of 5 - 6, is likely to have miserable clinical outcomes even if given intravenous thrombolysis (tPA).

Result Interpretation

Ranges Ranges
  • Critical High: DRAGON Score of 0 - 10 AND mRS Score of 5 - 6
  • Normal: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
  • Normal Adult Male: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
  • Normal Adult Female: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
  • Normal Pediatric: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
  • Normal Neonate Female: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
  • Normal Geriatric Male: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
  • Normal Geriatric Female: DRAGON Score of 0 - 10 AND mRS Score of 0 - 2
Result Low Conditions
  • Good clinical outcomes even if given intravenous thrombolysis (tPA)
Result High Conditions
  • Miserable clinical outcomes even if given intravenous thrombolysis (tPA)
Test Limitations
The study has some limitations. Although the study was controlled for known stroke outcome predictors, it could not rule out the possibility that additional baseline variable (unmeasured confounds) may have some impact. The score does not apply to patients with basilar artery occlusion who were excluded from the study because of the marked difference in their natural history and treatment protocol. Another limitation was the small size of the external validation cohort, and the score has to be further evaluated in other centers. The interrater reliability of the DRAGON score was not assessed, but assessment is warranted in future studies. However, they believed that there was little variability in their center because of the standardized training process in the stroke research unit.
References: 1

Studies

Study Validation 1
A retrospective cohort analysis was performed in stroke patients receiving IV-tPA within the 4.5 hour time window from January 2009 to September 2013. A total of 149 patients were included in the analysis. DRAGON scores were calculated for each patient and compared to modified Rankin scores (mRS) at 90-day follow up. Comparison of baseline patient characteristics to the original derivation cohort was made using Chi Square derived p-values for analysis where appropriate. Validity of the model was determined using area under the receiver operating characteristic (ROC) curve analysis for good and bad outcomes. Proportions of patients with good outcomes (mRS of 0-2) were 100%, 89%, 75%, 5%, 0% and 0% for DRAGON Scores 0-1, 2, 3, 7, 8 and 9-10 respectively. Proportions of patients with miserable outcomes (mRS of 5-6) were 0%, 5%, 4%, 82%, 100%, 80% for DRAGON Scores 0-1, 2, 3, 7, 8 and 9-10 respectively. AUC-ROC was 0.93 for our model. When using the score to evaluate only good or bad outcomes the AUC-ROC was 0.88 and 0.89, respectively. Despite statistically significant differences in baseline characteristics in this North American cohort compared to the derivation cohort, the DRAGON score model remains a reliable stratification tool with good predictive value.
References: 2
Study Validation 2
The present study calculated the ASTRAL and DRAGON scores in 36 131 and 33 716 patients, respectively, registered in Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register between 2003 and 2013. The proportion of patients with 3-month modified Rankin Scale scores of 3 to 6 was observed for each scale point and compared with the predicted proportion according to the risk scores. Calibration was assessed using calibration plots, and predictive performance was assessed using area under the curve of the receiver operating characteristic. Multivariate logistic regression coefficients for the variables in the 2 scores were compared with the original derivation cohorts. The ASTRAL showed an area under the curve of 0.790 (95% confidence interval, 0.786-0.795) and the DRAGON an area under the curve of 0.774 (95% confidence interval, 0.769-0.779). All ASTRAL parameters except range of visual fields and all DRAGON parameters were significantly associated with functional outcome in multivariate analysis. The ASTRAL and DRAGON scores show an acceptable predictive performance.
References: 3
Study Validation 3
Prospectively collected data of consecutive ischemic stroke patients who received intravenous thrombolysis in 12 stroke centers were merged (n=5471). The study excluded patients lacking data necessary to calculate the score and patients with missing 3-month modified Rankin scale scores. The final cohort comprised 4519 eligible patients. The study then assessed the performance of the DRAGON score with area under the receiver operating characteristic curve in the whole cohort for both good (modified Rankin scale score, 0-2) and miserable (modified Rankin scale score, 5-6) outcomes. Area under the receiver operating characteristic curve was 0.84 (0.82-0.85) for miserable outcome and 0.82 (0.80-0.83) for good outcome. Proportions of patients with good outcome were 96%, 93%, 78%, and 0% for 0 to 1, 2, 3, and 8 to 10 score points, respectively. Proportions of patients with miserable outcomes were 0%, 2%, 4%, 89%, and 97% for 0 to 1, 2, 3, 8, and 9 to 10 points, respectively. When tested separately for anterior and posterior circulation, there was no difference in performance (P=0.55); areas under the receiver operating characteristic curve were 0.84 (0.83-0.86) and 0.82 (0.78-0.87), respectively. No sex-related difference in performance was observed (P=0.25). The DRAGON score showed very good performance in the large merged cohort in both anterior and posterior circulation strokes. The DRAGON score provides rapid estimation of patient prognosis and supports clinical decision-making in the hyperacute phase of stroke care (eg, when invasive add-on strategies are considered).
References: 4
Study Additional 1
In this study, consecutive (2009-2013) anterior circulation stroke patients treated within 4.5 hours by IV-tPA in the Lille stroke unite (France), where MRI is the first-line pretherapeutic work-up, were reviewed. The discrimination and calibration of the MRI-DRAGON score to predict poor 3-month outcome, defined as modified Rankin Score >2, using c-statistic and the Hosmer-Lemeshow test, respectively, were then assessed. 230 patients (mean +/-SD age 70.4+/-16.0 years, median [IQR] baseline NIHSS 8 [5]-[14]; poor outcome in 78(34%) patients) were included in the study. The c-statistic was 0.81 (95%CI 0.75-0.87), and the Hosmer-Lemeshow test was not significant (p=0.54). The MRI-DRAGON score showed good prognostic performance in the external validation cohort. It could therefore be used to inform the patient's relatives about long-term prognosis and help to identify poor responders to IV-tPA alone, who may be candidates for additional therapeutic strategies, if they are otherwise eligible for such procedures based on the institutional criteria.
References: 5
Study Additional 2
This study aims to validate the DRAGON score in an Australian Safe Implementation of Treatment in Stroke (SITS) cohort and further refine parameters to enhance its prognostic power. A retrospect review of 1561 thrombolysis patients (853 male, 708 female) was performed from 15 Australian hospitals registered in the SITS registry between 2004 and June 2013. Relevant pre-treatment DRAGON score variables and 3 month outcome data were available for 1172 patients (649 male, 523 female). Further refinement of the score was achieved via analysis to estimate effect of independent variable on good versus miserable outcome. Logistic regression with clustering (with respect to different participating hospitals and their location) was used to derive the improved DRAGON score. Further comparison of the DRAGON scores was conducted by means of the receiver operating characteristic curve approach. As a result of the conducted logistic regression analysis, the original DRAGON score has been validated and refined (including the new weights for the considered risk factors) in the Australian context of a SITS cohort.
References: 6
Study Additional 3
A retrospective chart review of patients treated at our institution from February 2009 to October 2015 was conducted. All patients with computed tomography angiography (CTA) proven large vessel occlusions (LVO) who underwent intravenous thrombolysis and endovascular therapy were included. Baseline DRAGON scores and modified Rankin Score (mRS) at the time of hospital discharge was calculated. Good outcome was defined as mRS ≤3. Fifty-eight patients with LVO of the anterior circulation were studied. The mean DRAGON score of patients on admission was 5.3 (range, 3-8). All patients received IV tPA and endovascular therapy. Multivariate analysis demonstrated that DRAGON scores ≥7 was associated with higher mRS (P < 0.006) and higher mortality (P < 0.0001) compared with DRAGON scores ≤6. Patients with DRAGON scores of 7 and 8 on admission had a mortality rate of 3.8% and 40%, respectively. The DRAGON score can help predict better functional outcomes in ischemic stroke patients receiving both IV tPA and endovascular therapy. This data supports the use of the DRAGON score in selecting patients who could potentially benefit from more invasive therapies such as endovascular treatment. Larger prospective studies are warranted to further validate these results.
References: 7

Authors

Daniel Strbian
MD, PhD, University of Helsinki Central Hospital in Finland
Active researcher in the field of ischemic stroke, Practicing Neurologist
Research Interests: https://www.researchgate.net/profile/Daniel_Strbian

References

  1. Strbian D, Meretoja A, Ahlhelm FJ, Pitkäniemi J, Lyrer P, Kaste M, et al. Predicting outcome of IV thrombolysis-treated ischemic stroke patients: the DRAGON score. Neurology. 2012 Feb 7;78(6):427-32.
  2. Ermak DM, Adams C, Reichwein R, Bettermann K. Validation of the DRAGON Score in a North American Cohort. J Neurol Disord Stroke. 18 Dec 2014; 3(1): 1093.
  3. Cooray C, Mazya M, Bottai M, Dorado L, Skoda O, Toni D, et al. External Validation of the ASTRAL and DRAGON Scores for Prediction of Functional Outcome in Stroke. Stroke. 1 Apr 2018; 47 (6): 1493-9.
  4. Strbian D, Seiffge DJ, Breuer L, Numminem H, Michel P, Meretoja A, et al. Validation of the DRAGON Score in 12 Stroke Centers in Anterior and Posterior Circulation. Stroke. 2013;44:2718-2721.
  5. Turc G, Aguettaz P, Ponchelle-Dequatre N, Hénon H, Naggara O, Leclerc X, et al. External Validation of the MRI-DRAGON Score: Early Prediction of Stroke Outcome after Intravenous Thrombolysis. PLoS One. 4 Jun 2014; 9(6): e99164.
  6. Mushtaq U, Gramotnev G, Jannes J. Validation of the DRAGON score in an Australian Safe Implementation of Treatment in Stroke (SITS) cohort. Nov 2014;21(11):2041-2042.
  7. Wang A, Pednekar N, Lehrer R, Todo A, Sahni R, Marks S, et al. DRAGON score predicts functional outcomes in acute ischemic stroke patients receiving both intravenous tissue plasminogen activator and endovascular therapy. Surg Neurol Int. 2017; 8: 149.