Does Transcranial Magnetic Stimulation Have an Added Value to Clinical Assessment in Predicting Upper-Limb Function Very Early After Severe Stroke?

Maurits H J Hoonhorst, Rinske H M Nijland, Peter J S van den Berg, Cornelis H Emmelot, Boudewijn J Kollen, Gert Kwakkel, Maurits H J Hoonhorst, Rinske H M Nijland, Peter J S van den Berg, Cornelis H Emmelot, Boudewijn J Kollen, Gert Kwakkel

Abstract

Background: The added prognostic value of transcranial magnetic stimulation (TMS)-induced motor-evoked potentials (MEPs) to clinical modeling for the upper limb is still unknown early poststroke.

Objective: To determine the added prognostic value of TMS of the adductor digiti minimi (TMS-ADM) to the clinical model based on voluntary shoulder abduction (SA) and finger extension (FE) during the first 48 hours and at 11 days after stroke.

Methods: This was a prospective cohort study with 3 logistic regression models, developed to predict upper-limb function at 6 months poststroke. The first model showed the predictive value of SA and FE measured within 48 hours and at 11 days poststroke. The second model included TMS-ADM, whereas the third model combined clinical and TMS-ADM information. Differences between derived models were tested with receiver operating characteristic curve analyses.

Results: A total of 51 patients with severe, first-ever ischemic stroke were included. Within 48 hours, no significant added value of TMS-ADM to clinical modeling was found ( P = .369). Both models suffered from a relatively low negative predictive value within 48 hours poststroke. TMS-ADM combined with SA and FE (SAFE) showed significantly more accuracy than TMS-ADM alone at 11 days poststroke ( P = .039).

Conclusion: TMS-ADM showed no added value to clinical modeling when measured within first 48 hours poststroke, whereas optimal prediction is achieved by SAFE combined with TMS-ADM at 11 days poststroke. Our findings suggest that accuracy of predicting upper-limb motor function by TMS-ADM is mainly determined by the time of assessment early after stroke onset.

Keywords: TMS; prognosis; rehabilitation; stroke; upper extremity.

Conflict of interest statement

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Flowchart for recruitment of first-ever, cortical ischemic hemispheric stroke patients within 48 hours and follow-up combined with dropout at 11 days, and 3 and 6 months poststroke.
Figure 2.
Figure 2.
Receiver operating characteristic (ROC) curve plots for the 3 prediction models to predict upper-limb motor function within 48 hours poststroke. In the first model (blue line), the predictive value of transcranial magnetic stimulation–induced motor-evoked potentials of the adductor digiti minimi muscle (TMS-ADM) was investigated. The second model (green line) included clinical assessments alone, using voluntary shoulder abduction (SA) and finger extension (FE), whereas in the third model (red line) the variables SA, FE, and TMS-ADM were combined.
Figure 3.
Figure 3.
Receiver operating characteristic (ROC) curve plots for the 3 prediction models to predict upper-limb motor function at 11 days poststroke. In the first model (blue line), the predictive value of transcranial magnetic stimulation–induced motor-evoked potentials of the adductor digiti minimi muscle (TMS-ADM) was investigated. The second model (green line) included clinical assessments alone, using voluntary shoulder abduction (SA) and finger extension (FE), whereas in the third model (red line) the variables SA, FE, and TMS-ADM were combined.

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