{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T05:04:46Z","timestamp":1789362286774,"version":"build-2803163510"},"reference-count":18,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T00:00:00Z","timestamp":1789344000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The main limitation of the National Institutes of Health Stroke Scale (NIHSS) is the underestimation of clinical severity in posterior circulation (PC) strokes, which has been hypothesized to contribute to diagnostic delay and to reduce eligibility for reperfusion treatments in some patients. We aimed to evaluate the diagnostic performance of a previously developed modified version of the NIHSS, the Expanded NIHSS (e-NIHSS), for clinical assessment and outcome prediction in patients with anterior circulation (AC) and PC strokes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Prospective observational study of 249 consecutive stroke patients admitted to a Comprehensive Stroke Center during 1 year. NIHSS and e-NIHSS were administered by two independent examiners within 48\u202fh of onset. The primary outcome measure was an unfavorable outcome, defined as a modified Rankin Scale score of 3 to 6 at 3\u202fmonths. The discriminative performance of the e-NIHSS to predict unfavorable outcome was evaluated by calculating the area under the receiver operating characteristic curve (AUC-ROC).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The inter-rater reliability of the e-NIHSS between the two independent observers was excellent (intraclass correlation coefficient, 0.992 [95% CI 0.990\u20130.994]). The mean e-NIHSS score was higher than the mean classical NIHSS score (\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001). An unfavourable outcome at 3\u202fmonths was detected in 113 (45%) patients. The e-NIHSS showed a discriminative performance to predict unfavorable functional outcome comparable to the classical NIHSS for the total amount of strokes (AUC-ROC of the e-NIHSS for the first observer, 0.867 [95% CI, 0.823\u20130.911]; AUC-ROC of the e-NIHSS for the second observer, 0.871 [95% CI, 0.827\u20130.914]; AUC-ROC of the classical NIHSS, 0.849 [95% CI, 0.802\u20130.897]), AC strokes (AUC-ROC of the e-NIHSS for the first observer, 0.886 [95% CI, 0.841\u20130.932]; AUC-ROC of the e-NIHSS for the second observer, 0.892 [95% CI, 0.848\u20130.936]; AUC-ROC of the classical NIHSS, 0.870 [95% CI, 0.821\u20130.920]), and PC strokes (AUC-ROC of the e-NIHSS for the first observer, 0.800 [95% CI, 0.685\u20130.916]; AUC-ROC of the e-NIHSS for the second observer, 0.791 [95% CI, 0.672\u20130.910]; AUC-ROC of the classical NIHSS, 0.804 [95% CI, 0.689\u20130.920]). Net reclassification improvement, integrated discrimination improvement, and decision curve analysis showed a modest apparent incremental prognostic benefit of the e-NIHSS over the classical NIHSS in the whole cohort and in AC strokes, but not in PC strokes.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Compared to the classical NIHSS, the e-NIHSS showed a similar discriminative performance to predict 3-month functional outcome, capturing and quantifying additional PC-relevant clinical signs not fully represented in the classical NIHSS, with excellent inter-rater reliability.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fneur.2026.1788839","type":"journal-article","created":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T04:36:04Z","timestamp":1789360564000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Diagnostic performance of the expanded National Institutes of Health Stroke Scale for the assessment of anterior and posterior circulation strokes"],"prefix":"10.3389","volume":"17","author":[{"given":"Stefano","family":"Forlivesi","sequence":"first","affiliation":[{"name":"IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital","place":["Bologna, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Balbarini","sequence":"additional","affiliation":[{"name":"Local Health Authority of Modena, General Practice","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guido","family":"Bigliardi","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"D\u2019Amico","sequence":"additional","affiliation":[{"name":"Unit of Statistical and Methodological Support to Clinical Research, Azienda Ospedaliero-Universitaria","place":["Modena, Italy"]},{"name":"Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca","family":"Rosafio","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Vandelli","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Luisa","family":"Dell\u2019Acqua","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federica","family":"Casoni","sequence":"additional","affiliation":[{"name":"Local Health Authority of Modena, Healthcare Management","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefano","family":"Meletti","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital","place":["Modena, Italy"]},{"name":"Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Milena","family":"Cavazzuti","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital","place":["Modena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Zini","sequence":"additional","affiliation":[{"name":"IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital","place":["Bologna, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,14]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"864","DOI":"10.1161\/01.str.20.7.864","article-title":"Measurements of acute cerebral infarction: a clinical examination scale","volume":"20","author":"Brott","year":"1989","journal-title":"Stroke"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"603","DOI":"10.1016\/S1474-4422(06)70495-1","article-title":"Clinical interpretation and use of stroke scales","volume":"5","author":"Kasner","year":"2006","journal-title":"Lancet Neurol"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1159\/000016006","article-title":"Interrater reliability of the National Institutes of Health stroke scale: rating by neurologists and nurses in a community-based stroke incidence study","volume":"9","author":"Dewey","year":"1999","journal-title":"Cerebrovasc Dis"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"660","DOI":"10.1001\/archneur.1989.00520420080026","article-title":"Interrater reliability of the NIH stroke scale","volume":"46","author":"Goldstein","year":"1989","journal-title":"Arch Neurol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"2371","DOI":"10.1212\/01.wnl.0000304346.14354.0b","article-title":"Baseline NIH stroke scale score predicting outcome in anterior and posterior circulation strokes","volume":"70","author":"Sato","year":"2008","journal-title":"Neurology"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1159\/000358869","article-title":"Lower NIH stroke scale scores are required to accurately predict a good prognosis in posterior circulation stroke","volume":"37","author":"Inoa","year":"2014","journal-title":"Cerebrovasc Dis"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1161\/STROKEAHA.116.013432","article-title":"Clinical outcomes of posterior versus anterior circulation infarction with low National Institutes of Health stroke scale scores","volume":"48","author":"Kim","year":"2017","journal-title":"Stroke"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1001\/jama.2018.8496","article-title":"Effect of Alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: the PRISMS randomized clinical trial","volume":"320","author":"Khatri","year":"2018","journal-title":"JAMA"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"2135","DOI":"10.1001\/jama.2023.7827","article-title":"Dual antiplatelet therapy vs Alteplase for patients with minor nondisabling acute ischemic stroke: the ARAMIS randomized clinical trial","volume":"329","author":"Chen","year":"2023","journal-title":"JAMA"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"2597","DOI":"10.1016\/S0140-6736(24)00921-8","article-title":"Tenecteplase versus standard of care for minor ischaemic stroke with proven occlusion (TEMPO-2): a randomised, open label, phase 3 superiority trial","volume":"403","author":"Coutts","year":"2024","journal-title":"Lancet"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1016\/S0140-6736(24)01820-8","article-title":"Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis","volume":"405","author":"Nogueira","year":"2025","journal-title":"Lancet"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"3187","DOI":"10.1161\/STROKEAHA.125.051485","article-title":"Effectiveness of endovascular treatment for acute mild basilar artery occlusion stroke: a multicenter real-world study","volume":"56","author":"Xiao","year":"2025","journal-title":"Stroke"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"2953","DOI":"10.1016\/j.jstrokecerebrovasdis.2016.08.011","article-title":"E-NIHSS: an expanded National Institutes of Health stroke scale weighted for anterior and posterior circulation strokes","volume":"25","author":"Olivato","year":"2016","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1521","DOI":"10.1016\/0140-6736(91)93206-o","article-title":"Classification and natural history of clinically identifiable subtypes of cerebral infarction","volume":"337","author":"Bamford","year":"1991","journal-title":"Lancet"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1161\/01.str.24.1.35","article-title":"Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. TOAST. trial of org 10172 in acute stroke treatment","volume":"24","author":"Adams","year":"1993","journal-title":"Stroke"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"317","DOI":"10.1016\/j.clineuro.2006.12.008","article-title":"A new scale for assessing patients with vertebrobasilar stroke-the Israeli Vertebrobasilar stroke scale (IVBSS): inter-rater reliability and concurrent validity","volume":"109","author":"Gur","year":"2007","journal-title":"Clin Neurol Neurosurg"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1561","DOI":"10.1016\/j.jstrokecerebrovasdis.2019.03.005","article-title":"DEFENSIVE stroke scale: novel diagnostic tool for predicting posterior circulation infarction in the emergency department","volume":"28","author":"Yamada","year":"2019","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1247","DOI":"10.1161\/STROKEAHA.120.034019","article-title":"Posterior National Institutes of Health stroke scale improves prognostic accuracy in posterior circulation stroke","volume":"53","author":"Alemseged","year":"2022","journal-title":"Stroke"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1788839\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T04:36:07Z","timestamp":1789360567000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1788839\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,14]]},"references-count":18,"alternative-id":["10.3389\/fneur.2026.1788839"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1788839","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,14]]},"article-number":"1788839"}}