Malnutrition Status May Predict Stroke Outcomes After Intravenous Thrombolysis

Controlling nutritional status score and prognostic nutritional index are reliable predictors of stroke outcomes, such as END, following IVT.

Malnutrition status in patients who experience an acute ischemic may predict stroke outcomes, such as early neurological deterioration (END), following intravenous thrombolysis (IVT). These are the findings of a study published in BMC Neurology.

Nutritional guidelines for patients with acute ischemic stroke receiving IVT are not well defined, despite data showing that nutrition status impacts clinical outcomes. Researchers aimed to determine the relationship between objective nutritional markers and stroke outcomes in patients receiving IVT.

Researchers used a multicenter database to identify patients who experienced acute ischemic strokes treated with IVT. Follow up brain imaging was conducted within 24 hours following IVT.

The database provided demographic, medical, stroke, and laboratory data for all participants. Researchers assessed malnutrition levels using the controlling nutritional status (CONUT) score and the prognostic nutritional index (PNI). The CONUT score was categorized into mild (2-4), moderate (5-8), and severe (9-12) malnutrition.

[T]he different predictive values of CONUT score and PNI highlight the need for constantly updating the IVT strategy and guidelines.

Outcome measures were based on END and were categorized by etiology: symptomatic hemorrhagic transformation (END-SHT) or stroke progression (END-prog) after IVT. In this study, the CONUT cutoff was 5 and the PNI cutoff was 42.3 for END-SHT.

The primary outcome measures were the incidence of END-SHT and the occurrence of hemorrhagic transformation (HT) after IVT.

Of the 10,808 patients experiencing an acute ischemic stroke, 808 patients who received IVT alone were included in the analysis. The average age of participants was 66.7 years and 513 (63.5%) were men. The median CONUT score was 1 (range, 0-2), the median PNI was 52.5 (range, 47.1-57.5), and 39.6% of patients had malnutrition (mild, 34.2%; moderate to severe, 5.4%).

The primary outcome results show that higher CONUT scores are associated with increased occurrence rates of END-SHT (normal, 21 [4.3%]; mild, 9 [3.3%]; moderate to severe, 32 [72.7%]; P <.001) and HT (normal, 46 [9.4%]; mild, 28 [10.1%]; moderate to severe, 32 [72.7%], P <.001).

Lower PNI scores were associated with higher rates of END-SHT when compared with high PNI scores (33 [28.4%] vs 29 [4.2%]; P <.001) and similar trends were observed for HT (33 [28.4%] vs 73 [10.5%]; P <.001). Patients with a low PNI also had increased rates of poor functional outcomes at 3 months when compared to patients with high PNI (70 [60.3%] vs 246 [35.5%]; P <.001].

Factors associated with high CONUT scores were poor functional outcomes at 3 months (normal, 166 [34.0%]; mild, 123 [44.6%]; moderate to severe, 27 [61.4%]) and increased rates of END-prog (normal, 28 [5.7%]; mild, 6 [2.2%]; moderate to severe, 5 [11.4%]).

Based on multivariable analysis, CONUT scores indicating moderate to severe nutritional status showed a significant association with END-SHT (odds ratio [OR],14.52; 95% CI, 3.15-66.95; P =.001) and HT (OR, 9.40; 95% CI, 2.74-32.20; P <.001).

Overall, researchers showed that objective nutritional status measurements, such as CONUT and PNI, are reliable predictors of stroke outcomes following IVT. “Our novel findings showed that the different predictive values of CONUT score and PNI highlight the need for constantly updating the IVT strategy and guidelines,” they noted.

Study limitations include the lack of patient information at later stroke stages or discharge, the inability to access dietary intake and weight change information, and a small sample size of patients with moderate to severe malnutrition.


Kim Y, Lee M, Mo HJ, et al. The association between malnutrition status and hemorrhagic transformation in patients with acute ischemic stroke receiving intravenous thrombolysis. BMC Neurology. Published online March 14, 2023. doi:10.1186/s12883-023-03152-3