neurology

ASTRAL Score for Ischaemic Stroke Outcome Prediction

ASTRAL (Acute STroke Registry and Analysis of Lausanne) score predicts unfavourable functional outcome (modified Rankin Scale 3-6) at 3 months after ischaemic stroke. Based on 6 variables assessed at admission. Score 0-50; higher score = worse outcome. AUC 0.85 for predicting poor outcome. Validated by Ntaios et al. 2012 in 1,645 patients. Useful for early prognostication and goals of care discussions.

Age (years) -- each year adds 1 point (up to 50 points max in original but we use age directly)*(years)

NIHSS score at admission (divided by 5 for score contribution -- see formula)*(NIHSS points)

Time from symptom onset to admission (hours)*

Visual field defect (hemianopia or quadrantanopia on NIHSS item 3)*

Admission glucose*

Reduced level of consciousness at admission (NIHSS level of consciousness item 1a above 0)*

Score interpretation

Lower Risk of Unfavourable Outcome (ASTRAL below 25) 0–24

ASTRAL below 25 -- more favourable stroke outcome predicted

→ Optimistic but not certain prognosis; pursue active stroke management (thrombolysis/thrombectomy if eligible, stroke unit care); secondary prevention: antiplatelets (aspirin 300 mg then 75 mg OD or clopidogrel 75 mg OD), statin (atorvastatin 40-80 mg OD), antihypertensives; SWALLOW screen before oral intake; physiotherapy, occupational therapy, speech therapy assessment; early supported discharge if eligible; document ASTRAL score and prognosis discussion in notes; patient and family goals of care discussion.

Moderate Risk of Unfavourable Outcome (ASTRAL 25-34) 25–34

ASTRAL 25-34 -- intermediate risk of poor 3-month outcome

→ Discuss prognosis with patient/family in sensitive and non-deterministic terms (score is probabilistic, not absolute); pursue all eligible acute treatments (thrombolysis, mechanical thrombectomy if LVO); stroke unit admission; SWALLOW screen; intensive multidisciplinary rehabilitation (physiotherapy, OT, SALT); dysphagia management; urinary continence support; early palliative care liaison if patient frail; DNACPR discussion if appropriate; 3-month mRS review as goal; secondary prevention medications; social work assessment for discharge planning.

High Risk of Unfavourable Outcome (ASTRAL 35 or above) ≥ 35

ASTRAL 35 or above -- high probability of poor functional outcome at 3 months (above 80% chance mRS 3-6)

→ Frank but compassionate goals of care discussion with patient (if capacity) and family; not preclude active treatment -- thrombectomy/thrombolysis if eligible regardless of ASTRAL; ASTRAL helps frame discussions, not withhold treatment; if palliative approach: comfort-focused care, dysphagia management (speech therapy), PEG consideration only if agreed by patient/family and prognosis uncertain; DNACPR and ceiling of treatment; palliative care referral early; stroke specialist nurse support for family; nursing home placement planning; document all discussions and MDT decisions.

Interpretation bands for the ASTRAL Score. Apply clinical judgement and local guidance.

References

Ntaios G et al. An integer-based score to predict functional outcome in acute ischemic stroke: the ASTRAL score. Neurology. 2012;78(24):1916-1922.
NICE NG128. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE. 2019 (updated 2023).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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