Stroke recovery patterns and predictors in India: a post-hoc analysis from the ATTEND trial

Background: Functional recovery after stroke remains poor in India. However, only few data exist on stroke recovery using the modified Rankin Scale (mRS). We aimed to assess patterns and predictors of stroke recovery from a cohort of participants with acute stroke of mild to moderate severity in India.  Methods:  Post-hoc analysis of the Family-led Rehabilitation after Stroke in India (ATTEND), a multicentre, prospective, randomised, open blinded endpoint (PROBE) trial conducted at 14 hospitals in India. Data were obtained on the modified Rankin Scale (mRS) at baseline, 3 and 6 months. A multivariable partial proportional logistic regression model was used to identify the predictors of recovery after stroke and reported as odds ratio (aOR) and 95% confidence intervals (CI).  Results:  Of 1,250 randomised participants, 1156 had sufficient data for analysis. Overall, the severity of mRS decreased over time; the mean change in mRS [mean (SD] was- 0.96 (1.40) between baseline and 3 months and -0.30(0.83) between 3 months and 6 months. Overall, 66.7% improved on their stroke symptoms at 3 months compared to baseline. Further, 34% improved their stroke symptoms at 6 months compared to 3 moths. A higher mRS score at 6 months was associated with participants aged 40-60 years (1.84, 95% CI 1.16 - 2.93), and >60 years (2.83, 1.69 - 4.75) at stroke onset compared to those aged <40 years, having daughter or daughter in law (1.44, 1.01 - 2.06) as the main caregiver compared to spouse, being dependent at home (4.93, 1.61 - 15.14) compared to being independent at home, and receiving treatment in Assam (2.43, 1.35 - 4.37), Kerala (3.52, 2.13 - 5.81), Tamil Nadu (2.76, 1.74 - 4.37), Chandigarh (1.93, 1.05 - 3.55), and Hyderabad (2.00, 1.12 - 3.58) compared to Delhi. Regarding clinical variables, not having disability (>3 mRS) at baseline (0.19, 0.12 - 0.30), and lower stroke severity scores: NIHSS 0 - <5 (0.07, 0.04 - 0.12), 5 - <10 (0.20, 0.13 - 0.30) and 10 - <15 (0.59, 0.39 - 0.88) compared to higher scores (≥15) were associated with lower mRS scores at 6 months.  Conclusions:  Nearly 67% of patients recovered at 3 months compared to baseline, consistent with previous research. Additional follow-up at six months showed that 48% sustained their previous functional status and 34% reported improvement between 3 and 6 months. These findings also highlight that both demographic and clinical factors significantly influence recovery outcomes in patients with mild to moderate stroke severity.