For healthcare professionals
ASTRAL Score for 3-Month Outcome After Ischemic Stroke
The ASTRAL score adds points for six findings at admission for acute ischemic stroke: age, stroke severity on the NIH Stroke Scale (NIHSS), time from symptom onset to admission, a visual field defect, acute glucose and level of consciousness. It was built to predict an unfavourable outcome, a modified Rankin Scale (mRS) score over 2, at 3 months. This tool is written for clinicians. It is not a self-check and not a diagnosis.
The six items
Variables and points as printed by Drozdowska and colleagues (Drozdowska 2019). The short notes are our own. Nothing you enter leaves this page.
You can work out the NIHSS with our NIHSS calculator.
What you will see
The ASTRAL score and the points from each item.
Educational only, not medical advice. A score supports clinical judgment; it does not decide treatment on its own.
Source
Ntaios G et al., Neurology 2012 (the original score, cited only). Variables and points as printed in Drozdowska BA et al., Front Neurol 2019 (CC BY), Table 4; the same six items and the outcome also in Mainali S et al., Neurocrit Care 2026 (CC BY).
Validated in
Derived in the Acute Stroke Registry and Analysis of Lausanne (Switzerland, single center, January 2003 to July 2010; patients with pre-stroke mRS over 2 excluded), 1,645 patients; validated in cohorts from Athens and Vienna (Drozdowska 2019). For adults with acute ischemic stroke.
Limits
For clinicians, not a diagnosis. It uses admission findings only and does not account for thrombectomy or other treatment, pre-stroke dependency, imaging or events in hospital (Mainali 2026). The probability for each score is not shown here; see the original paper. The open source gives 1 point per every 5 years of age and states that an integer score is assigned, but it does not print how age is rounded. When age is not a multiple of 5 we show the total as a range, from age divided by 5 rounded down to rounded up (for example, 72 years gives 14 or 15 points). Use it with, not instead of, clinical judgment.
How the score works
The ASTRAL score uses six input variables to predict an unfavourable functional outcome at 3 months (mRS over 2): age, stroke severity on the NIHSS, time from symptom onset to admission, range of visual fields, acute glucose and level of consciousness (Drozdowska 2019). A 2026 guideline lists the same six predictors and defines poor functional outcome as an mRS score of 3 to 6 at 90 days (Mainali 2026). The score was first described by Ntaios and colleagues (Ntaios 2012). The points below are as printed in Table 4 of Drozdowska and colleagues (Drozdowska 2019).
| Variable | Level or category | Points |
|---|---|---|
| Acute glucose | Below 3.7 or above 7.3 mmol/L | 1 |
| Age | Per every 5 years | 1 |
| Any stroke-related visual field defect | Yes | 2 |
| Level of consciousness | Decreased | 3 |
| Symptom onset to admission time | Over 3 hours | 2 |
| Stroke severity (NIHSS) | Per every point | 1 |
Table 4 of that review labels the time item "symptom onset to treatment time"; the text of the same review describes it as time from symptom onset to admission (Drozdowska 2019).
What the score predicts
In the derivation cohort, 559 of 1,645 patients (34%) had an mRS of 3 to 6 at 3 months, and the area under the ROC curve was 0.85 (Drozdowska 2019). The derivation paper also reported validation in two independent cohorts from Athens and Vienna, with AUROC values of 0.94 and 0.77 (Drozdowska 2019). The original paper gives the probability of an unfavourable outcome for each score (Ntaios 2012). We do not show those figures, because we could not find them printed in two open sources.
How well it performed and its limits
Seven studies have externally validated the ASTRAL score; of the six that reported AUROC values, all but one found fair to good discrimination, and one Brazilian cohort had an AUROC of 0.67 (Drozdowska 2019). A 2026 guideline on prognosis after acute ischemic stroke in critically ill adults reported C statistics of 0.73 to 0.94. It suggests that the ASTRAL score not be considered a reliable predictor of poor functional outcome at 3 months or later when counseling these patients or their surrogates, a weak recommendation (Mainali 2026). Its main reason is that the score uses admission variables only and does not consider thrombectomy or other effective treatment (Mainali 2026).
Related calculators
To score stroke severity, see the NIH Stroke Scale calculator. To grade disability before and after a stroke, see the modified Rankin Scale. For other outcome scores after ischemic stroke, see the THRIVE score and the DRAGON score. Other bedside scores are listed under For healthcare professionals.
Sources
- Ntaios G, Faouzi M, Ferrari J, Lang W, Vemmos K, Michel P. An integer-based score to predict functional outcome in acute ischemic stroke: the ASTRAL score. Neurology. 2012;78(24):1916-1922. doi:10.1212/WNL.0b013e318259e221. PMID 22649218. Original score (cited only). doi.org/10.1212/WNL.0b013e318259e221
- Drozdowska BA, Singh S, Quinn TJ. Thinking about the future: a review of prognostic scales used in acute stroke. Front Neurol. 2019;10:274. doi:10.3389/fneur.2019.00274. PMID 30949127. Open access (CC BY). Table 4: ASTRAL variables and points; Table 2 and text: derivation (1,645 patients, mRS 3-6 at 3 months in 559, 34%, AUROC 0.85), Athens and Vienna validation (AUROC 0.94 and 0.77), external validation studies. pmc.ncbi.nlm.nih.gov/articles/PMC6437031/
- Mainali S, Fontaine GV, Rajajee V, Montellano FA, Muehlschlegel S, Wartenberg KE, et al. Guidelines for neuroprognostication in critically ill adults with acute ischemic stroke. Neurocrit Care. 2026;44(3):745-769. doi:10.1007/s12028-026-02486-3. PMID 41942818. Open access (CC BY). ASTRAL: six predictors, poor outcome mRS 3-6 at 90 days, C statistic 0.73-0.94, weak recommendation that it not be considered a reliable predictor. pmc.ncbi.nlm.nih.gov/articles/PMC13249629/
Written and maintained by the uncovermyrisk.com editorial team. We do not have a medical reviewer; every claim links to its primary source above. Last reviewed: 2026-11-04. Spotted an error? See About.