What is the PLAN score?

The PLAN score is a bedside prediction rule for adults hospitalized with acute ischemic stroke. The acronym stands for Preadmission comorbidities, Level of consciousness, Age, and Neurologic deficit. It estimates the probability of death and severe disability (modified Rankin Scale 5–6) using variables available at admission without advanced imaging scores.

PLAN was developed and validated in consecutive acute ischemic stroke admissions from the Registry of the Canadian Stroke Network. The score ranges from 0 to 25, with higher totals associated with progressively worse 30-day mortality, 1-year mortality, and combined death or severe dependence at discharge in the original registry cohorts.

PLAN is a prognostic tool for counseling, disposition planning, and risk communication. It must not be used to support or withhold intravenous thrombolysis, endovascular therapy, or other standard-of-care reperfusion treatments.

Clinical context: prognostication after ischemic stroke

Stroke teams routinely need early estimates of course to guide goals-of-care discussions, rehabilitation planning, and family expectations. NIHSS quantifies deficit severity but does not alone incorporate pre-stroke dependence, selected comorbidities, and age in a single mortality-calibrated index. PLAN was designed as a simple additive model that can be completed at the bedside within minutes of admission.

The primary derivation and validation analyses focused on patients not treated with thrombolysis in the registry era studied. Performance may differ in modern thrombolysis and thrombectomy cohorts, lacunar stroke subtypes, and centers with different case mix. External validation outside the Canadian registry is limited; apply population percentages cautiously to individuals.

Score structure (maximum 25 points)

PLAN sums four domains. Several items use fractional points (1.5) as published in the original rule.

P: Preadmission comorbidities (maximum 5 points)

• Preadmission dependence (+1.5): patient required assistance with activities of daily living before the stroke (not independent at baseline).
• Cancer (+1.5): documented history of malignancy.
• Congestive heart failure (+1): history of CHF.
• Atrial fibrillation (+1): history of AF (whether or not it is the presumed stroke mechanism).

These items capture frailty and cardiac comorbidity associated with worse recovery trajectories independent of the acute deficit.

L: Level of consciousness (+5 if reduced)

Award 5 points when level of consciousness is reduced compared with normal alertness at admission assessment. Reduced consciousness is a dominant driver of PLAN totals and correlates strongly with early mortality and poor functional outcome in registry analyses.

Apply consistent definitions with your local stroke scale documentation (for example somnolence, stupor, or coma on the admitting exam). Do not double-count isolated inattention without altered arousal unless your protocol maps that finding to reduced consciousness per PLAN instructions.

A: Age (+1 per decade, maximum 10)

Age contributes 1 point per decade using the floor of age divided by 10 (for example age 64 → 6 points; age 72 → 7 points), capped at 10 points (ages 100+ still contribute 10). This stepwise age term reflects increasing mortality and dependence with advancing age in the cohort.

N: Neurologic deficit (maximum 5 points)

• Arm weakness, significant or total (+2): not mild weakness; for comprehension deficits, limb power unequal to the contralateral side counts as weakness per the original rule.
• Leg weakness, significant or total (+2): same severity threshold as arm weakness.
• Neglect or aphasia (+1): either neglect or aphasia satisfies this single combined item (not double-counted if both are present).

Mild weakness alone does not meet the threshold. PLAN neurologic items are simplified compared with full NIHSS itemization but align with bedside screening for major cortical and motor deficits.

Total score and risk bands

PLAN total = preadmission comorbidities + level of consciousness + age points + neurologic deficit

This calculator also assigns three risk strata used for summary messaging:

PLAN total	Risk stratum	Clinical framing
< 10	Lower risk	In the derivation cohort, scores under 10 identified a lower-risk group with roughly 2% in-hospital death or mRS 5–6 at discharge among those with score <10.
10–15	Intermediate risk	Progressively higher observed mortality and severe disability rates across the registry.
> 15	Higher risk	Associated with a high burden of death or severe dependence at discharge (about 64% in the combined cohort for scores above 15).

Observed outcomes by score (validation cohort)

The table below reports cohort percentages from the combined derivation/validation registry (primary analysis without thrombolysis). Individual patients may differ substantially. The CalcMD calculator looks up the row matching the rounded total score.

PLAN score	30-day mortality	1-year mortality	Death or mRS 5–6 at discharge
<6	0.7%	2.1%	0.9%
6	1.9%	4.8%	1.2%
7	1.4%	4.5%	1.3%
8	2.1%	6.4%	2.5%
9	4.4%	13.1%	4.3%
10	4.4%	16.2%	6.0%
11	7.6%	21.7%	9.8%
12	10.9%	26.3%	14.8%
13	15.3%	32.0%	20.3%
14	21.7%	42.2%	30.7%
15	29.3%	46.0%	35.8%
16	35.4%	57.7%	43.9%
17	42.5%	63.3%	54.4%
18	50.5%	74.3%	65.0%
19	61.2%	73.8%	73.2%
>19	65.9%	83.6%	78.4%

Notice the steep rise in adverse outcomes from the low teens upward. A score of 18, for example, maps to roughly half 30-day mortality and two-thirds death or severe disability at discharge in these registry estimates.

How PLAN compares with NIHSS and other tools

NIHSS remains the standard measure of acute neurologic severity and is required for thrombolysis documentation and many trial endpoints. PLAN incorporates age, baseline dependence, selected comorbidities, and a simplified motor/cortical deficit scheme rather than the full 15-item NIHSS scale.

PLAN does not include imaging variables (ASPECTS, infarct volume), blood glucose, or physiologic parameters. It is intentionally lightweight for admission prognostication when imaging is pending or when teams want a mortality-calibrated number alongside NIHSS.

Do not treat PLAN and NIHSS as interchangeable: a patient may have moderate NIHSS with high PLAN because of age, cancer, and reduced consciousness, or conversely a young patient with dense hemiparesis but low comorbidity burden.

Appropriate uses at admission

• Prognostic counseling: frame expected ranges of mortality and severe disability using cohort percentages, with explicit uncertainty.
• Disposition and goals of care: higher scores may prompt early palliative care involvement when consistent with patient values (PLAN does not dictate limitations).
• Quality and research: risk-adjust outcomes across sites when variable definitions are standardized.
• Serial reassessment: stroke trajectory may change after admission; repeat neurologic examination and imaging may refine prognosis beyond the admission PLAN snapshot.

Important exclusions and limitations

• Not validated for intracerebral hemorrhage in the primary PLAN publications; apply only to acute ischemic stroke unless local evidence supports broader use.
• Thrombolysis era: reduced precision reported for lacunar stroke and post-thrombolysis subgroups; modern reperfusion may alter observed event rates relative to historical registry percentages.
• Does not replace neuroimaging, vessel imaging, or specialist assessment for etiology and treatment eligibility.
• Must not withhold reperfusion: a high PLAN score is not a contraindication to IV alteplase or endovascular therapy when guidelines and imaging support treatment.
• Documentation: record how weakness severity, neglect, aphasia, and consciousness were determined to improve reproducibility.

Using this CalcMD calculator

Enter age and answer each yes/no item. The tool computes domain subtotals (preadmission comorbidities, neurologic deficit), the PLAN total (0–25), the validation-cohort outcome row (30-day mortality, 1-year mortality, death or mRS 5–6 at discharge), and the lower, intermediate, or higher risk stratum. Use the output for education and structured documentation alongside NIHSS, imaging, and clinical judgment.