A Proposal for the Classification of Etiologies of Neurologic Deterioration after Acute Ischemic Stroke

Abstract

Background Neurologic deterioration (ND) occurs in one third of patients with ischemic stroke and contributes to morbidity and mortality in these patients. Etiologies of ND and clinical outcome according to ND etiology are incompletely understood. Methods We conducted a retrospective investigation of all patients with ischemic stroke admitted to our center (July 2008 to December 2010), who were known to be last seen normal less than 48 hours before arrival. First-time episodes of ND during hospitalization were collected in which a patient experienced a 2-point increase or more in National Institutes of Health Stroke Scale score within a 24-hour period. Proposed etiologies of reversible ND include infectious, metabolic, hemodynamic, focal cerebral edema, fluctuation, sedation, and seizure, whereas new stroke, progressive stroke, intracerebral hemorrhage, and cardiopulmonary arrest were nonreversible. Results Of 366 included patients (median age 65 years, 41.4% women, 68.3% black), 128 (34.9%) experienced ND (median age 69 years, 42.2% women, 68.7% black). Probable etiologies of ND were identified in 90.6% of all first-time ND events. The most common etiology of ND, progressive stroke, was highly associated with poor outcome but not death. Etiologies most associated with mortality included edema (47.8%), new stroke (50%), and intracerebral hemorrhage (42.1%). Conclusions In the present study, the authors identified probable etiologies of ND after ischemic stroke. Delineating the cause of ND could play an important role in the management of the patient and help set expectations for prognosis after ND has occurred. Prospective studies are needed to validate these proposed definitions of ND.

Progression in acute ischemic stroke: Is widespread atherosclerotic background a risk factor?

“…[8,9] The frequency of neurological deterioration in this singlecenter study was 15.4%, which was higher than that of a retrospective study which assessed deteriorations within the first two days [10] and lower than those of two prospective studies (35% and 37%, respectively). [11,12] The studies for early neurological deterioration in non- thrombolyzed patients were found to have frequencies between 13 to 37% [13][14][15][16][17] Our patients with neurological progression had worse NIHSS scores on discharge, compared to non-progressive patients (8 vs 3.7), while the NIHSS scores were not different on admission between these two groups. These findings are consistent with previous reports.…”

Time to Neurological Deterioration in Ischemic Stroke

“…ND was defined as an increase of 2 or more points on a patient's NIHSS within a 24-hour period, as previously described since this threshold has been associated with several poor outcome measures including discharge disability and death. 3 We used previously described etiologies as defined by Siegler et al 21 Patients with ND secondary to progressive stroke, new stroke, or intracerebral hemorrhage were classified as having nonreversible ND due to the fact that these etiologies may produce or extend any areas of ischemic neurologic injury from temporary or permanent impairment in cerebral perfusion (in keeping with our prior definitions). 6,21 Patients with ND secondary to edema, fluctuation in symptoms, seizure, extubation, sedation, or any hemodynamic, toxic, metabolic, or infectious etiology were classified as having a reversible cause of ND.…”

“…3 We used previously described etiologies as defined by Siegler et al 21 Patients with ND secondary to progressive stroke, new stroke, or intracerebral hemorrhage were classified as having nonreversible ND due to the fact that these etiologies may produce or extend any areas of ischemic neurologic injury from temporary or permanent impairment in cerebral perfusion (in keeping with our prior definitions). 6,21 Patients with ND secondary to edema, fluctuation in symptoms, seizure, extubation, sedation, or any hemodynamic, toxic, metabolic, or infectious etiology were classified as having a reversible cause of ND. 21 Several etiologies of clinical deterioration after stroke have been previously investigated, 2,22,23 but this does not encompass all potential causes of ND.…”

“…6,21 Patients with ND secondary to edema, fluctuation in symptoms, seizure, extubation, sedation, or any hemodynamic, toxic, metabolic, or infectious etiology were classified as having a reversible cause of ND. 21 Several etiologies of clinical deterioration after stroke have been previously investigated, 2,22,23 but this does not encompass all potential causes of ND. Selected etiologies of ND for this investigation have been previously described at our center, classified as reversible or nonreversible, and were defined in a codebook prior to data abstraction from medical records in order to reduce the potential for bias.…”

“…Selected etiologies of ND for this investigation have been previously described at our center, classified as reversible or nonreversible, and were defined in a codebook prior to data abstraction from medical records in order to reduce the potential for bias. 6,21 Stroke etiology was defined according to the Trial of Org 10172 for Acute Stroke Treatment (TOAST). 24 Vascular risk factors were defined in keeping with previous definitions.…”