Neurofluctuation in patients with subcortical ischemic stroke

Abstract

Objective: The purpose of this study was to assess the incidence of deterioration, fluctuation, and associated risk of poor outcome in patients with subcortical stroke (SCS). Methods:We conducted a prospective observational study, enrolling patients admitted with SCS based on their clinical examination and imaging studies. An NIH Stroke Scale evaluation was performed daily and whenever deterioration in examination was detected. Neurologic deterioration was defined as a motor score increase of at least 1 on the NIH Stroke Scale. Modified Rankin Scale scores at discharge were used to assess outcome.Results: Among 90 enrolled patients, 37 (41%) deteriorated, 75% of them in the first 24 hours after enrollment. Administration of tissue plasminogen activator was significantly associated with deterioration (hazard ratio 2.25; 95% confidence interval [CI]: 1.13-4.49) even after controlling for the association of deterioration with the early poststroke period. Deterioration conferred an increased risk of poor outcome (modified Rankin Scale scores 3-6) at discharge (relative risk: 1.80; 95% CI: 1.71-1.93). Reversion back to predeterioration deficits occurred in 38% of patients, and was associated with reduced risk of poor outcome at discharge (relative risk: 0.12; 95% CI: 0.02-0.83). Treatment with tissue plasminogen activator conferred better chances of spontaneous recovery to predeterioration deficits after initial deterioration (hazard ratio: 4.36; 95% CI: 1.36-14.01). Conclusion:More than 40% of patients with SCS deteriorate neurologically. Deterioration tends to occur early after stroke, spontaneously reverses in approximately one-third of cases, and poses an increased risk of poor outcome. Therapies are needed to prevent, arrest, or reverse deterioration in patients with SCS. Neurology ® 2014;83:398-405 GLOSSARY CI 5 confidence interval; HR 5 hazard ratio; IQR 5 interquartile range; m-NIHSS 5 motor component of the NIH Stroke Scale; mRS 5 modified Rankin Scale; ND 5 neurologic deterioration; NIHSS 5 NIH Stroke Scale; SCS 5 subcortical stroke; tPA 5 tissue plasminogen activator.Neurologic deterioration (ND) occurs in 20% to 40% of patients with acute ischemic stroke, [1][2][3] and is associated with increased morbidity and mortality. 4 Various factors associated with ND have been reported. [5][6][7][8][9][10] Deterioration and fluctuations are particularly characteristic of subcortical strokes (SCS), 11,12 and almost one-third of patients with this particular stroke subtype are left dependent.13 SCS have also been reported as the most likely cause of ND during the first week after stroke onset, with a proportion of patients undergoing neurologic fluctuation estimated to range between 20% and 70%.14 Unfortunately, once deterioration has occurred, there are no effective therapies to arrest or reverse it.Although deterioration and fluctuation are common, there is a lack of prospective data on the natural history and clinical course of neurofluctuation in SCS. The cause of deterioration in these patients is uncer...

Epoxyeicosatrienoic Acids are Mediated by <i>EPHX2</i> Variants and may be a Predictor of Early Neurological Deterioration in Acute Minor Ischemic Stroke

“…In the present study, we did not observe such an association. Our results were consistent with one recent study in the literature 5 ) . However, these findings must be validated in larger, multi-center studies in the future.…”

“…Previous studies have reported the prevalence of END to be approximately 21%–50% in patients with MIS 4 , 5 ) . Using this estimate, we calculated a minimum sample-size requirement of 310 patients for determining the true incidence rate within ± 15% with 95% confidence.…”

“…END is a common occurrence in patients with minor ischemic stroke (MIS) 3 , 4 ) . Studies have shown that 21% to 50% of MIS patients suffer from END during the 7–10 days after stroke onset 4 , 5 ) , and approximately 15% to 30% of these patients were dead or disabled at the time of 3-month follow-up, despite mild symptoms at presentation 6 ) . The underlying mechanisms of this association are not completely understood, although biochemical factors associated with END have been reported 7 , 8 ) .…”

Imaging Parameters and Recurrent Cerebrovascular Events in Patients With Minor Stroke or Transient Ischemic Attack

“…Recurrent TIA was included given its inclusion in prior risk-stratification scores 11 as an important outcome; neurological deterioration was included given evidence that it can cause long-term disability 14 and was used in prior TIA-S clinical trials. 4 Recurrent TIA-S included new neurological symptoms in the absence of hemorrhage on brain imaging, not attributable to any other medical condition and confirmed clinically or by imaging.…”

Matrix metalloproteinase‐9 gene polymorphisms are associated with ischemic stroke severity and early neurologic deterioration in patients with atrial fibrillation

“…Early neurological deterioration (END) is fairly common in patients with acute IS, and is associated with increased morbidity and mortality (Vahidy et al, 2014;Yi, Han, Zhou, Lin, & Liu, 2016). It is very important to investigate the mechanisms of END, and prevent this detrimental event.…”