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

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.06.012Get rights and content

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.

Introduction

Neurologic deterioration (ND) is common after ischemic stroke, occurring in up to one third of all patients. Nearly half of the patients who experience ND will do so within the first 48 hours of the index stroke,1, 2, 3 and this significantly contributes to morbidity and mortality.2, 4, 5

The distinction between and definitions for etiologies of ND have not yet been described. Certain structural changes may contribute to potentially nonreversible worsening neurologic status after stroke (eg, focal cerebral edema and hemorrhagic transformation); however, other systemic issues may introduce secondary structural damage or may transiently disrupt neurologic function (eg, infection and metabolic abnormalities). Primary (cerebral) causes of ND may only be amenable to reperfusion and recanalization, but the permanence of secondary (systemic) damage–producing ND is not clearly elucidated. Secondary neurologic damage may be mitigated by early recognition and intervention, as is potentially the case for infection with fever and leukocytosis during episodes of ND.6

In the present study, we propose standard definitions for ND etiology and analyze the clinical outcomes associated with specific ND etiologies. We expect that this information will aid neurologists in identifying the cause of ND in acute stroke and provide the patient and their families with more accurate prognostic information and provide uniform definitions for classifying ND in subsequent investigations.

Section snippets

Patient Population

We conducted a single-center retrospective analysis of all consecutive patients who presented with acute ischemic stroke between July 2008 and December 2010 using a prospective registry.7 Patients were excluded if they experienced an in-hospital stroke, presented more than 48 hours after last seen normal, or had an unknown time of last seen normal because ND is more likely to occur earlier after the cerebrovascular event and is the target for neuroprotection.8 ND was defined as the first

Results

Of 596 patients screened, 366 met inclusion criteria (median age 65 years, 41.4% women, 68.3% black). One hundred twenty-eight (34.9%) experienced at least 1 episode of ND (median age 69 years, 42.2% women, 68.7% black). Demographic information comparing patients with and without ND are displayed in Table 2.

Discussion

In the present study, we have identified likely causes of first-time ND following acute ischemic stroke in more than 90% of all cases. The most common etiology of ND was progressive stroke, occurring 38.3% of the time and among 13.4% of the total population of ischemic stroke patients studied. ND because of edema was the most frequently observed in cardioembolic strokes (40.9% of all cases of edema). However, there were no other clinically significant relationships between stroke etiology and

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    Sources of funding: The project described was supported by award numbers 5 T32 HS013852-10 from the Agency for Healthcare Research and Quality, 3 P60 MD000502-08S1 from the National Institute on Minority Health and Health Disparities, National Institutes of Health, and 13PRE13830003 from the American Heart Association. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality, American Heart Association, or the National Institutes of Health.

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