Deteriorating Ischemic Stroke in 4 Clinical Categories Classified by the Oxfordshire Community Stroke Project

Abstract

Background and Purpose-The aim of this study was to investigate the frequency, possible predictive factors, and prognosis of deteriorating ischemic stroke in 4 clinical categories according to the classification of the Oxfordshire Community Stroke Project (OCSP). Methods-A total of 350 patients with first-ever ischemic stroke who presented within 24 hours of onset were enrolled.Based on the OCSP criteria, cerebral infarctions were divided into the following 4 clinical categories: total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), lacunar infarcts (LACI), and posterior circulation infarcts (POCI). Clinical deterioration was defined as a decrease of Ն1 points in the Canadian Neurological Scale (CNS) (in TACI, PACI, and LACI) or Rankin Scale (RS) (in POCI) during 7 days from the onset. In each clinical category, deteriorating (D) and nondeteriorating (ND) patients were compared in terms of their background characteristics, risk factors, vital signs, laboratory data, and cranial CT at the time of hospitalization. The acute-phase mortality and functional outcome were also compared. Results-The subjects comprised 86 patients (24.6%) with TACI, 63 (18.0%) with PACI, 141 (40.3%) with LACI, and 60 (17.1%) with POCI. Overall, 90 patients (25.7%) deteriorated. The frequency was very high in TACI (41.9%), followed by LACI (26.2%) and POCI (21.7%), whereas it was very low in PACI (6.3%). There were some clinical variables that differed significantly between D and ND groups. In the patients with TACI, early abnormalities of the cranial CT and significant stenoses in corresponding arteries were more frequent in the D than the ND group. In those with LACI, the CNS and hematocrit were lower in the D than the ND group. In those with POCI, cerebral atrophy was more severe and significant stenoses in vertebrobasilar arteries were more frequent in the D than ND group. The mortality of the D groups of patients with TACI and POCI exceeded 35%, and the functional outcome was worse in the D group than in the ND group of patients with TACI, LACI, and POCI. Conclusions-The frequency of deterioration in acute ischemic stroke significantly differed among the OCSP subgroups, and deterioration worsened the prognosis. There were some factors that could predict deterioration: early CT findings in TACI, large-artery atherosclerosis in TACI and POCI, and stroke severity in LACI. Further research to find sophisticated radiological and chemical markers appears to be needed.

Multimodal CT Provides Improved Performance for Lacunar Infarct Detection

“…The frequency and significance of perfusion abnormality in LI was previously addressed in several small series. [26][27][28] One of the largest studies (22 patients) demonstrated MTT abnormality in 68.2% of LIs, comparing favorably with 61% in the present series.…”

“…Other smaller studies report perfusion abnormality in 0% 26,28 to 100% 14 of cases. Clinically, perfusion abnormality in LI was previously shown to be associated with the persistence of symptoms beyond 24 hours.…”

“…8,13,14 Early clinical deterioration occurs in 27%-62% of LI cases and is not reliably predicted clinically. 26,28 Perfusion abnormality absence was highly predictive of clinical stability in 1 study, while one-third of patients with perfusion abnormality experienced clinical deterioration. 14 Yamada et al 13 demonstrated higher MTT ratios and lower CBF ratios in patients experiencing clinical deterioration.…”

Worsening in Ischemic Stroke Patients: Is it Time for a New Strategy?

“…4 Among 350 Japanese patients in one study, 25% progressed after admission; worsening in the hospital occurred in 26% of lacunar stroke patients. 5 A number of studies focused on progression and worsening in series of patients with lacunar strokes. In a Spanish study of 225 lacunar infarct patients, the deficit accrued within hours in 50.5% and within days in 16%.…”

Stroke severity, early recovery and outcome are each related with clinical classification of stroke: Data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’ (TAIST)

“…14 Clinical classification is also predictive of the risk of deterioration, with TACS having the greatest risk and LACS the least; deterioration is associated with a worse prognosis. 15 The relationship between clinical classification and degree and timing of stroke recovery is less clear, and has been further examined here using data from the 'Tinzaparin in Acute Ischaemic Stroke Trial' (TAIST). 16 …”