Early Neurologic Deterioration in Lacunar Stroke

Abstract

Objective.To determine the rate and predictors of early neurological deterioration (END) in patients with lacunar strokes as well as its implications for management and outcome.Methods.We enrolled consecutive patients with MRI-defined lacunar stroke who presented within 12 hours after symptom onset from a prospective stroke database (2015-2019). END was defined as any persisting increase in National Institutes of Health Stroke Scale (NIHSS) score of ≥2 points within 24 hours after admission and favorable outcome as modified Rankin Scale (mRS) of 0-2 at 90 days. We assessed the association of END with clinical and imaging variables, acute treatment and outcome using multivariable regression, calculating adjusted odds ratios.Results.Sixty-one of 365 (16.7%) patients with acute lacunar stroke (median age 71.8 years, 39.5% female, median NIHSS score on admission 3) had END. Lower NIHSS score on admission (per point, aOR 0.81, p=0.006), capsular warning syndrome (aOR 7.00, p<0.001), ventral pontine infarct (aOR 3.49, p=0.008) and hypoperfusion on imaging (aOR 2.13, p=0.026) were associated with END. Acute dual antiplatelet therapy was associated with reduced risk of END (aOR 0.10, p=0.04). Patients with END had less favorable outcome at 90 days (aOR 0.13 p<0.001), but intravenous thrombolysis (IVT) was associated with favorable outcome at 90 days (aOR 3.95, p=0.002).Conclusion.One in six patients with lacunar stroke has END and patients at high risk of END can be identified using radiological and clinical variables. Targeted therapeutic trials for this population seem justified.Classification of evidence.This study provides Class II evidence that early neurologic deterioration in patients with acute lacunar stroke predicts poorer functional outcome at 90 days as determined by the modified Rankin Scale.

Risk factors for early neurologic deterioration in single small subcortical infarction without carrier artery stenosis: predictors at the early stage

“…To ensure the homogeneity of the study subjects, patients with cranial MRI findings were included, and patients with moderate-to-severe carotid artery stenosis, cardiogenic embolism, and stroke due to other etiologies were excluded. The results indicated that about one in six patients developed END, which was in line with the findings of another MR-based study [ 4 ] and indicated that END was not rare in patients with SSSI.…”

“…A binomial logistic regression model was utilized to assess the association between variables and END. The variables imported into the univariate regression analysis were obtained from characteristics with between-group differences in baseline data ( P ≤ 0.1) and the probable risk factors of END that were confirmed in previous studies [age, gender, location in corona radiata, infarction in internal capsule and brainstem [ 4 , 13 , 14 ]; BAD [ 12 ]; visible layers on DWI [ 15 ]; history of diabetes [ 16 ]; blood pressure on admission [ 17 ]; leukocyte count [ 18 ]; glucose [ 19 ]; hypertriglyceridemia [ 20 ]; D-dimer and uric acid [ 21 ]; BUN/CR ratio [ 22 ] and D-dimer [ 23 ]. A multivariate logistic regression model was used to analyze possible independent factors for END and poor function outcome at 3-month after the onset using variables with P ≤ 0.1 in the univariate analysis.…”

“…This phenomenon is called early neurological deterioration (END) [ 3 ]. END is generally associated with less favorable outcomes than patients without deterioration [ 4 ]. Therefore, it is essential to assess the risk factors and prevention of END.…”

The Potential Impact of Neuroimaging and Translational Research on the Clinical Management of Lacunar Stroke

“…Other studies (extending the time for thrombolysis in emergency neurological deficits trial, ECASS IV-ExTEND), based on penumbra quantification using CT perfusion, demonstrated the efficacy of IV thrombolysis in stroke with large volume, thus excluding patients with small subcortical infarcts [173]. Future studies should assess which perfusion maps are most accurate for selecting patients with small perfusion deficits for reperfusion in the extended time window, including those with mild symptoms and focal hypoperfusion, in the territory of a perforating artery that might be at risk of neurological deterioration [174].…”

“…A post hoc analysis of the CHANCE trial showed that patients with multiple strokes had lower stroke recurrences than those with a single stroke (about half of them were classified as lacunar strokes), which benefited more from DAPT vs. ASA alone [180]. Some observational studies showed that DAPT is safe in patients with lacunar infarct and early neurological deterioration, even in those who received IV tPA, and seemed to improve the functional outcomes [174,181,182]. In the SPS3 trial, patients treated with DAPT had a risk of major bleeding, compared to ASA alone, but this difference was due to extracranial hemorrhage and mainly occurred after one year of DAPT.…”