Mechanisms, predictors and clinical impact of early neurological deterioration: the protocol of the Trondheim early neurological deterioration study

Abstract

Background10-40% of patients with acute ischemic stroke (AIS) suffer an early neurological deterioration (END), which may influence their long term prognosis. Multiple definitions of END exist, even in recently published papers. In the search for causes, various biochemical, clinical, and imaging markers have been found to be associated to END after AIS in some but not in other studies.The primary aim of this study is to assess the contribution of END to functional level at 3 months post stroke measured by modified Rankin Scale (mRS). Secondary aims are to identify factors and mechanisms associated with END and to define the prevalence, degree and timing of END in relation to stroke onset, and to compare Scandinavian Stroke Scale (SSS) and National Institute of Health Stroke Scale (NIHSS) based END-definitions.We hypothesized that END detected by changes in NIHSS and SSS (according to previously published criteria) at a threshold of 2 points indicate worsened prognosis, and that SSS is not inferior to NIHSS in predicting such a change. We further hypothesized that clinical deterioration has several causes, including impaired physiological homeostasis, vascular pathology, local effects and reactions secondary to the ischemic lesion, along with biochemical disturbances.MethodsSingle-centre prospective observational study.Participants: Previously at home-dwelling patients admitted to our stroke unit within 24 hours after ictus of AIS are included into the study, and followed for 3 months. They are managed according to current procedures and national guidelines. A total of 368 patients are included by the end of the enrolment period (December 31st 2013), and the material will be opened for analysis by June 30th 2014.Frequent neurological assessments, continuous monitoring, and repeated imaging and blood samples are performed in all patients in order to test the hypotheses.DiscussionStrengths and weaknesses of our approach, along with reasons for the methods chosen in this study are discussed.

Outcomes after Early Neurological Deterioration and Transitory Deterioration in Acute Ischemic Stroke Patients

“…In spite of this, we found strong associations between neurological deterioration and prognosis. Further, patients eligible for fibrinolysis were more prone to inclusion [16]. However, adjustments for fibrinolysis did not weaken our findings.…”

“…Stringent inclusion criteria applied to 46 patients [16]. During the main study, approximately 1,150 patients were discharged from the SU with AIS.…”

“…Other central aims in the protocol were to identify predictors and possible mechanisms associated with neurological deterioration after acute ischemic stroke, and also to compare the END definition used in the current study with a 2 point worsening in National Institute of Health Stroke Scale (NIHSS). The detailed protocol has been published elsewhere [16].…”

Decreasing serum 25‐hydroxyvitamin D levels and risk of early neurological deterioration in patients with ischemic stroke

“…Although most ischemic stroke patients tend to improve over the subsequent few days after symptoms onset, a sizeable fraction does not substantially recover but even deteriorates, which has been identified as early neurological deterioration (END) (Seners, Turc, Oppenheim, & Baron, ). Previous studies reported that END after acute ischemic stroke is observed in 5%–40% patients and often leads to an increasing risk of functional disability and mortality (Helleberg, Ellekjær, Rohweder, & Indredavik, ; Kwon, Lee, Bae, & Kang, ; Seners et al., ; Sun et al., ; Zhang et al., ). Accordingly, more precise understanding of the potential mechanisms involved in END could provide valuable insights for improving stroke outcomes.…”

Early Clinical Implications of Microalbuminuria in Patients with Acute Ischaemic Stroke

“…Many clinical trials have suggested that albuminuria should not only be considered as a risk assessment marker but a treatment target [2,4]. END in acute ischaemic stroke is a commonly occurring event and has poor long and short term outcomes [11,12]. The predictors of END (Clinical or Radiological), in acute stroke has been repeatedly studied.…”