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

Abstract

Background and Purpose: Early neurological deterioration (END) occurs in 10-40% of acute ischemic stroke (AIS) patients and has been associated with worse outcome. Recent improvements in treatment may have reduced the prevalence of END. A single early control or repeated observations have been applied to detect END close to occurrence, in order to improve the poor outcome associated with END, as clinical interventions may still be effective. Deterioration detected through repeated observations may be transitory or lead to END. Our aim was to study outcome after END and transitory deterioration (TD). Methods: In acute ischemic stroke patients, key Scandinavian Stroke Scale (SSS) items were scored 12 times from admission to 72 h. END was defined as ≥2 point decrease in any key SSS item from admission to 72 h. Early deterioration episode was defined as similar worsening between two consecutive assessments within 72 h, and TD as early deterioration episode in patients without END. Main outcome measures were odds ratios (OR) for worse functional outcome (including death) measured by modified Rankin scale at 90 days for END and TD compared with stable patients. Results: 368 patients were included. 13.9% had END and 28.3% had TD. Both deterioration groups were associated with worse outcome at 12 weeks compared with stable patients, with ORs of 35.1 (95% CI 8.8-140) for death/dependency and 5.8 (95% CI 1.8-19.4) for death in END patients and ORs of 2.3 (95% CI 1.1-4.8) for death/dependency and 1.9 (95% CI 0.5-6.3) for death in patients with TD. LOS increased by 6.4 days for END (p < 0.001) and 1.1 days for TD (p = 0.014) compared with stable patients. Conclusion: We found a strong association between END and worse outcome, and even TD doubled the OR for death/dependency compared to stable patients. Early deterioration episodes identified through frequent observations are therefore clinically significant and such frequent observations may detect worsening sufficiently close to occurrence for potentially effective treatment to be applied.

Early Neurological Deterioration Despite Recanalization in Basilar Artery Occlusion Treated by Endovascular Therapy

“…Our study demonstrated that END was associated with symptomatic hemorrhage and hernia within 7 days and was also associated with poor outcome at 3 months. Similar findings have been consistently reported in previous studies (10,18). There is no significant correlation between extensive brainstem infarction and END.…”

“…According to different severity thresholds and the time scales between assessments, the incidence of END varies widely from study to study. The typical definition of END (8,9) is an increase ≥4 points in the National Institutes of Health Stroke Scale (NIHSS) or death within the first 24 h after stroke, and END affects stroke patients' long-term outcomes (10)(11)(12).…”

Pilot study of volume contracted state and hospital outcome after stroke

“…This is important as early neurologic worsening after stroke has been repeatedly demonstrated to affect longer-term outcome, most recently in an analysis of 368 patients who demonstrated a 35 times increased odds of death or dependency if they demonstrated early neurologic worsening. 32 Different from prior studies, we did not see a high rate of transient neurologic fluctuation in this cohort, as previously reported. 2 Thus, our study provides essential markers to allow us to address persistent questions specific to the relationship between fluid volume and outcomes after stroke.…”

Frailty, Acute Organ Dysfunction, and Increased Disability After Hospitalization in Older Adults Who Survive Critical Illness: A Prospective Cohort Study

“…Some previous studies have shown that delirium duration is associated with worse disability scores at 12 months posthospitalization in critically ill adults 26 but, to our knowledge, no previous prospective cohort studies in the ICU have suggested an association between early acute brain dysfunction and posthospital physical disability outcomes in critically ill older adults in stroke survivors, both delirium and acute brain dysfunction have been previously shown to be an important predictor of physical disability outcomes. 27,28 A strong association between early brain dysfunction in critically ill adults and posthospital physical disability would be consistent with the emerging literature in geriatrics that cognitive function is intricately linked to mobility and physical disability. 29,30 In a clinical trial of early exercise and mobilization in a cohort of adults who were functionally independent prior to enrollment, the mobilization intervention was associated with shorter duration of delirium and improvement in functional outcomes which is consistent with the interconnections between physical and cognitive outcomes in critically ill adults.…”