Progression in Lacunar Stroke Is Related to Elevated Acute Phase Parameters

Abstract

Background and Purpose: Despite the small size of lacunar infarcts, progression of neurological deficits is a common problem in this stroke subtype. This investigation studied the frequency and the course of neurological deterioration as well as predictors and possible underlying pathomechanisms of early progression in lacunar stroke. Methods: Fourty-six consecutive patients with acute lacunar stroke were prospectively evaluated by daily clinical neurological examination including the National Institutes of Health Stroke Scale (NIHSS) and follow-up using the Barthel Index after 3 months. Progressive neurological deficit was defined as worsening by ≧1 point in the NIHSS for motor function. Progressive and stable patients were compared regarding clinical profile, inflammatory parameters (leukocytes, body temperature, C-reactive protein), coagulation parameters (fibrinogen, D-dimer, vWF, PTT), and glutamate plasma concentration, as well as blood glucose and blood pressure. Results: Eleven patients (23.9%) showed progression of stroke symptoms, 9 of these within the first 24 h after admission. The score on the NIHSS on admission was similar in patients with progressive stroke and stable patients, but significantly higher in the progressive stroke group on days 2 (p = 0.01), 3 (p = 0.001) and at discharge (p = 0.003). Deterioration was significantly associated with a higher leukocyte count (p = 0.012), higher body temperature (p = 0.031) and a higher fibrinogen concentration (p = 0.046) on admission. Barthel Index at discharge (p = 0.001) and after 90 days (p < 0.001) was significantly worse in the progressive stroke group. Conclusions: Progression in lacunar stroke usually occurs within 24 h and may be related to an acute-phase response. The long-term prognosis of progressive stroke patients is persistently worse compared with patients with nonprogressive stroke.

What Change in the National Institutes of Health Stroke Scale Should Define Neurologic Deterioration in Acute Ischemic Stroke?

“…12 Currently, clinical studies use inconsistent definitions of ND with differing stroke scales in order to quantify clinical worsening over days, [13][14][15][16] weeks, 17 or months 18 ( Table 1). Some definitions of ND might be too narrow 19,20 and may exclude patients whose neurologic function may be recoverable, while other definitions may be too broad 14,21 and could prompt the unnecessary work-up of false-positive episodes of ND. While each of these definitions may relate to clinically significant outcome measures, hardly any are reused in other studies.…”

Neuroimaging Markers for Early Neurologic Deterioration in Single Small Subcortical Infarction

“…Previous studies have usually been limited to retrospective data collection and smaller sample sizes. 5,8,[10][11][12]14,16,[27][28][29][30] From our research experience in collecting the acute complications of acute stroke cases, 21 we established detailed definitions and protocols about END and successfully implemented these into our daily clinical practice. When a nursing staff member or duty resident detected END, the information was readily spread via a texting service to the on-duty doctors and attending physicians.…”

“…4,[8][9][10][11][12][13][14][15][16] However, these studies were conflicting and mostly conducted in a retrospective manner. A potential breakthrough about this issue may come from a detailed analysis of imaging findings that implicate 2 different pathological processes that contribute to the occurrence of SSSIs.…”

Induced-hypertension in progressing lacunar infarction

“…There has been no clear explanation on the mechanism of progressing lacunar infarction and motor recovery after induced hypertension [5,[22][23][24][25]. Nevertheless, there is a case report of the benefit of induced-hypertension, which early neurological deterioration due to perfusion defect in a progressing large artery territory infarction was restored [6].…”