Very early neurological deterioration after thrombolysis in patients with acute ischemic stroke

Abstract

BackgroundEarly neurological deterioration within 24 h after thrombolysis in patients with acute ischemic stroke (AIS) is associated with poor outcomes. Evidence is lacking regarding neurological deterioration within 1 h after thrombolysis.MethodsPatients who received intravenous thrombolysis with tissue plasminogen activator (tPA) for AIS between January 2018 and December 2021 were consecutively enrolled. Very early neurological deterioration (VEND) was defined as a ≥ 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score within 1 h after starting thrombolysis compared with the pre-treatment score. A modified Rankin Scale score of 3–6 at 3 months was defined as a poor functional outcome.ResultsOf the 353 AIS patients (age 69.7 ± 13.3 years, 57% men) receiving thrombolysis with tPA, 29 (8.4%) had VEND. VEND was associated with symptomatic intracranial atherosclerotic disease (ICAD) (41% vs. 17%,P= 0.005) and was an independent predictor of poor functional outcomes at 3 months (adjusted odds ratio 3.04,P= 0.043). The VEND group had higher NIHSS scores at 1 h (19.2 ± 7.3 vs. 9.0 ± 7.1,P< 0.001) and 24 h (14.1 ± 9.8 vs. 7.3 ± 7.5,P= 0.001) after initiating tPA than the non-VEND group. In patients with an initial NIHSS score < 6, VEND was significantly associated with ICAD, receiving endovascular thrombectomy (EVT), and poor functional outcomes. In patients with VEND, EVT with successful recanalization led to lower NIHSS scores at 24 h than in those without successful recanalization (12 ± 9 vs. 26 ± 7,P= 0.047), and 24-h NIHSS scores predicted poor functional outcomes.ConclusionsIn patients receiving thrombolysis, VEND was independently associated with poor functional outcomes. Identifying VEND is crucial for underlying ICAD and salvageability by EVT. Successful recanalization by EVT effectively reduced 24-h stroke severity in patients with VEND.