Worsening in Ischemic Stroke Patients: Is it Time for a New Strategy?

Pearls & Oy-sters

“…Clinical worsening after lacunar infarction has been extensively reported and may result from thrombi propagation, flow limiting arterial lesion supplying the ischemic zone, and perilesional edema. 9,10 We suspect that secondary neuronal degeneration, apoptosis, or abnormal plasticity involving local synaptic interconnections may explain the delay in the development of Ondine's curse after lateral medullary infarction, ranging several days to several months postinfarct. Likewise, hypoxemia secondary to altered automatic breathing in brainstem infarctions with hypercapnia-induced cerebral vasoconstriction can increase ischemia.…”

Lateral medullary syndrome with Ondine's curse

“…The sudden apnea during sleep may be caused by clinical worsening by thrombi propagation, reduced blood flow in the ischemic zone, and perilesional edema [6,7]. Stroke patients with Sleep-Disordered Breathing (SDB) may have potential risk for Ondine's curse as well, because most Ondine's curse occurred in the night-time.…”

Induced-hypertension in progressing lacunar infarction

“…According to previous studies, a history of hypertension itself is a well-known risk factor of motor progression but the mechanism of motor progression in patients with history of hypertension has not yet been elucidated [9,27,28]. In general, patients with a history of hypertension have a right-shifted curve for cerebral blood flow (CBF) autoregulation [29,30].…”

“…The deleterious effects of a sudden drop of blood pressure in acute ischemic stroke have been strongly emphasized due to cerebral autoregulation failure of ischemic tissue [5,6]. In lacunar infarction, early neurological deterioration depends on perfusion failure of regional ischemic tissue [7,8] or a lack of rapid development of adequate collateral blood flow to ischemic zones [9]. Caplan stated a possible mechanism for progressing lacunar infarction is a perfusion failure to ischemic zones [9].…”

“…In lacunar infarction, early neurological deterioration depends on perfusion failure of regional ischemic tissue [7,8] or a lack of rapid development of adequate collateral blood flow to ischemic zones [9]. Caplan stated a possible mechanism for progressing lacunar infarction is a perfusion failure to ischemic zones [9]. Therefore, conventional regimens targeting on mechanisms other than perfusion failure are not beneficial to the brain with inadequate blood flow.…”