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Progressing Neurological Deficit Secondary to Acute Ischemic Stroke: A Study on Predictability, Pathogenesis, and Prognosis

Progressing Neurological Deficit Secondary to Acute Ischemic Stroke: A Study on Predictability,... Abstract Objectives: To identify predictors and possible pathogenetic mechanisms of early neurological deterioration in patients with acute ischemic strokes and to evaluate their impact on clinical outcome. Design: Case series. Setting: University hospital's stroke unit. Patients: A continuous series of 152 patients with firstever ischemic hemispheric strokes were hospitalized within 5 hours of onset, evaluated with the Canadian Neurological Scale, and underwent a computed tomographic (CT) scan. The initial subset of 80 patients also underwent angiography. A repeated CT scan or autopsy was performed within 5 to 9 days of a patient's stroke. Progressing neurological deficit was defined as a decrease of one point or more in the global neurological scale score during hospitalization, when compared with that at entry. Results: The conditions of 39 patients (26%) deteriorated during the initial 4 days; 20 patients (51%) had an impaired level of consciousness, and 19 patients (49%) had impaired limb strength and/or speech. They had been hospitalized earlier and had higher serum glucose levels at admission; the baseline CT scans of these patients showed an early focal hypodensity and initial mass effect more frequently. On the repeated CT scan (144 patients) or at autopsy (eight patients), patients with a progressing course more frequently had large infarcts, severe mass effect, and hemorrhagic infarction. We found no differences with regard to demographic data, medical history, and treatments that were given; only subcutaneous heparin calcium was more frequently administered to patients with a progressing course. Twenty-two (27%) of the 80 patients who underwent angiography had a progressing course, of whom 20 (91%) had an intracranial and/or extracranial arterial occlusion, with collateral blood supply in seven patients (35%). Logistic regression analysis showed that the independent predictors of progression were the serum glucose levels at admission and the early focal hypodensity with cortical and corticosubcortical locations, with the positive predictive values of the latter being 34% (95% confidence interval [CI], 26% to 42%) and 57% (95% CI, 47% to 67%), respectively. Among patients who underwent angiography, logistic regression analysis showed a significant correlation between carotid siphon occlusion and a progressing course. The 30-day case-fatality ratio and disability (Barthel index, <60) were higher in patients with a progressing course (36% and 54% vs 12% and 35%, respectively). Conclusions: Early stroke deterioration is still an event that is difficult to predict; it is largely determined by cerebral edema following an arterial occlusion, as indicated by an early focal hypodensity and initial mass effect on the baseline CT scan. Since early deterioration anticipates a bad outcome in 90% of patients, it might be used as an early surrogate end point in therapeutic trials. References 1. Jones HR, Millikan CH. Temporal profile (clinical course) of acute carotid system cerebral infarction . Stroke . 1976;7:64-71.Crossref 2. Jones HR, Millikan CH, Burton AS. Temporal profile (clinical course) of acute vertebrobasilar system cerebral infarction . Stroke . 1980;11:173-177.Crossref 3. Baker RN, Broward JA, Fang HC, et al. Anticoagulant therapy in cerebral infarction . Neurology . 1962;12:823-835.Crossref 4. Britton MD, Rödén A. Progression of stroke after arrival at hospital . Stroke . 1985;16:629-632.Crossref 5. Mohr JP, Caplan LR, Melsky JW, et al. The Harvard cooperative stroke registry: a prospective registry . Neurology . 1978;28:754-762.Crossref 6. Dávalos A, Cendra E, Teruel J, Martinez M, Genis D. Deteriorating ischemic stroke: risk factors and prognosis . Neurology . 1990;40:1865-1869.Crossref 7. Sterman AB, Furlan AJ, Pessin M, Kase C, Caplan L, Williams G. Acute stroke therapy trials: an introduction to recurring design issues . Stroke . 1987;18: 524-527.Crossref 8. Pulsinelli W. Pathophysiology of acute ischemic stroke . Lancet . 1992;339:533-536.Crossref 9. Warlow C. Disorders of the cerebral circulation . In: Walton J, ed. Brain's Diseases of the Nervous System . New York, NY: Oxford University Press Inc; 1993: 197-268. 10. Duke RJ, Bloch RF, Turpie AGG, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progressing in acute partial stable stroke: a randomized controlled trial . Ann Intern Med . 1986;105:825-828.Crossref 11. Kittner SJ, Sharkness CM, Price TR, et al. Infarcts with a cardiac source of embolism in the NINCDS stroke data bank: historical features . Neurology . 1990; 40:281-284.Crossref 12. Mahoney FJ, Barthel DW. Functional evaluation: the Barthel index . Md Med J . 1965;21:61-65. 13. Coté R, Hachinski VC, Shurvell BL, Norris IW, Wolfson C. The Canadian Neurological Scale: a preliminary study in acute stroke . Stroke . 1986;17:731-737.Crossref 14. Tomura N, Uemura K, Inugami A, Fujita H, Higano S, Shishido F. Early CT finding in cerebral infarction: obscuration of the lentiform nucleus . Radiology . 1988;168:463-467.Crossref 15. Okada Y, Yamaguchi T, Minematsu K, et al. Hemorrhagic transformation in cerebral embolism . Stroke . 1989;20:598-603.Crossref 16. Damasio H. A computed tomography guide to the identification of cerebral vascular territories . Arch Neurol . 1983;40:138-142.Crossref 17. Brott T, Marler JR, Olinger CP, et al. Measurements of acute cerebral infarction: lesion size by computed tomography . Stroke . 1989;20:871-875.Crossref 18. Fieschi C, Argentino C, Lenzi GL, Sacchetti ML, Toni D, Bozzao L. Clinical and instrumental evaluation of patients with ischemic stroke within the first six hours . J Neurol Sci . 1989;91:311-322.Crossref 19. Saito I, Segawa H, Shiokawa Y, Taniguchi M, Tsutsumi K. Middle cerebral artery occlusion: correlation of computed tomography and angiography with clinical outcome . Stroke . 1987;18:863-868.Crossref 20. Price TR. Progressing ischemic stroke . In: Barnett HJM, Stein BM, Mohr JP, Yatsu FM, eds. Stroke Pathophysiology, Diagnosis, and Management . New York, NY: Churchill Livingstone Inc; 1986:1059-1068. 21. Toni D, Sacchetti ML, Argentino C, et al. Does hyperglycaemia play a role on the outcome of acute ischemic stroke patients? J Neurol . 1992;239:382-386. 22. Toni D, De Michele M, Fiorelli M, et al. Influence of hyperglycaemia on infarct size and clinical outcome of acute ischemic stroke patients with intracranial arterial occlusion . J Neurol Sci . 1994;123:129-133.Crossref 23. Berger L, Hakim AM. The association of hyperglycemia with cerebral edema in stroke . Stroke . 1986;17:865-871.Crossref 24. Horowitz SH, Zito JL, Donnarumma R, Patel M, Alvir J. Computed tomographicangiographic findings within the first five hours of cerebral infarction . Stroke . 1991;22:1245-1253.Crossref 25. Von Kummer R, Meyding-Lamadé U, Forsting M, et al. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk . AJNR Am J Neuroradiol . 1994;15:9-15. 26. Rogvi-Hansen B, Boysen G. Intravenous glycerol treatment of acute stroke: a statistical review . Cerebrovasc Dis . 1992;2:11-13.Crossref 27. Bozzao L, Angeloni U, Bastianello S, Fantozzi LM, Pierallini A, Fieschi C. Early angiographic and CT findings in patients with hemorrhagic infarction in the distribution of the middle cerebral artery . AJNR Am J Neuroradiol . 1991;12: 1115-1121. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Neurology American Medical Association

Progressing Neurological Deficit Secondary to Acute Ischemic Stroke: A Study on Predictability, Pathogenesis, and Prognosis

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9942
eISSN
1538-3687
DOI
10.1001/archneur.1995.00540310040014
Publisher site
See Article on Publisher Site

Abstract

Abstract Objectives: To identify predictors and possible pathogenetic mechanisms of early neurological deterioration in patients with acute ischemic strokes and to evaluate their impact on clinical outcome. Design: Case series. Setting: University hospital's stroke unit. Patients: A continuous series of 152 patients with firstever ischemic hemispheric strokes were hospitalized within 5 hours of onset, evaluated with the Canadian Neurological Scale, and underwent a computed tomographic (CT) scan. The initial subset of 80 patients also underwent angiography. A repeated CT scan or autopsy was performed within 5 to 9 days of a patient's stroke. Progressing neurological deficit was defined as a decrease of one point or more in the global neurological scale score during hospitalization, when compared with that at entry. Results: The conditions of 39 patients (26%) deteriorated during the initial 4 days; 20 patients (51%) had an impaired level of consciousness, and 19 patients (49%) had impaired limb strength and/or speech. They had been hospitalized earlier and had higher serum glucose levels at admission; the baseline CT scans of these patients showed an early focal hypodensity and initial mass effect more frequently. On the repeated CT scan (144 patients) or at autopsy (eight patients), patients with a progressing course more frequently had large infarcts, severe mass effect, and hemorrhagic infarction. We found no differences with regard to demographic data, medical history, and treatments that were given; only subcutaneous heparin calcium was more frequently administered to patients with a progressing course. Twenty-two (27%) of the 80 patients who underwent angiography had a progressing course, of whom 20 (91%) had an intracranial and/or extracranial arterial occlusion, with collateral blood supply in seven patients (35%). Logistic regression analysis showed that the independent predictors of progression were the serum glucose levels at admission and the early focal hypodensity with cortical and corticosubcortical locations, with the positive predictive values of the latter being 34% (95% confidence interval [CI], 26% to 42%) and 57% (95% CI, 47% to 67%), respectively. Among patients who underwent angiography, logistic regression analysis showed a significant correlation between carotid siphon occlusion and a progressing course. The 30-day case-fatality ratio and disability (Barthel index, <60) were higher in patients with a progressing course (36% and 54% vs 12% and 35%, respectively). Conclusions: Early stroke deterioration is still an event that is difficult to predict; it is largely determined by cerebral edema following an arterial occlusion, as indicated by an early focal hypodensity and initial mass effect on the baseline CT scan. Since early deterioration anticipates a bad outcome in 90% of patients, it might be used as an early surrogate end point in therapeutic trials. References 1. Jones HR, Millikan CH. Temporal profile (clinical course) of acute carotid system cerebral infarction . Stroke . 1976;7:64-71.Crossref 2. Jones HR, Millikan CH, Burton AS. Temporal profile (clinical course) of acute vertebrobasilar system cerebral infarction . Stroke . 1980;11:173-177.Crossref 3. Baker RN, Broward JA, Fang HC, et al. Anticoagulant therapy in cerebral infarction . Neurology . 1962;12:823-835.Crossref 4. Britton MD, Rödén A. Progression of stroke after arrival at hospital . Stroke . 1985;16:629-632.Crossref 5. Mohr JP, Caplan LR, Melsky JW, et al. The Harvard cooperative stroke registry: a prospective registry . Neurology . 1978;28:754-762.Crossref 6. Dávalos A, Cendra E, Teruel J, Martinez M, Genis D. Deteriorating ischemic stroke: risk factors and prognosis . Neurology . 1990;40:1865-1869.Crossref 7. Sterman AB, Furlan AJ, Pessin M, Kase C, Caplan L, Williams G. Acute stroke therapy trials: an introduction to recurring design issues . Stroke . 1987;18: 524-527.Crossref 8. Pulsinelli W. Pathophysiology of acute ischemic stroke . Lancet . 1992;339:533-536.Crossref 9. Warlow C. Disorders of the cerebral circulation . In: Walton J, ed. Brain's Diseases of the Nervous System . New York, NY: Oxford University Press Inc; 1993: 197-268. 10. Duke RJ, Bloch RF, Turpie AGG, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progressing in acute partial stable stroke: a randomized controlled trial . Ann Intern Med . 1986;105:825-828.Crossref 11. Kittner SJ, Sharkness CM, Price TR, et al. Infarcts with a cardiac source of embolism in the NINCDS stroke data bank: historical features . Neurology . 1990; 40:281-284.Crossref 12. Mahoney FJ, Barthel DW. Functional evaluation: the Barthel index . Md Med J . 1965;21:61-65. 13. Coté R, Hachinski VC, Shurvell BL, Norris IW, Wolfson C. The Canadian Neurological Scale: a preliminary study in acute stroke . Stroke . 1986;17:731-737.Crossref 14. Tomura N, Uemura K, Inugami A, Fujita H, Higano S, Shishido F. Early CT finding in cerebral infarction: obscuration of the lentiform nucleus . Radiology . 1988;168:463-467.Crossref 15. Okada Y, Yamaguchi T, Minematsu K, et al. Hemorrhagic transformation in cerebral embolism . Stroke . 1989;20:598-603.Crossref 16. Damasio H. A computed tomography guide to the identification of cerebral vascular territories . Arch Neurol . 1983;40:138-142.Crossref 17. Brott T, Marler JR, Olinger CP, et al. Measurements of acute cerebral infarction: lesion size by computed tomography . Stroke . 1989;20:871-875.Crossref 18. Fieschi C, Argentino C, Lenzi GL, Sacchetti ML, Toni D, Bozzao L. Clinical and instrumental evaluation of patients with ischemic stroke within the first six hours . J Neurol Sci . 1989;91:311-322.Crossref 19. Saito I, Segawa H, Shiokawa Y, Taniguchi M, Tsutsumi K. Middle cerebral artery occlusion: correlation of computed tomography and angiography with clinical outcome . Stroke . 1987;18:863-868.Crossref 20. Price TR. Progressing ischemic stroke . In: Barnett HJM, Stein BM, Mohr JP, Yatsu FM, eds. Stroke Pathophysiology, Diagnosis, and Management . New York, NY: Churchill Livingstone Inc; 1986:1059-1068. 21. Toni D, Sacchetti ML, Argentino C, et al. Does hyperglycaemia play a role on the outcome of acute ischemic stroke patients? J Neurol . 1992;239:382-386. 22. Toni D, De Michele M, Fiorelli M, et al. Influence of hyperglycaemia on infarct size and clinical outcome of acute ischemic stroke patients with intracranial arterial occlusion . J Neurol Sci . 1994;123:129-133.Crossref 23. Berger L, Hakim AM. The association of hyperglycemia with cerebral edema in stroke . Stroke . 1986;17:865-871.Crossref 24. Horowitz SH, Zito JL, Donnarumma R, Patel M, Alvir J. Computed tomographicangiographic findings within the first five hours of cerebral infarction . Stroke . 1991;22:1245-1253.Crossref 25. Von Kummer R, Meyding-Lamadé U, Forsting M, et al. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk . AJNR Am J Neuroradiol . 1994;15:9-15. 26. Rogvi-Hansen B, Boysen G. Intravenous glycerol treatment of acute stroke: a statistical review . Cerebrovasc Dis . 1992;2:11-13.Crossref 27. Bozzao L, Angeloni U, Bastianello S, Fantozzi LM, Pierallini A, Fieschi C. Early angiographic and CT findings in patients with hemorrhagic infarction in the distribution of the middle cerebral artery . AJNR Am J Neuroradiol . 1991;12: 1115-1121.

Journal

Archives of NeurologyAmerican Medical Association

Published: Jul 1, 1995

References

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