Neurologic worsening during the acute phase of ischemic stroke

Background: Although capacities for intensive monitoring of patients with, stroke are still limited, patients at risk for early neurologic worsening are poorly defined. Objective: To identify patients at risk for neurologic worsening. Design: An inception cohort was assessed using the National Institutes of Health Stroke Scale (NIH-SS) at hospital admission and again 48 to 72 hours later. Setting: Eleven neurologic departments with acute stroke units. Patients: A total of 1964 consecutive patients admitted within 4 hours of the onset of acute cerebral ischemic symptoms. Main Outcome Measures: Underlying reasons for and possible predictors of neurologic worsening. Results: A total of 256 patients (13.0%) had an increased score of 1 point or more on the NIH-SS after 48 to 72 hours. Neurologic worsening was attributed to progressive stroke in 33.6% of patients, increased intracranial pressure in 27.3%, recurrent cerebral ischemia in 11.3%, and secondary parenchymal hemorrhage in 10.5%. A multivariate logistic regression analysis identified internal carotid artery occlusion, medial cerebral artery (M1) occlusion, territorial infarction, brainstem infarction, and diabetes mellitus as independent predictors of neurologic worsening on the NIH-SS. Worsening of key neurologic functions (consciousness, gaze, arm or leg motor function, and speech) occurred in 223 patients (11.4%), and worsening of 4 points or more on the NIH-SS total score occurred in 148 patients (7.5%). Conclusion: Besides initial stroke severity and comorbid conditions, ultrasound and imaging can provide valuable information about the risk of worsening of stroke symptoms in the acute phase and thus can identify patients who could benefit most from intensive monitoring.