(Stroke. 1999;30:2631.)
© 1999 American Heart Association, Inc.
Original Contributions |
Neurological Deterioration in Acute Ischemic Stroke
Potential Predictors and Associated Factors in the European Cooperative Acute Stroke Study (ECASS) I
From the Departments of Neurology (A.D.), Hospital Universitari Doctor Josep Trueta, Girona; Hospital Universitario Xeral de Galicia (J.C.), Santiago de Compostela, Spain; Departments of Neurological Sciences (D.T.) and Neuroradiology (S.B.), University La Sapienza, Rome, Italy; and the Biostatistical Centre for Clinical Trials (F.I., E.L.), Leuven, Belgium.
Background and Purpose—The present study was undertaken to identify potential predictors of and factors associated with early and late progression in acute stroke. We performed secondary analysis of the clinical, biochemical, and radiological data recorded in the acute phase of stroke patients enrolled in the European Cooperative Acute Stroke Study (ECASS) I.
Methods—Early progressing stroke (EPS) was diagnosed when there
was a decrease of 
2 points in consciousness or motor power or a
decrease of 3 points in speech scores in the Scandinavian
Neurological Stroke Scale from baseline to the 24-hour evaluation, and
late progressing stroke (LPS) was diagnosed when 1 of these decreases
occurred between the 24-hour evaluation and the evaluation at day 7.
Using logistic regression analyses, we looked for baseline
variables that predicted EPS and LPS and for factors measured after
the early or late acute phase and associated with the 2 clinical
courses.
Results—Of the 615 patients studied, 231 (37.5%) worsened during the first 24 hours after inclusion. The overall incidence of EPS was 37% in the placebo group and 38% in the recombinant tissue plasminogen activator group (P=0.68, Fisher’s Exact Test). Focal hypodensity (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.9) and hyperdensity of the middle cerebral artery sign (OR, 1.8; 95% CI, 1.1 to 3.1) on baseline computed tomography, longer delay until treatment (OR, 1.2; 95% CI, 1.1 to 1.4) and history of coronary heart disease (OR, 1.7; 95% CI, 1.1 to 2.8) and diabetes (OR, 1.8; 95% CI, 1.0 to 3.1) were independent prognostic factors for EPS. Extent of hypodensity >33% in the middle cerebral artery territory (OR, 2.5; 95% CI, 1.6 to 4.0) and brain swelling (OR, 1.8; 95% CI, 1.1 to 3.2) on CT at 24 hours but not hemorrhagic transformation of cerebral infarct nor decrease in systolic blood pressure within the first 24 hours after treatment were associated with EPS in multivariate analyses. LPS was observed in 20.3% of patients. Older age, a low neurological score, and brain swelling at admission independently predicted late worsening.
Conclusions—In the setting of a multicenter trial, EPS and LPS are mainly related to computed tomographic signs of cerebral edema. Treatment with recombinant tissue plasminogen activator, hemorrhagic transformation, and moderate changes in systolic blood pressure did not influence the early clinical course.
Key Words: brain edema • stroke outcome • stroke, acute • thrombolytic therapy • tomography, x-ray computed
This article has been cited by other articles:
 |
|
 |
|
  A. V. Alexandrov, H. T. Nguyen, M. Rubiera, A. W. Alexandrov, L. Zhao, I. Heliopoulos, A. Robinson, J. DeWolfe, and G. Tsivgoulis Prevalence and Risk Factors Associated With Reversed Robin Hood Syndrome in Acute Ischemic Stroke Stroke, August 1, 2009; 40(8): 2738 - 2742. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. A. Alawneh, R. R. Moustafa, and J.-C. Baron Hemodynamic Factors and Perfusion Abnormalities in Early Neurological Deterioration Stroke, June 1, 2009; 40(6): e443 - e450. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Kobayashi, J. M. Wardlaw, R. I. Lindley, S. C. Lewis, P. A.G. Sandercock, A. Czlonkowska, and on behalf of the IST-3 Collaborative Group Oxfordshire Community Stroke Project Clinical Stroke Syndrome and Appearances of Tissue and Vascular Lesions on Pretreatment CT in Hyperacute Ischemic Stroke Among the First 510 Patients in the Third International Stroke Trial (IST-3) Stroke, March 1, 2009; 40(3): 743 - 748. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Hallevi, K. C. Albright, S. Martin-Schild, A. D. Barreto, S. I. Savitz, M. A. Escobar, N. R. Gonzales, E. A. Noser, K. Illoh, and J. C. Grotta Anticoagulation After Cardioembolic Stroke: To Bridge or Not to Bridge? Arch Neurol, September 1, 2008; 65(9): 1169 - 1173. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B Thanvi, S Treadwell, and T Robinson Early neurological deterioration in acute ischaemic stroke: predictors, mechanisms and management Postgrad. Med. J., August 1, 2008; 84(994): 412 - 417. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. Mahajan, P.T. Minshew, J. Khoury, P.P. Shu, M. Muzaffar, T. Abruzzo, J.L. Leach, and T.A. Tomsick Eye Position Information on CT Increases the Identification of Acute Ischemic Hypoattenuation AJNR Am. J. Neuroradiol., June 1, 2008; 29(6): 1144 - 1146. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Chamorro Magnetic resonance perfusion diffusion mismatch, thrombolysis, and clinical outcome in acute stroke J. Neurol. Neurosurg. Psychiatry, May 1, 2007; 78(5): 443 - 443. [Full Text] [PDF]
|
|
|
|
|
|
A. Rocco, M. Pasquini, E. Cecconi, G. Sirimarco, M. C. Ricciardi, E. Vicenzini, M. Altieri, V. Di Piero, and G. L. Lenzi Monitoring After the Acute Stage of Stroke: A Prospective Study Stroke, April 1, 2007; 38(4): 1225 - 1228. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M.S.V. Elkind, S. Prabhakaran, J. Pittman, W. Koroshetz, M. Jacoby, K. C. Johnston, and for the GAIN Americas Investigators Sex as a predictor of outcomes in patients treated with thrombolysis for acute stroke Neurology, March 13, 2007; 68(11): 842 - 848. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Saqqur, K. Uchino, A. M. Demchuk, C. A. Molina, Z. Garami, S. Calleja, N. Akhtar, F. O. Orouk, A. Salam, A. Shuaib, et al. Site of Arterial Occlusion Identified by Transcranial Doppler Predicts the Response to Intravenous Thrombolysis for Stroke Stroke, March 1, 2007; 38(3): 948 - 954. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. Dzialowski, J. H. W. Pexman, P. A. Barber, A. M. Demchuk, A. M. Buchan, M. D. Hill, and on behalf of the CASES Investigators Asymptomatic Hemorrhage After Thrombolysis May Not Be Benign: Prognosis by Hemorrhage Type in the Canadian Alteplase for Stroke Effectiveness Study Registry Stroke, January 1, 2007; 38(1): 75 - 79. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Saqqur, C. A. Molina, A. Salam, M. Siddiqui, M. Ribo, K. Uchino, S. Calleja, Z. Garami, K. Khan, N. Akhtar, et al. Clinical Deterioration After Intravenous Recombinant Tissue Plasminogen Activator Treatment: A Multicenter Transcranial Doppler Study Stroke, January 1, 2007; 38(1): 69 - 74. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Kwan and P. Hand Early neurological deterioration in acute stroke: clinical characteristics and impact on outcome QJM, September 1, 2006; 99(9): 625 - 633. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Blanco, M. A. Moro, A. Davalos, R. Leira, M. Castellanos, J. Serena, J. Vivancos, M. Rodriguez-Yanez, I. Lizasoain, and J. Castillo Increased Plasma Levels of 15-Deoxy {Delta} Prostaglandin J2 Are Associated With Good Outcome in Acute Atherothrombotic Ischemic Stroke Stroke, June 1, 2005; 36(6): 1189 - 1194. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. D. Schellinger, J. A. Chalela, D.-W. Kang, L. L. Latour, and S. Warach Diagnostic and Prognostic Value of Early MR Imaging Vessel Signs in Hyperacute Stroke Patients Imaged <3 Hours and Treated with Recombinant Tissue Plasminogen Activator AJNR Am. J. Neuroradiol., March 1, 2005; 26(3): 618 - 624. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Weimar, T. Mieck, J. Buchthal, C. E. Ehrenfeld, E. Schmid, H.-C. Diener, and for the German Stroke Study Collaboration Neurologic Worsening During the Acute Phase of Ischemic Stroke Arch Neurol, March 1, 2005; 62(3): 393 - 397. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. Aiyagari, A. Gujjar, A. R. Zazulia, and M. N. Diringer Hourly Blood Pressure Monitoring After Intravenous Tissue Plasminogen Activator for Ischemic Stroke: Does Everyone Need It? Stroke, October 1, 2004; 35(10): 2326 - 2330. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Davalos, M. Blanco, S. Pedraza, R. Leira, M. Castellanos, J. M. Pumar, Y. Silva, J. Serena, and J. Castillo The clinical-DWI mismatch: A new diagnostic approach to the brain tissue at risk of infarction Neurology, June 22, 2004; 62(12): 2187 - 2192. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Somford, M. P. Marks, V. N. Thijs, and D. C. Tong Association of Early CT Abnormalities, Infarct Size, and Apparent Diffusion Coefficient Reduction in Acute Ischemic Stroke AJNR Am. J. Neuroradiol., June 1, 2004; 25(6): 933 - 938. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Kent, J. Hinchey, L. L. Price, S. R. Levine, and H. P. Selker In Acute Ischemic Stroke, Are Asymptomatic Intracranial Hemorrhages Clinically Innocuous? Stroke, May 1, 2004; 35(5): 1141 - 1146. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. A. Molina, A. V. Alexandrov, A. M. Demchuk, M. Saqqur, K. Uchino, and J. Alvarez-Sabin Improving the Predictive Accuracy of Recanalization on Stroke Outcome in Patients Treated With Tissue Plasminogen Activator Stroke, January 1, 2004; 35(1): 151 - 156. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J M Wardlaw, T M West, P A G Sandercock, S C Lewis, and O Mielke Visible infarction on computed tomography is an independent predictor of poor functional outcome after stroke, and not of haemorrhagic transformation J. Neurol. Neurosurg. Psychiatry, April 1, 2003; 74(4): 452 - 458. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. E. Latchaw, H. Yonas, G. J. Hunter, W. T.C. Yuh, T. Ueda, A. G. Sorensen, J. L. Sunshine, J. Biller, L. Wechsler, R. Higashida, et al. Guidelines and Recommendations for Perfusion Imaging in Cerebral Ischemia: A Scientific Statement for Healthcare Professionals by the Writing Group on Perfusion Imaging, From the Council on Cardiovascular Radiology of the American Heart Association Stroke, April 1, 2003; 34(4): 1084 - 1104. [Full Text] [PDF]
|
|
|
|
|
|
N. Vila, J. Castillo, A. Davalos, A. Esteve, A. M. Planas, and A. Chamorro Levels of Anti-Inflammatory Cytokines and Neurological Worsening in Acute Ischemic Stroke Stroke, March 1, 2003; 34(3): 671 - 675. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. V. Alexandrov and J. C. Grotta Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator Neurology, September 24, 2002; 59(6): 862 - 867. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. F. Arenillas, A. Rovira, C. A. Molina, E. Grive, J. Montaner, J. Alvarez-Sabin, and K.-O. Lovblad Prediction of Early Neurological Deterioration Using Diffusion- and Perfusion-Weighted Imaging in Hyperacute Middle Cerebral Artery Ischemic Stroke * Editorial Comment Stroke, September 1, 2002; 33(9): 2197 - 2205. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. Steinke and S. C. Ley Lacunar Stroke Is the Major Cause of Progressive Motor Deficits Stroke, June 1, 2002; 33(6): 1510 - 1516. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Schwarz, D. Georgiadis, A. Aschoff, and S. Schwab Effects of Induced Hypertension on Intracranial Pressure and Flow Velocities of the Middle Cerebral Arteries in Patients With Large Hemispheric Stroke Stroke, April 1, 2002; 33(4): 998 - 1004. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Iranzo, J. Santamaria, J. Berenguer, M. Sanchez, and A. Chamorro Prevalence and clinical importance of sleep apnea in the first night after cerebral infarction Neurology, March 26, 2002; 58(6): 911 - 916. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Schneweis, M. Grond, F. Staub, G. Brinker, M. Neveling, C. Dohmen, R. Graf, W.-D. Heiss, and A. Shuaib Predictive Value of Neurochemical Monitoring in Large Middle Cerebral Artery Infarction Editorial Comment Stroke, August 1, 2001; 32(8): 1863 - 1867. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. C. Grotta, K. M. A. Welch, S. C. Fagan, M. Lu, M. R. Frankel, T. Brott, S. R. Levine, P. D. Lyden, and P. D. Lyden Clinical Deterioration Following Improvement in the NINDS rt-PA Stroke Trial Stroke, March 1, 2001; 32(3): 661 - 668. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Tei, S. Uchiyama, K. Ohara, M. Kobayashi, Y. Uchiyama, and M. Fukuzawa Deteriorating Ischemic Stroke in 4 Clinical Categories Classified by the Oxfordshire Community Stroke Project Stroke, September 1, 2000; 31(9): 2049 - 2054. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Davalos, J. Castillo, J. Marrugat, J. M. Fernandez-Real, A. Armengou, P. Cacabelos, and R. Rama Body iron stores and early neurologic deterioration in acute cerebral infarction Neurology, April 25, 2000; 54(8): 1568 - 1574. [Abstract] [Full Text] [PDF]
|
|