(Stroke. 2000;31:915.)
© 2000 American Heart Association, Inc.
Original Contributions |
Deterioration Following Spontaneous Improvement
Sonographic Findings in Patients With Acutely Resolving Symptoms of Cerebral Ischemia
From the Center for Noninvasive Brain Perfusion Studies, Stroke Treatment Team, University of Texas–Houston Medical School.
Correspondence to Dr A.V. Alexandrov, Department of Neurology, University of Texas–Houston Medical School, 6431 Fannin, MSB 7.044, Houston, TX 77030. E-mail avalexandrov{at}worldnet.att.net
Background and Purpose—Some stroke patients will deteriorate following improvement (DFI), but the cause of such fluctuation is often unclear. While resolution of neurological deficits is usually related to spontaneous recanalization or restoration of collateral flow, vascular imaging in patients with DFI has not been well characterized.
Methods—We prospectively studied patients who presented
with a focal neurological deficit that resolved spontaneously within 6
hours of symptom onset. Patients were evaluated with bedside
transcranial Doppler (TCD). Digital subtraction
angiography (DSA), computed tomographic angiography (CTA), or magnetic
resonance angiography (MRA) were performed when feasible. DFI was
defined as subsequent worsening of the neurological deficit by 
4
National Institutes of Health Stroke Scale points within 24 hours of
the initial symptom onset.
Results—We studied 50 consecutive patients presenting at
165±96 minutes from symptom onset. Mean age was 61±14 years; 50%
were females. All patients had TCD at the time of
presentation, and 68% had subsequent angiographic
examinations (DSA 10%, CTA 4%, and MRA 44%). Overall, large-vessel
occlusion on TCD was found in 16% of patients (n=8); stenosis
was found in 18% (n=9); 54% (n=27) had normal studies; and 6 patients
(12%) had no temporal windows. DFI occurred in 16% (n=8) of the 50
patients: in 62% of patients with TCD and angiographic evidence of
occlusion, in 22% with stenosis, and in 4% with normal
vascular studies (P<0.001, 
=0.523,
2=12.05). DFI occurred in 31% of patients with
large-vessel atherosclerosis, 23% with
cardioembolism, and 9% with small-vessel disease when
stroke mechanisms were determined within 2 to 3 days after admission
(P=0.2, NS).
Conclusions—DFI is strongly associated with the presence of large-vessel occlusion or stenosis of either atherosclerotic or embolic origin. Normal vascular studies and lacunar events were associated with stable spontaneous resolution without subsequent fluctuation. Urgent vascular evaluation may help identify patients with resolving deficits and vascular lesions who may be candidates for new therapies to prevent subsequent deterioration.
Key Words: angiography • cerebral ischemia • disease progression • ultrasonography
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