title: Deterioration following spontaneous improvement : sonographic findings in patients with acutely resolving symptoms of cerebral ischemia.
abstract: OBJECTIVE
  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, Phi=0.523, chi(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.
authors.affiliation: Center for Noninvasive Brain Perfusion Studies, Stroke Treatment Team, University of Texas-Houston Medical School, Houston, TX 77030, USA.
authors.forename: A V
authors.initials: AV
authors.lastname: Alexandrov
authors.forename: R A
authors.initials: RA
authors.lastname: Felberg
authors.forename: A M
authors.initials: AM
authors.lastname: Demchuk
authors.forename: I
authors.initials: I
authors.lastname: Christou
authors.forename: W S
authors.initials: WS
authors.lastname: Burgin
authors.forename: M
authors.initials: M
authors.lastname: Malkoff
authors.forename: A W
authors.initials: AW
authors.lastname: Wojner
authors.forename: J C
authors.initials: JC
authors.lastname: Grotta
mesh_terms: D000208:Acute Disease; D000368:Aged; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology*; D002533:Cerebral Angiography; D003327:Coronary Disease / Q000150:complications; D018450:Disease Progression; D004617:Embolism / Q000150:complications; D005260:Female; D006801:Humans; D002537:Intracranial Arteriosclerosis / Q000150:complications; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D009316:National Institutes of Health (U.S.); D019095:Point-of-Care Systems; D011446:Prospective Studies; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D017585:Ultrasonography, Doppler, Transcranial; D014481:United States