title: Early neurological stability predicts adverse outcome after acute ischemic stroke.
abstract: Background Deterioration in the National Institutes of Health Stroke Scale (NIHSS) in the early days after stroke is associated with progressive infarction, brain edema, and/or hemorrhage, leading to worse outcome. Aims We sought to determine whether a stable NIHSS score represents an adverse or favorable course. Methods Brain magnetic resonance images from a research cohort of acute ischemic stroke patients were analyzed. Using NIHSS scores at baseline and follow-up (day 3-5), patients were categorized into early neurological deterioration (ΔNIHSS ≥ 4), early neurological recovery (ΔNIHSS ≤ -4) or early neurological stability (ΔNIHSS between -3 and 3). The association between these categories and volume of infarct growth, volume of swelling, parenchymal hemorrhage, and 3-month modified Rankin Scale score were evaluated. Results Patients with early neurological deterioration or early neurological stability were less likely to be independent (modified Rankin Scale = 0-2) at 3 months compared to those with early neurological recovery ( P < 0.001). Patients with early neurological deterioration or early neurological stability were observed to have significantly greater infarct growth and swelling volumes than those with early neurological recovery ( P = 0.03; P < 0.001, respectively). Brain edema was more common than the other imaging markers investigated and was independently associated with a stable or worsening NIHSS score after adjustment for age, baseline stroke volume, infarct growth volume, presence of parenchymal hemorrhage, and reperfusion ( P < 0.0001). Conclusions Stable NIHSS score in the subacute period after ischemic stroke may not be benign and is associated with tissue injury, including infarct growth and brain edema. Early improvement is considerably more likely to occur in the absence of these factors.
authors.affiliation: 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA.
authors.forename: Hannah J
authors.initials: HJ
authors.lastname: Irvine
authors.affiliation: 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA.
authors.forename: Thomas Wk
authors.initials: TW
authors.lastname: Battey
authors.affiliation: 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA.
authors.forename: Ann-Christin
authors.initials: AC
authors.lastname: Ostwaldt
authors.affiliation: 2 Department of Medicine and Neurology, University of Melbourne, Parkville, Australia.|3 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia.
authors.forename: Bruce Cv
authors.initials: BC
authors.lastname: Campbell
authors.affiliation: 2 Department of Medicine and Neurology, University of Melbourne, Parkville, Australia.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Davis
authors.affiliation: 3 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia.
authors.forename: Geoffrey A
authors.initials: GA
authors.lastname: Donnan
authors.affiliation: 4 Division of Neurocritical Care and Emergency Neurology, Yale New Haven Hospital, New Haven, USA.
authors.forename: Kevin N
authors.initials: KN
authors.lastname: Sheth
authors.affiliation: 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA.|5 J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, USA.
authors.forename: W Taylor
authors.initials: WT
authors.lastname: Kimberly
mesh_terms: D000368:Aged; D001921:Brain / Q000000981:diagnostic imaging* / Q000503:physiopathology; D001929:Brain Edema / Q000000981:diagnostic imaging / Q000503:physiopathology; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy*; D015331:Cohort Studies; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D011379:Prognosis; D012720:Severity of Illness Index; D020521:Stroke / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome
keywords: Outcome; deterioration; edema; ischemic stroke; magnetic resonance image; secondary neurological injury