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Abstract

Objective: To determine the frequency of early neurologic deterioration with infarct expansion (ENDIE) and poor outcomes among ischemic stroke patients not treated with reperfusion therapies because of rapidly improving or mild symptoms (RIMS) and to study the predictive value of hyperacute MRI in these patients.
Methods: We identified consecutive patients with symptoms of acute stroke undergoing multimodal MRI within 6 hours of onset without evidence of hemorrhage on imaging. Medical records were reviewed for evidence of early neurologic deterioration within 48 hours. All deteriorating patients had repeat MRI to ascertain causes of worsening. Poor outcome was defined as a discharge modified Rankin Scale (mRS) score of ≥3.
Results: We identified 74 patients with stroke symptoms ≤6 hours from onset. Forty had RIMS, and 39 did not receive reperfusion therapies because of RIMS. Among these 39, 4 experienced ENDIE, and 8 were discharged with mRS score of ≥3. Eight of the 39 patients had large-vessel occlusions on MR angiography. Three of 8 patients with large-vessel occlusion as against only one of 31 patients without occlusion had ENDIE (odds ratio [OR] 18, 95% CI 1.6 to 209, p = 0.02). Four of 8 patients with large-vessel occlusion as against 4 of 31 patients without occlusion had a discharge mRS score of ≥3 (OR 7, 95% CI 1.2 to 38, p = 0.04).
Conclusions: About 10% of patients eligible for acute reperfusion therapy excluded on the basis of mild or rapidly improving symptoms show early neurologic deterioration with infarct expansion within 48 hours, and about 20% show poor outcome at discharge. Persisting large-vessel occlusion substantially increases the risk of early worsening and poor functional outcome.

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References

1.
Adams HP Jr, Adams RJ, Brott T, et al. Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056–1083.
2.
Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism JAMA 1999;282:2003–2011.
3. Epub 2005 Jun 16.
Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005;36:1432–1438.
4.
Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM. Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology 2001;56:1015–1020.
5.
Katzan IL, Hammer MD, Hixson ED, Furlan AJ, Abou-Chebl A, Nadzam DM. Cleveland Clinic Health System Stroke Quality Improvement Team. Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004;61:346–350.
6.
Grotta JC, Welch KM, Fagan SC, et al. Clinical deterioration following improvement in the NINDS rt-PA Stroke Trial. Stroke 2001;32:661–668.
7.
Kleindorfer D, Kissela B, Schneider A, et al. Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: a population-based study. Stroke 2004;35:e27–e29.
8. Epub 2005 Oct 6.
Smith EE, Abdullah AR, Petkovska I, Rosenthal E, Koroshetz WJ, Schwamm LH. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke 2005;36:2497–2499.
9.
Biller J, Love BB, Marsh EEIII, et al. Spontaneous improvement after acute ischemic stroke. A pilot study. Stroke 1990;21:1008–1012.
10.
Alexandrov AV, Felberg RA, Demchuk AM, et al. Deterioration following spontaneous improvement: sonographic findings in patients with acutely resolving symptoms of cerebral ischemia. Stroke 2000;31:915–919.
11.
Saver JL, Starkman S. State of the art medical management of acute ischemic stroke. J Stroke Cerebrovasc Dis 1997;6:189–194.
12. Abstract.
Rajajee V, Kidwell C, Starkman S, et al. Accuracy of clinical diagnosis of lacunar infarct within 6 hours of onset compared to early MRI-DWI and MRA. Stroke 2004;35:262.
13.
National Institute of Neurological Disorders Stroke rt-PA Stroke Study Group. Recombinant tissue plasminogen activator for minor strokes: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study experience. Ann Emerg Med 2005;46:243–252.

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Published In

Neurology®
Volume 67Number 6September 26, 2006
Pages: 980-984
PubMed: 17000964

Publication History

Published online: September 25, 2006
Published in print: September 26, 2006

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Authors

Affiliations & Disclosures

V. Rajajee, MD
From the UCLA Medical Center, Los Angeles, CA.
C. Kidwell, MD
From the UCLA Medical Center, Los Angeles, CA.
S. Starkman, MD
From the UCLA Medical Center, Los Angeles, CA.
B. Ovbiagele, MD
From the UCLA Medical Center, Los Angeles, CA.
J. R. Alger, PhD
From the UCLA Medical Center, Los Angeles, CA.
P. Villablanca, MD
From the UCLA Medical Center, Los Angeles, CA.
F. Vinuela, MD
From the UCLA Medical Center, Los Angeles, CA.
G. Duckwiler, MD
From the UCLA Medical Center, Los Angeles, CA.
R. Jahan, MD
From the UCLA Medical Center, Los Angeles, CA.
A. Fredieu, MD
From the UCLA Medical Center, Los Angeles, CA.
S. Suzuki, MD
From the UCLA Medical Center, Los Angeles, CA.
J. L. Saver, MD
From the UCLA Medical Center, Los Angeles, CA.

Notes

Address correspondence and reprint requests to Dr. V. Rajajee, 28 Second Main Road, C.I.T Colony, Chennai 600004, India; e-mail: [email protected]

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