Early Major Worsening in Ischemic Stroke: Predictors and Outcome

Introduction: We aimed to investigate the characteristics and outcome of patients suffering early major worsening (EMW) after acute ischemic stroke (AIS) and assess the parameters associated with it. Methods: All consecutive patients with AIS in the ASTRAL registry until 10/2010 were included. EMW was defined as an NIHSS increase of ≥8 points within the first 24h after admission. The Bootstrap version of the Kolmogorov-Smirnov test and the χ 2-test were used for the comparison of continuous and categorical covariates, respectively, between patients with and without EMW. Multiple logistic regression analysis was performed to identify independent predictors of EMW. Results: Among 2155 patients, 43 (2.0%) had an EMW. EMW was independently associated with hemorrhagic transformation (OR 22.6, 95% CI 9.4-54.2), cervical artery dissection (OR 9.5, 95% CI 4.4-20.6), initial dysarthria (OR 3.7, 95% CI 1.7-8.0), and intravenous thrombolysis (OR 2.1, 95% CI 1.1-4.3), whereas a negative association was identified with initial eye deviation (OR 0.4, 95% CI 0.2-0.9). Favorable outcome at 3 and 12months was less frequent in patients with EMW compared to patients without (11.6 vs. 55.3% and 16.3 vs. 50.7%, respectively), and case fatality was higher (53.5 vs. 12.9% and 55.8 vs. 16.8%, respectively). Stroke recurrence within 3months in surviving patients was similar between patients with and without EMW (9.3 vs. 9.0%, respectively). Conclusions: Worsening of ≥8 points in the NIHSS score during the first 24h in AIS patients is related to cervical artery dissection and hemorrhagic transformation. It justifies urgent repeat parenchymal and arterial imaging. Both conditions may be influenced by targeted interventions in the acute phase of stroke