Early recovery after cerebral ischemia risk of subsequent neurological deterioration

Given the high short‐term risk of stroke after transient ischemic attack, we hypothesized that substantial acute neurological recovery in patients presenting with cerebral ischemia would be associated with a greater risk of subsequent neurological deterioration due to recurrent cerebral ischemia. Data from the Trial of ORG10172 in Acute Stroke Treatment, a randomized trial of the heparinoid danaparoid, were analyzed to determine whether substantial acute recovery, defined as an improvement of greater than or equal to 75% on National Institutes of Health Stroke Scale (NIHSS) between baseline and 24 hours, was associated with a greater risk of subsequent deterioration, defined as a worsening on the NIHSS between day 1 and day 90. Of 1,184 subjects meeting entry criteria, 63 (5.3%) had substantial acute recovery. Subsequent deterioration was more common in those with substantial acute recovery compared with others (48 vs 33%; p = 0.028 by Fisher's exact test). In multivariable models, substantial acute recovery remained an independent predictor of subsequent deterioration (odds ratio, 3.0; 95% confidence interval, 1.7–5.2; p < 0.001). Among patients with acute cerebral ischemia, those who recover substantially within 24 hours may be at greater risk of subsequent neurological deterioration due to causes other than hemorrhage.

[1]  M. Edwards,et al.  Trial , 2004, The Lancet.

[2]  S. Johnston,et al.  Are Patients With Acutely Recovered Cerebral Ischemia More Unstable? , 2003, Stroke.

[3]  J. Weinberger.  Clinical trials report , 2003 .

[4]  S. Warach,et al.  Patterns of perfusion-weighted imaging in patients with carotid artery occlusive disease. , 2003, Archives of neurology.

[5]  Scott E Kasner,et al.  Utility of the NIH Stroke Scale as a Predictor of Hospital Disposition , 2003, Stroke.

[6]  Ku-ChouChang,et al.  Prediction of Length of Stay of First-Ever Ischemic Stroke , 2002 .

[7]  A. Alexandrov,et al.  Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator , 2002, Neurology.

[8]  T. Kwon,et al.  Sonographic appearance of a free‐floating atheromatous plaque in a patient with acute stroke , 2002, Journal of clinical ultrasound : JCU.

[9]  S. Dimauro,et al.  Cytochrome c oxidase deficiency due to a novel SCO2 mutation mimics Werdnig-Hoffmann disease. , 2002, Archives of neurology.

[10]  Andrew M. Demchuk,et al.  Markers of Increased Risk of Intracerebral Hemorrhage After Intravenous Recombinant Tissue Plasminogen Activator Therapy for Acute Ischemic Stroke in Clinical Practice: The Multicenter rt-PA Acute Stroke Survey , 2002, Circulation.

[11]  J. Grotta,et al.  Clinical Deterioration Following Improvement in the NINDS rt-PA Stroke Trial , 2001, Stroke.

[12]  S. Sidney,et al.  Short-term prognosis after emergency department diagnosis of TIA. , 2000, JAMA.

[13]  A. Alexandrov,et al.  Deterioration following spontaneous improvement : sonographic findings in patients with acutely resolving symptoms of cerebral ischemia. , 2000, Stroke.

[14]  V. Fuster,et al.  Acute Coronary Syndromes: Pathophysiology and Preventive Priorities , 1999, Thrombosis and Haemostasis.

[15]  C. Anderson,et al.  Long-term risk of first recurrent stroke in the Perth Community Stroke Study. , 1998, Stroke.

[16]  R. Califf,et al.  Acute Coronary Syndromes in the GUSTO-IIb Trial Prognostic Insights and Impact of Recurrent Ischemia , 1998 .

[17]  R. Sacco,et al.  Risk factors for early recurrence after ischemic stroke: the role of stroke syndrome and subtype. , 1998, Stroke.

[18]  W. O'Fallon,et al.  Survival and recurrence after first cerebral infarction , 1998, Neurology.

[19]  S. Uchiyama,et al.  Alterations of Platelet, Coagulation, and Fibrinolysis Markers in Patients with Acute Ischemic Stroke , 1997, Seminars in thrombosis and hemostasis.

[20]  F. Buonanno,et al.  Pharmacological elevation of blood pressure in acute stroke. Clinical effects and safety. , 1997, Stroke.

[21]  H. Adams,et al.  Design of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). , 1997, Controlled clinical trials.

[22]  Zheng-Ming Chen,et al.  CAST: randomised placebo-controlled trial of early aspirin use in 20 000 patients with acute ischaemic stroke , 1997, The Lancet.

[23]  Peter Sandercock,et al.  The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19 435 patients with acute ischaemic stroke , 1997, The Lancet.

[24]  A. Ahuja,et al.  Low-molecular-weight heparin for the treatment of acute ischemic stroke , 1995 .

[25]  C. Anderson,et al.  Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study , 1995, Acta psychiatrica Scandinavica.

[26]  T. Brott,et al.  Improved Reliability of the NIH Stroke Scale Using Video Training , 1994, Stroke.

[27]  G. Friday,et al.  A Multifactorial Analysis of Risk Factors for Recurrence of Ischemic Stroke , 1994, Stroke.

[28]  R. Sacco,et al.  Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community , 1994, Neurology.

[29]  J Bamford,et al.  Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. , 1994, Stroke.

[30]  C. Yutani,et al.  Mechanisms of cerebral artery thrombosis: a histopathological analysis on eight necropsy cases. , 1994, Journal of neurology, neurosurgery, and psychiatry.

[31]  A. Algra,et al.  Does Cerebral Infarction After a Previous Warning Occur in the Same Vascular Territory? , 1993, Stroke.

[32]  David Lee Gordon,et al.  Classification of Subtype of Acute Ischemic Stroke: Definitions for Use in a Multicenter Clinical Trial , 1993, Stroke.

[33]  Daniel B Hier,et al.  Stroke recurrence within 2 years after ischemic infarction. , 1991, Stroke.

[34]  J Bamford,et al.  Prognosis of transient ischemic attacks in the Oxfordshire Community Stroke Project. , 1990, Stroke.

[35]  Daniel B Hier,et al.  Determinants of early recurrence of cerebral infarction. The Stroke Data Bank. , 1989, Stroke.

[36]  H. Adams,et al.  A randomized trial of aspirin or heparin in hospitalized patients with recent transient ischemic attacks. A pilot study. , 1989, Stroke.

[37]  H. Adams,et al.  Usefulness of heparin in initial management of patients with recent transient ischemic attacks. , 1985, Archives of neurology.

[38]  H. Morgenstern,et al.  Epidemiologic Research: Principles and Quantitative Methods. , 1983 .

[39]  W. O'Fallon,et al.  Reversible ischemic neurologic deficit (RIND) in a community: Rochester, Minnesota, 1955-1974. , 1982, Neurology.

[40]  J. Marshall,et al.  Transient ischemic attacks and strokes with recovery prognosis and investigation. , 1981, Stroke.

[41]  L. Elveback,et al.  Transient cerebral ischemic attacks in a community. Rochester, Minnesota, 1955 through 1969. , 1973, Mayo Clinic proceedings.

[42]  A. Buchan,et al.  Short-term prognosis following acute cerebral ischaemia , 2002 .

[43]  K. Lee,et al.  Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators. , 1998, Circulation.

[44]  T. N. t-P. S. S. Group,et al.  Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. The NINDS t-PA Stroke Study Group. , 1997, Stroke.

[45]  T. Iwamoto,et al.  Platelet activation in the cerebral circulation in different subtypes of ischemic stroke and Binswanger's disease. , 1995, Stroke.