Deterioration following spontaneous improvement

Sonographic findings in patients with acutely resolving symptoms of cerebral ischemia

Andrei Alexandrov, Robert A. Felberg, Andrew M. Demchuk, Ioannis Christou, W. Scott Burgin, Marc Malkoff, Anne Alexandrov, James C. Grotta

Research output: Contribution to journalArticle

111 Citations (Scopus)

Abstract

Background and Purpose - 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, Φ=0.523, χ2=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.

Original languageEnglish (US)
Pages (from-to)915-919
Number of pages5
JournalStroke
Volume31
Issue number4
DOIs
StatePublished - Jan 1 2000
Externally publishedYes

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Brain Ischemia
Blood Vessels
Pathologic Constriction
Digital Subtraction Angiography
Magnetic Resonance Angiography
Stroke
Angiography
National Institutes of Health (U.S.)
Atherosclerosis

All Science Journal Classification (ASJC) codes

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Deterioration following spontaneous improvement : Sonographic findings in patients with acutely resolving symptoms of cerebral ischemia. / Alexandrov, Andrei; Felberg, Robert A.; Demchuk, Andrew M.; Christou, Ioannis; Burgin, W. Scott; Malkoff, Marc; Alexandrov, Anne; Grotta, James C.

In: Stroke, Vol. 31, No. 4, 01.01.2000, p. 915-919.

Research output: Contribution to journalArticle

Alexandrov, Andrei ; Felberg, Robert A. ; Demchuk, Andrew M. ; Christou, Ioannis ; Burgin, W. Scott ; Malkoff, Marc ; Alexandrov, Anne ; Grotta, James C. / Deterioration following spontaneous improvement : Sonographic findings in patients with acutely resolving symptoms of cerebral ischemia. In: Stroke. 2000 ; Vol. 31, No. 4. pp. 915-919.
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T2 - Sonographic findings in patients with acutely resolving symptoms of cerebral ischemia

AU - Alexandrov, Andrei

AU - Felberg, Robert A.

AU - Demchuk, Andrew M.

AU - Christou, Ioannis

AU - Burgin, W. Scott

AU - Malkoff, Marc

AU - Alexandrov, Anne

AU - Grotta, James C.

PY - 2000/1/1

Y1 - 2000/1/1

N2 - Background and Purpose - 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, Φ=0.523, χ2=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.

AB - Background and Purpose - 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, Φ=0.523, χ2=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.

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