Early Neurological Deterioration Following Acute Ischaemic Stroke

1. Early Neurological Deterioration (END)
Following Acute Ischemic Stroke
Ade Wijaya, MD
March 2018

2. Outline
• Introduction
• Etiology
• Pathophysiology
• Management
• Summary

3. Introduction
• END predicts poor outcome
• Straightforward causes vs progressive stroke
•  NIHSS > 4 or  NIHSS > 2 in minor stroke
• Incidence: 10-41 %
Seners P, Turc G, Oppenheim C, Baron JC (2015) Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke: a systematic review with pathophysiological implications. J Neurol
Neurosurg Psychiatry 86(1):87–94.
Siegler JE, Boehme AK, Albright KC, George AJ, Monlezun DJ, Beasley TM et al (2013) A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke. J Stroke Cerebrovasc Dis 22(8):e549–e556
Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 44(3):870–947
Kim JM, Moon J, Ahn SW, Shin HW, Jung KH, Park KY (2016) The etiologies of early neurological deterioration after thrombolysis and risk factors of ischemia progression. J Stroke Cerebrovasc Dis 25(2):383–388
Seners, P., & Baron, J. C. (2018). Revisiting ‘progressive stroke’: incidence, predictors, pathophysiology, and management of unexplained early neurological deterioration following acute ischemic stroke. Journal of neurology, 265(1), 216-225.

4. Etiology
• Spontaneuous ICH
• Malignant edema
• Early seizures
• Early reccurent ischaemic stroke
• Early systemic medical complication (massive myocardial infarction or
pneumonia)
• Progressive stroke
Seners P, Turc G, Oppenheim C, Baron JC (2015) Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke: a systematic review with pathophysiological implications. J Neurol Neurosurg Psychiatry 86(1):87–94.
Siegler JE, Boehme AK, Albright KC, George AJ, Monlezun DJ, Beasley TM et al (2013) A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke. J Stroke Cerebrovasc Dis 22(8):e549–e556
Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke
Association. Stroke 44(3):870–947
Kim JM, Moon J, Ahn SW, Shin HW, Jung KH, Park KY (2016) The etiologies of early neurological deterioration after thrombolysis and risk factors of ischemia progression. J Stroke Cerebrovasc Dis 25(2):383–388

5. Pathophysiology
• Extension of symptomatic ischemic tissue into asymptomatic tissue
• Hypo-/hyper- glycemia
• Reperfusion injury
• Vascular events such as extension of the original thrombus, new emboli in
the same territory, ‘collateral failure’, and blood pressure drops
Seners, P., & Baron, J. C. (2018). Revisiting ‘progressive stroke’: incidence, predictors, pathophysiology, and management of unexplained early neurological deterioration following acute ischemic stroke. Journal of neurology, 265(1), 216-225.

6. Management
• Indentify and manage the causes
• For unidentified causes  no clear action is usually taken to revert the
deficit.
Kim JT, Heo SH, Yoon W, Choi KH, Park MS, Saver JL et al (2016) Clinical outcomes of patients with acute minor stroke receiving rescue IA therapy following early neurological deterioration. J Neurointerv Surg 8(5):461–465
Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 44(3):870–947

7. Seners P, Turc G, Tisserand M, Legrand L, Labeyrie MA, Calvet D et al (2014) Unexplained early neurological deterioration after intravenous thrombolysis: incidence, predictors, and associated factors. Stroke 45(7):2004–2009
Tisserand M, Seners P, Turc G, Legrand L, Labeyrie MA, Charron S et al (2014) Mechanisms of unexplained neurological deterioration after intravenous thrombolysis. Stroke 45(12):3527–3534
Seners P, Hurford R, Tisserand M, Turc G, Legrand L, Naggara O et al (2017) Is unexplained early neurological deterioration after intravenous thrombolysis associated with thrombus extension? Stroke 48(2):348–352
Kim JM, Moon J, Ahn SW, Shin HW, Jung KH, Park KY (2016) The etiologies of early neurological deterioration after thrombolysis and risk factors of ischemia progression. J Stroke Cerebrovasc Dis 25(2):383–388

8. Summary
• END in 24 hours following AIS is not uncommon
• Related to poor prognosis
• No clear causes in majority of cases
• Vascular events such as thrombus extension and re-embolization likely the
main underlying mechanisms.