Objectives: The aim of our study was to assess image biomarkers of early neurological deterioration in single subcortical infarction (SSI) without any relevant artery stenosis. Methods: Between June 2005 and December 2009, consecutive patients with SSI within 24 hours of symptom onset were enrolled. Magnetic resonance angiography of the brain and neck was performed on all patients to confirm the absence of any stenosis of the relevant artery. Early neurological deterioration (END) was defined as neurological worsening by ≥ 2 points based on the initial National Institutes of Health Stroke Scale score during the first week after admission or prior to hospital discharge. A multiple logistic regression analysis was used to evaluate the independent predictors of END in SSI. Results: The final cohort consisted of 205 patients (109 males; 63.9 ± 11.0-years-old; ranging from 39 to 90), of whom 158 (77%) remained stable or improved and 47 (23%) showed neurological worsening. A univariate analysis revealed significant differences between patients with and without END in terms of maximum diameter of the largest area on an axial view and the number of slices showing the cerebral infarction on a transverse plane. A multiple logistic regression analysis revealed that the occurrence of three or more slices showing the cerebral infarction on a transverse plane was an independent predictor of END in SSI without relevant artery stenosis (1 vs 3; OR 14.281; 95% CI 1.76 ‒ 115.8; p = 0.013, 1 vs 4; OR 14.04; 95% CI 1.65 ‒ 119.57; p = 0.016) Conclusion: The longitudinal length of the infarcted lesion along the perforating artery predicts END in cases of acute SSI without any relevant artery stenosis.

BACKGROUND: Early neurological deterioration (END) is a frequent complication of acute ischemic stroke. Although END worsens clinical outcomes, standardized treatment strategies remain undefined, resulting in variability in clinical practice. This study examines real-world treatment patterns for END and compares the effects of different strategies on neurological and functional outcomes. METHODS: This study analyzed data from a nationwide, prospective, multicenter stroke registry in South Korea, including patients with noncardioembolic stroke who developed END due to stroke progression between January 2019 and August 2024. END was defined as new or worsening neurological symptoms meeting National Institutes of Health Stroke Scale criteria (≥2-point total or ≥1 point in consciousness or motor subscores) with radiological confirmation. Patients were classified into conservative management, antithrombotics change, and induced hypertension (iHTN). The primary outcomes were neurological improvement, defined as a ≥2-point reduction in the National Institutes of Health Stroke Scale score, and 3-month functional outcome measured by modified Rankin Scale ordinal shift. Secondary outcomes included good functional recovery (modified Rankin Scale score, 0–2) and composite vascular events (death, stroke, and myocardial infarction). Multivariable analyses adjusted for age, sex, prestroke modified Rankin Scale, initial National Institutes of Health Stroke Scale score, vascular risk factors, the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification, acute thrombolysis, and laboratory covariates. RESULTS: Among 3067 patients with END due to stroke progression, 1840 (60.0%) received conservative management, 747 (24.4%) underwent antithrombotic changes, and 480 (15.7%) were treated with iHTN. Neurological improvement occurred in 34.2% of patients, with the highest in the iHTN group (41.5%) compared with the conservative (32.2%) and antithrombotics change groups (34.4%; P <0.001). In adjusted analyses, iHTN increased the odds of neurological improvement (adjusted odds ratio, 1.55 [95% CI, 1.25–1.92]) and a favorable 3-month modified Rankin Scale shift (adjusted odds ratio, 1.24 95% CI, 1.03–1.48]) compared with conservative management, particularly in patients with large artery atherosclerosis. Antithrombotics change showed no significant association with neurological or functional recovery. CONCLUSIONS: In patients with noncardioembolic ischemic stroke who developed END due to stroke progression, iHTN was associated with favorable clinical outcomes.

Kim DY, et al. J Korean Med Sci. 2024 Aug;39(34):e278. https://doi.org/10.3346/jkms.2024.39.e278

Altered levels of consciousness (ALCs) is a challenging issue; however, data describing its etiology and frequency are lacking. This study aimed to clarify and classify the etiologies of ALCs in the emergency room (ER) and to evaluate their destinations and the form of discharge. This retrospective study included patients with an ALC who visited the ER of a university hospital between January 2018 and December 2020. The cause and classification of the ALCs were carefully determined by a consortium of board-certified faculty members in emergency medicine, internal medicine, and neurology. The reference point for determining the etiology of ALC was discharge from the ER. In total, 2028 patients with ALCs were investigated. More than half (1037, 51.1%) visited the ER between 9:00 and 18:00. The most common etiology was systemic infection (581, 28.6%), followed by metabolic causes (455, 22.4%), and stroke (271, 13.4%). The two leading etiologies were extracranial and had a majority of the cases (1036, 51.5%). The overall mortality rate was 17.2%. This study provides fundamental information on ALC in the ER. Although intracranial etiologies have been foregrounded, this study demonstrated that extracranial etiologies are the main cause of ALC in the ER.