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Vynckier J, Maamari B, Grunder L, Goeldlin MB, Meinel TR, Kaesmacher J, Hakim A, Arnold M, Gralla J, Seiffge DJ, Fischer U. Early Neurologic Deterioration in Lacunar Stroke: Clinical and Imaging Predictors and Association With Long-term Outcome. Neurology 2021; 97:e1437-e1446. [PMID: 34400585 DOI: 10.1212/wnl.0000000000012661] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/06/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To determine the rate and predictors of early neurologic deterioration (END) in patients with lacunar strokes and its implications for management and outcome. METHODS We enrolled consecutive patients with MRI-defined lacunar stroke who presented within 12 hours after symptom onset from a prospective stroke database (2015-2019). END was defined as any persisting increase in NIH Stroke Scale (NIHSS) score of ≥2 points within 24 hours after admission and favorable outcome as modified Rankin Scale (mRS) score of 0 to 2 at 90 days. We assessed the association of END with clinical and imaging variables, acute treatment, and outcome using multivariable regression, calculating adjusted odds ratios (aORs). RESULTS Sixty-one of 365 (16.7%) patients with acute lacunar stroke (median age 71.8 years, 39.5% female, median NIHSS score on admission 3) had END. Lower NIHSS score on admission (per point, aOR 0.81, p = 0.006), capsular warning syndrome (aOR 7.00, p < 0.001), ventral pontine infarct (aOR 3.49, p = 0.008), and hypoperfusion lesion on imaging (aOR 2.13, p = 0.026) were associated with END. Acute dual antiplatelet therapy was associated with reduced risk of END (aOR 0.10, p = 0.04). Patients with END had less favorable outcome at 90 days (aOR 0.13 p < 0.001), but IV thrombolysis (IVT) was associated with favorable outcome at 90 days (aOR 3.95, p = 0.002). DISCUSSION One in 6 patients with lacunar stroke has END, and patients at high risk of END can be identified with radiologic and clinical variables. Targeted therapeutic trials for this population seem justified. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that early neurologic deterioration in patients with acute lacunar stroke predicts poorer functional outcome at 90 days as determined by the mRS.
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Affiliation(s)
- Jan Vynckier
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland.
| | - Basel Maamari
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Lorenz Grunder
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Martina Béatrice Goeldlin
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Thomas Raphael Meinel
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Johannes Kaesmacher
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Arsany Hakim
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Marcel Arnold
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Jan Gralla
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - David Julian Seiffge
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Urs Fischer
- From the Department of Neurology (J.V., B.M., L.G., M.B.G., T.R.M., J.K., M.A., J.G., D.J.S., U.F.), Institute of Diagnostic and Interventional Neuroradiology (L.G., J.K., A.H., J.G.), and Institute of Diagnostic Interventional and Pediatric Radiology (L.G., J.K., J.G.), Inselspital, Bern University Hospital and University of Bern, Switzerland
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