Early Deterioration After Stroke a 'Missed Opportunity'

July 30, 2018

Neurologic deterioration in acute stroke patients in the "ultra-early" time window, defined as 3 to 4 hours after symptom onset and including the prehospital period, is common and represents a currently almost untapped opportunity to improve outcomes, the authors of a new study say.  

The study, a secondary analysis of the FAST-MAG trial, which investigated the prehospital administration of magnesium to stroke patients, showed that ultra-early neurologic deterioration occurred in 1 in 3 patients with intracranial hemorrhage and in 1 in 16 patients with acute cerebral ischemia. This ultra-early neurologic deterioration was associated with markedly reduced functional independence and increased mortality.

The study was published online in JAMA Neurology on July 23.

"We wanted to look at the ultra-early period in stroke patients — the prehospital stage and the initial hour or so when they are first in hospital," lead author Kristina Shkirkova, BS, University of California, Los Angeles, told Medscape Medical News. "There is an urgent need to characterize what is happening to the patients during this time, and no previous studies have looked at this in such detail."

"Our findings are striking," Shkirkova added. "This very early deterioration determines outcome but often in practice or in clinical trials, we don't even look at this. We are missing so much."

Their data show that it is not sufficient to wait for the patients to get to the hospital, she added. "There is an opportunity to treat these patients much earlier — in the prehospital phase — but we are not taking advantage of that."  

For the study, the researchers analyzed data on 1690 patients, 73% of whom had acute cerebral ischemia, 23% intracranial, and 4% neurovascular mimics.

Neurologic status was evaluated by using the Glasgow Coma Scale (GCS) on first presentation to emergency services (median, 23 minutes from "last known well" time), on arrival at the emergency department (median, 58 minutes from last known well) and early in the course of emergency department assessments (median, 149 minutes from last known well).  

Results showed that from prehospital to early postarrival, ultra-early neurologic deterioration, defined as a worsening on the GCS of 2 points or more, occurred in 11.8% of patients.

This was more common in patients with intracranial hemorrhage (30.8%) than among those with acute cerebral ischemia (6.1%). 

Patterns of deterioration were prehospital worsening without early recovery (3.1%), stable prehospital course but early emergency department deterioration (5.1%), and continuous deterioration in both prehospital and early hospital phases (2.8%).

Unsurprisingly, ultra-early neurologic deterioration was associated with worse 3-month outcomes, including increased global disability (modified Rankin Scale [mRS] score, 4.6 vs 2.4), reduced functional independence (mRS score, 0 - 2; 16.0% vs 56.6%), and increased mortality (43.5% vs 11.8%).

Focus on Blood Pressure

The researchers also found that blood pressure seems to play a major role in this very early deterioration.

"In ischemic stroke patients, systolic blood pressure was lower in those who deteriorated early, and this correlated with bad outcomes; but in hemorrhagic stroke, higher blood pressure was associated with early deterioration," Shkirkova noted. "This suggests there is a need for therapeutic guidance for blood pressure in this early phase."

At present, there is no clear information on what the blood pressure should be, she noted.

"Our results suggest that more should be done to identify these patients who are deteriorating in this very early period and we need clinical trials of imaging and therapeutics in the prehospital phase in these individuals," she concluded.  

In the paper the researchers state, "For prehospital system planning, the present study provides unique insight into the frequency of deterioration occurring between paramedic evaluation in the field and emergency department arrival."

"Our study findings indicated that emergency medical services system planners may anticipate that approximately 1 in10 patients with stroke (including about 1 in 4 patients with acute ICH [intracranial hemorrhage]) will deteriorate between the scene and ED [emergency department] arrival," they conclude.

"This frequency of prehospital deterioration reflects transport in a largely urban or suburban setting with relatively short transport times. In rural settings with longer transport times, the frequency of deterioration will be higher, as suggested by the 1 in 8 rate of deterioration in the present study between the scene and the later ED course evaluation."

This study was supported by a Research Project Cooperative Agreement award from the National Institute of Neurological Disorders and Stroke. The authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online July 23, 2018.  Abstract

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