Shkirkova K, et al. - Among patients in the ultra-early period following ischemic stroke or intracranial hemorrhage, researchers characterized the frequency, predictors, and outcomes of neurological deterioration. They found ultra-early neurological deterioration (U-END) in 1 in 8 ambulance-transported patients with acute cerebrovascular disease, including 1 in 3 patients with intracranial hemorrhage and 1 in 16 patients with acute cerebral ischemia. U-END was correlated with distinctly reduced functional independence and increased mortality. For future prehospital therapeutics, averting U-END could be a target.

Methods

• This study was an exploratory analysis of the prehospital, randomized Field Administration of Stroke Therapy-Magnesium (FAST-MAG) Trial, conducted from 2005 to 2013 within 315 ambulances and 60 stroke-patient-receiving hospitals in Southern California.
• Participants in the study were consecutively enrolled patients with suspected acute stroke who were transported by ambulance within 2 hours of stroke onset.
• Neurological deterioration was the main outcome, characterized as a worsening of 2 or more points on the Glasgow Coma Scale (GCS), a level of consciousness scale ranging from 3 to 15, with higher scores indicating more alertness.
• Ischemic or hemorrhagic injury extent found during the first brain imaging scan were imaging outcomes.
• Global disability level (assessed using the modified Rankin Scale [mRS]; range, 0-6, with higher numbers indicating greater disability) and mortality were the included outcomes at 3 months.

Results

• According to the findings, among the 1,690 patients (99.4%), the mean (SD) age was 69.4 (13.5) years, and 43% were female.
• Acute cerebral ischemia in 1,237 subjects (73.2%), intracranial hemorrhage in 386 subjects (22.8%), and neurovascular mimic in 67 subjects (4.0%) were the final diagnoses.
• It was observed that the median (interquartile range [IQR]) minutes between the last well-known time and GCS assessments were 23 (14-42) minutes for prehospital, 58 (46-79) minutes for ED arrival, and 149 (120-180) minutes for early ED course assessments.
• U-END occurred in 200 of 1,690 patients (11.8%), more often among patients with intracranial hemorrhage than those with acute cerebral ischemia (119 of 386 [30.8%] vs 75 of 1237 [6.1%], P < .001) from prehospital to early postarrival.
• Researchers reported that patterns of U-END were prehospital U-END without early recovery in 30 of 965 patients (3.1%), stable prehospital course but early ED deterioration in 49 of 965 patients (5.1%), and continuous deterioration in both prehospital and early ED phases in 27 of 965 patients (2.8%).
• Findings revealed that U-END was related to worse 3-month outcomes, including increased global disability (mRS score, 4.6 vs 2.4; P < .001), reduced functional independence (mRS score 0-2, 32 of 200 [16.0%] vs 844 of 1490 [56.6%]; P< .001), and increased mortality (87 of 200 [43.5%] vs 176 of 1490 [11.8%]; P < .001).