Shkirkova K, et al. - Researchers investigated the frequency, predictors, and outcomes of neurological deterioration among patients in the ultra-early period following ischemic stroke or intracranial hemorrhage in this exploratory analysis involving 1,690 patients enrolled in the FAST-MAG trial. According to findings, ultra-early neurological deterioration occurred 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. This is noted to be associated with markedly reduced functional independence and increased mortality. Hence, the authors emphasized reducing ultra-early neurological deterioration during prehospital and early post-arrival to improve outcomes among patients with acute stroke.

Methods

• The FAST-MAG trial was conducted from 2005-2013 within 315 ambulances and 60 stroke patient who received care from hospitals in Southern California.
• Patients with suspected acute stroke who were transported by ambulance within 2 hours of stroke onset were enrolled.
• Neurological deterioration was assessed as the main outcome; it was defined as a worsening of ≥ 2 points on the Glasgow Coma Scale (GCS)—level of consciousness scale ranging from 3-15, with higher scores indicating more alertness.
• Ischemic or hemorrhagic injury extent identified during the first brain imaging scan comprised the imaging outcomes.
• Global disability level (assessed using the modified Rankin Scale; range, 0-6, with higher numbers indicating greater disability) and mortality were the outcomes assessed at 3 months.

Results

• The mean (SD) age of enrolled patients was 69.4 (13.5) years, and 43% were female.
• In 1,237 patients (73.2%), final diagnoses were acute cerebral ischemia, intracranial hemorrhage in 386 patients (22.8%), and neurovascular mimic in 67 patients (4.0%).
• The median minutes between the last well-known time and GCS assessments for prehospital, emergency department arrival, and early emergency department course assessments were 23 minutes, 58 minutes, and 149 minutes, respectively.
• From prehospital to early post-arrival, 11.8% displayed ultra-early neurological deterioration (U-END); patients with intracranial hemorrhage displayed U-END more frequently vs those with acute cerebral ischemia.
• In 30 of 965 patients (3.1%), U-END pattern was prehospital U-END without early recovery; in 49 of 965 patients (5.1%), stable prehospital course but early emergency department deterioration; and in 27 of 965 patients (2.8%), continuous deterioration in both prehospital and early emergency department phases.
• Researchers observed worse 3-month outcomes, including increased global disability, reduced functional independence, and increased mortality in correlation with ultra-early neurological deterioration.