Association between neurological deterioration and outcomes in patients with stroke

Abstract

Background: Neurological deterioration (ND) shortly after stroke is common in Chinese patients. We aimed to determine the effects of ND during hospitalization on stroke prognosis.

Methods: We retrospectively reviewed files from the stroke registry of the Department of Neurology of Tianjin Huanhu Hospital between October 1, 2008, and December 31, 2015. The inclusion criteria were: age ≥18 years, diagnosis of acute ischemic stroke, and first-ever ischemic stroke occurring within 7 days prior to admission. ND was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points during hospitalization. Early neurological deterioration (END) was defined as an increase in the NIHSS score by ≥4 points between the baseline and 48-hour evaluations. Late neurological deterioration (LND) was defined as an increase in the NIHSS score by ≥4 points between the 48-hour and discharge evaluations. Multivariate regression was used to evaluate the relationship between early and late ND and short- and long-term outcomes. Primary and secondary outcomes based on the modified Rankin scale (mRS) were evaluated at 3 months and 1 year. Favorable and poor outcomes were defined as mRS scores of 0-2 and ≥3, respectively.

Results: A total of 9,650 patients were included. ND occurred in 293 patients (3.0%) during hospitalization. Among them, 192 (65.5%) were in the END group, and 101 (34.5%) were in the LND group. After adjusting for age, gender, and NIHSS scores, END was a significant independent predictor of poor outcome at both 3 months (primary outcome OR 8.069, secondary outcome OR 8.194) and 1 year (primary outcome OR 7.895, secondary outcome OR 5.679). The same pattern was seen in the LND group (3 months primary outcome OR 7.608, secondary outcome OR 6.349, 1-year primary outcome OR 10.793, secondary outcome OR 5.245).

Conclusions: ND during hospitalization, regardless of whether it occurs in the early or late period after stroke, is an independent predictor of poor prognosis.

Keywords: Acute stroke; follow-up; neurological deterioration (ND); outcome; predictor.

Figure 1

Flow chart of patient selection.

Figure 2

Odds ratios for END and LND groups based model and the outcome variables. The figure included the variables of confounders that were identified as significant in the univariate analyses (age, male sex, NIHSS, cerebral artery stenosis, diabetes and alcohol drinkers). (A) Model 1: at 3 months, the primary outcomes showed that END had a significant tendency to increase the risk of poor outcomes. (B) Model 2: the secondary outcomes were similar to the primary outcomes after 3-month follow-up. (C) Model 3, at 1 year, the primary outcomes showed that END had a tendency to increase the risk of poor outcomes. (D) Model 4, the secondary outcomes were similar to the primary outcomes after 1-year follow-up. (E) Model 5: follow-up for 3 months, the primary outcomes showed that LND was an independent predictor of poor outcomes. (F) Model 6: the secondary outcomes were similar to the primary outcomes after 3-month follow-up. (G) Model 7, follow-up for 1 year, the primary outcomes showed that LND was an independent predictor of poor outcomes (H) Model 8, the secondary outcomes were similar to the primary outcomes after 1-year follow-up.