Stroke: a third of patients had neurological worsening.

Clinical bottom line (level 2b-)

  1. Nearly a third of patients with a first-ever stroke suffered neurological worsening.
  2. About a third of patients who had a haemorrhagic or noncardioembolic first-stroke had neurological worsening, whereas only a sixth of patients with a cardioembolic stroke did.
Yamamoto et al: Archives of Neurology 1998; 55: 481-483
Expires November 2002

The study

Retrospective cohort study with ?objective ?blinded outcomes, adjusted for confounding factors, validated in an independent set of patients.

Setting: community-based, primary-care centre, Switzerland

3038 patients (aged range 16 to 97 years; mean 63, 62% male) first stroke (brain infarct or haemorrhage)

Excluded if
  • possible early recurrent stroke and deterioration of general condition


    • Intravenous continuous heparin was given for neurological worsening in patients with supposed thrombus propagation or cardioembolism, if there was no contraindication. Oral aspirin (200 mg/day) was given systemically to patients with ischaemic stroke but not under anticoagulation.

    Logistic multiple regression analysis was performed to adjust for confounding factors.

    followed for
    Outcomes studied:
  • neurological worsening worsening of neurological condition, including consciousness level, was observed by investigators at and after admission in care unit
  • neurological worsening with brain haemorrhage
  • neurological worsening with cardioembolic brain infarct
  • neurological worsening with noncardioembolic brain infarct

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    neurological worsening ? 898/3038 29.6%
    (27.9% to 31.2%)
    neurological worsening with brain haemorrhage ? 114/300 38.0%
    (32.5% to 43.5%)
    neurological worsening with cardioembolic brain infarct ? 116/770 15.1%
    (12.5% to 17.6%)
    neurological worsening with noncardioembolic brain infarct ? 669/1968 34%
    (31.9% to 36.1%)

    • In stroke caused by large-artery atherosclerosis, posterior circulation and reduced level of consciousness may be risk factors for neurological worsening.
    • In stroke caused by small-artery disease, age >64 years, superficial anterior circulation and TIA may decrease the risk for neurological worsening, and hypertension and reduced level of consciousness may increase the risk.

    Comments

    1. Risk factors for neurological factors were given as coefficients and not relative risks or odds ratios, so NNF+ could not be calculated.

    Citation

    1. Yamamoto H, Bogousslavsky J, van Melle G: Different predictors of neurological worsening in different causes of stroke. Archives of Neurology 1998; 55: 481-483
    Contributor: Clare Wotton and Musab Hayatli, November 1999
    Reviewer: Martin Mueller

    Clinical Question.
    Patient first stroke
    Intervention or Exposure haemorrhagic, embolic, predictors
    Comparison cardioembolic
    Outcome neurological worsening