Worsening in ischemic stroke patients: is it time for a new strategy?

Abstract

What can be more frustrating for physicians (and, of course, for their patients) than deterioration during treatment? Expectations are high that patients will get better when they come to the hospital, not get worse. Unfortunately, worsening is a common occurrence in patients with brain ischemia despite present treatment. In this issue of Stroke , Steinke and Ley show that, among their stroke patients, worsening of motor function, a very important component of disability, was most common among those who had lacunar strokes.1 The term worsening , as presently used, is arbitrary in that it depends on an extremely variable starting time—entry into medical care. If an individual who becomes considerably more hemiplegic 4 hours after the first symptom of weakness and then stabilizes enters a hospital at hour 2, he or she is classified as worsening. If, instead, the patient enters the hospital at hour 5, he or she would not be classified as worsening. Present designation of worsening then depends on when the clock starts running. I avoid terms based on worsening such as “stroke-in-evolution” and “progressing stroke,” since they depend on a shifting start time. Ideally, physicians should attempt to alter a declining course of illness graph that begins at the time of symptom onset. Worsening during the first few hours often has quite different explanations than worsening during hours 12 to 48. Unfortunately, it is often difficult to quantify deficits present before the patient is seen by a physician experienced in stroke care using only the accounts of the patient and observers. There are mainly 3 different large categories of worsening: (1) Medical complications, especially febrile illnesses, which affect the patient systemically and may also lead to increased brain ischemia. These complications usually do not develop on the day of admission, and these patients are sick …