Skip to main content Accessibility help
Hostname: page-component-6c8bd87754-x25dq Total loading time: 0.684 Render date: 2022-01-17T00:48:56.032Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Chapter 7 - Neurological Deterioration in Acute Ischemic Stroke

Published online by Cambridge University Press:  28 October 2019

Mary Carter Denny
Georgetown University Hospital
Ahmad Riad Ramadan
Henry Ford Hospital, Detroit
Sean I. Savitz
University of Texas Health Science Center, Houston
James Grotta
Memorial Hermann Texas Medical School
Get access


Although, classically, stroke symptoms are maximal at onset and patients gradually recover over days, weeks, and months, patients sometimes deteriorate. People have termed the phenomenon stroke progression, stroke in evolution, stroke deterioration, and symptom fluctuation. There is no consistent terminology. The phenomenon occurs from different causes and is incompletely understood. Although the typical definition of a significant neurological deterioration in trials has been a gain of ≥ 1 point on item 1a (level of consciousness) or ≥ 4 points in the motor items of the NIHSS, any detectable deterioration should prompt careful assessment and a tailored work-up.

Acute Stroke Care , pp. 101 - 118
Publisher: Cambridge University Press
Print publication year: 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Thomalla, G, Simonsen, CZ, Boutitie, F, et al.; WAKE-UP Investigators. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med 2018; 379: 611622.CrossRefGoogle ScholarPubMed
Nogueira, RG, Jadhav, AP, Haussen, DC, et al.; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378: 1121.CrossRefGoogle ScholarPubMed
Albers, GW, Marks, MP, Kemp, S, et al.; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378: 708718.CrossRefGoogle ScholarPubMed
Anderson, CS, Arima, H, Lavados, P, et al.; HeadPoST Investigators and Coordinators. Cluster-randomized, crossover trial of head positioning in acute stroke. N Engl J Med 2017; 376: 24372447.CrossRefGoogle ScholarPubMed
Johnston, SC, Easton, JD, Farrant, M, et al. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med 2018; 379: 215225.CrossRefGoogle ScholarPubMed
Wang, Y, Wang, Y, Zhao, X, et al.; CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013; 369: 1119.CrossRefGoogle ScholarPubMed
Chimowitz, MI, Lynn, MJ, Derdeyn, CP, et al.; SAMMPRIS Trial Investigators. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011; 365: 9931003.CrossRefGoogle ScholarPubMed
Berge, E, Abdelnoor, M, Nakstad, PH, Sandset, PM. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet 2000; 355: 12051210.CrossRefGoogle Scholar
Hart, RG, Palacio, S, Pearce, LA. Atrial fibrillation, stroke, and acute antithrombotic therapy: analysis of randomized clinical trials. Stroke 2002; 33: 27222727.CrossRefGoogle ScholarPubMed
Saxena, R, Lewis, S, Berge, E, Sandercock, PA, Koudstaal, PJ. Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke 2001; 32: 23332337.CrossRefGoogle ScholarPubMed
Kang, DW, Latour, LL, Chalela, JA, Dambrosia, J, Warach, S. Early ischemic lesion recurrence within a week after acute ischemic stroke. Ann Neurol 2003; 54: 6674.CrossRefGoogle ScholarPubMed
Lovett, JK, Coull, AJ, Rothwell, PM. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology 2004; 62: 569573.CrossRefGoogle ScholarPubMed
Vahedi, K, Vicaut, E, Mateo, J, et al.; DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007; 38: 25062517.CrossRefGoogle Scholar
Hofmeijer, J, Kappelle, LJ, Algra, A, et al.; HAMLET Investigators. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009; 8: 326333.CrossRefGoogle ScholarPubMed
Jüttler, E, Schwab, S, Schmiedek, P, et al.; DESTINY Study Group. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007; 38: 25182525.CrossRefGoogle ScholarPubMed
Vahedi, K, Hofmeijer, J, Juettler, E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6: 215222.CrossRefGoogle ScholarPubMed
Jüttler, E, Unterberg, A, Woitzik, J, et al.; DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014; 370: 10911100.CrossRefGoogle ScholarPubMed
Kolias, AG, Kirkpatrick, PJ, Hutchinson, PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol 2013; 9: 405415.CrossRefGoogle ScholarPubMed
Fiorelli, M, Bastianello, S, von Kummer, R, et al. Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke 1999; 30: 22802284.CrossRefGoogle Scholar
Topcuoglu, MA, Saka, E, Silverman, SB, et al. Recrudescence of deficits after stroke: clinical and imaging phenotype, triggers, and risk factors. JAMA Neurol 2017; 74: 10481055.CrossRefGoogle ScholarPubMed
Vahidy, FS, Hicks, WJ, Acosta, I, et al. Neurofluctuation in patients with subcortical stroke. Neurology 2014; 83: 398405.CrossRefGoogle Scholar
Schneider, LS, Dagerman, KS, Insel, P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005; 294: 19341943.CrossRefGoogle ScholarPubMed

Send book to Kindle

To send this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Send book to Dropbox

To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Dropbox.

Available formats

Send book to Google Drive

To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Google Drive.

Available formats