Deterioration following spontaneous improvement - Sonographic findings in patients with acutely resolving symptoms of cerebral ischemia

Background and Purpose-Some stroke patients will deteriorate following impr ovement (DFI), but the cause of such fluctuation is often unclear. While re solution of neurological deficits is usually related to spontaneous recanal ization or restoration of collateral flow, vascular imaging in patients wit h DFI has not been well characterized. Methods-We prospectively studied patients who presented with a focal neurol ogical deficit that resolved spontaneously within 6 hours of symptom onset. Patients were evaluated with bedside transcranial Doppler (TCD). Digital s ubtraction angiography (DSA), computed tomographic angiography (CTA), or ma gnetic resonance angiography (MRA) were performed when feasible. DFI was de fined as subsequent worsening of the neurological deficit by greater than o r equal to 4 National Institutes of Health Stroke Scale points within 24 ho urs of the initial symptom onset. Results-We studied 50 consecutive patients presenting at 165+/-96 minutes f rom symptom onset. Mean age was 61+/-14 years; 50% were females. All patien ts had TCD at the time of presentation, and 68% had subsequent angiographic examinations (DSA 10%, CTA 4%, and MRA 44%). Overall, large-vessel occlusi on on TCD was found in 16% of patients (n=8); stenosis was found in 18% (n= 9); 54% (n=27) had normal studies; and 6 patients (12%) had no temporal win dows. DFI occurred in 16% (n=8) of the 50 patients: in 62% of patients with TCD and angiographic evidence of occlusion, in 22% with stenosis, and in 4 % with normal vascular studies (P<0.001, Phi=0.523, chi(2)=12.05). DFI occu rred in 31% of patients with large-vessel atherosclerosis, 23% with cardioe mbolism, and 9% with small-vessel disease when stroke mechanisms were deter mined within 2 to 3 days after admission (P=0.2, NS). Conclusions-DFI is strongly associated with the presence of large-vessel oc clusion or stenosis of either atherosclerotic or embolic origin. Normal vas cular studies and lacunar events were associated with stable spontaneous re solution without subsequent fluctuation. Urgent vascular evaluation may hel p identify patients with resolving deficits and vascular lesions who may be candidates for new therapies to prevent subsequent deterioration.