Clinical Deterioration and Early Imaging Changes after Intravenous Tissue Plasminogen Activator Administration in...

Clinical worsening is a known complication following acute ischemic stroke. This study attempted to determine the mechanism of deterioration by correlating clinical findings with changes on computed tomography or magnetic resonance.

From a single university medical center, 30 consecutive acute ischemic stroke patients who received intravenous tissue plasminogen activator within 3 hours of symptom onset during a 3-year period were identified from a quality database that included all hospitalized patients either admitted with strokes or with in-hospital strokes. Images were reviewed by a single neuroradiologist for changes including edema, extension of infarct, hemorrhage, herniation, and midline shift and were correlated to National Institutes of Health Stroke Scale (NIHSS) scores obtained from data in the medical chart.

Ten patients had documented clinical deterioration with a corresponding increase in the NIHSS score. Of these, 4 patients had follow-up scans that showed worsening changes concurrent with deterioration. In the 20 patients who remained clinically stable, 3 patients had worsening changes on follow-up scans. Patients who deteriorated were no more likely to have imaging changes than those who had a stable clinical course. Appearance of herniation, both subfalcine and uncal, was the only specific imaging change associated with clinical deterioration.

This study demonstrates that processes besides hemorrhage, including edema, midline shift, herniation, extension of infarct, and new infarct, are neither frequent nor specific for predicting clinical course. Other factors associated with these processes that may or may not be quantifiable on imaging are likely involved. Furthermore, in over half of the cases of worsening, deterioration occurs without associated imaging, metabolic, or infectious etiologies.