Risk Factors And Predictive Models Of Early Neurological Deterioration In Acute Ischemic Stroke

Objective:The main aim of this study was to investigate the correlation between TCM syndrome and early neurological deterioration (END), and to identify factors and mechanisms associated with END, as well as to develop an imaging-based early prognostic model for END in patients with acute ischemic stroke.Methods:Database from two randomized controlled trials of acute ischemic stroke was used. The Magnetic Resonance Imaging (MRI) and clinical characteristics including demographics,medical history, complication, vital sign,the National Institute of Health Stroke Scale(NIHSS), TCM syndrome elements of stroke. Barthel index, and modified Rankin scale were extracted from the database. END was defined as an increase of one or more points in the NIHSS score in total between baseline and day 7. The frequency of Six TCM syndrome elements of stroke at baseline, day 7, and day 10 were analyzed to demonstrate the distribution and evolution of TCM syndrome. After standardization of clinical characteristics,univariate analysis was performed to compare 24 variables between patients with or without END. Significant variables (P<0.1) were subjected to multivariate logistic regression analysis.Significant variables (P<0.05) in multivariate analysis were identified as independent factors for END. Furthermore. 120 of 547 cases with baseline MR imaging were assessed by two independent assessors using Alberta Stroke Program Early CT score (ASPECTS) method.Diffusion weighted imaging-based ASPECTS (DWI-ASPECTS) consists of ten anatomically defined regions in the middle cerebral artery territory. The correlations between END and ischemic distribution in each regions were analyzed by univariate analysis. Predictive value of DWI-ASPECTS was investigated for END using Receiver Operating Curve (ROC)analysis. Cut-off value of DWI-ASPECTS was determined according Youden’s index.Results:547 patients with acute ischemic stroke were included in analysis. 47 of them (8.6%)occurred END within 7 days after stroke onset. According to the distribution of TCM syndrome elements of stroke within 10 days, inner-wind (neifeng), phlegm-dampness (tanshi),and blood stasis (xueyu) syndrome occurred most frequently at baseline with 94.4%, 71.7%,and 61.5%, respectively. The inner-wind decreased rapidly at day 7. Both phlegm-dampness and blood stasis maintained high frequency within 10 days. All of the six TCM syndrome presented stable between day 7 and day 10. Univariate analysis demonstrated that age(P=0.012),hypertension (P=0.085),coronary heart disease (P=0.006),atrial fibrillation(P=0.028),complication (P=0.004),consciousness (P=0.098),baseline systolic blood pressure (P=0.063), and baseline NIHSS score (P=0.036) were predictors of END. Among them, only atrial fibrillation (P=0.000, OR 0.075) and complication (P=0.004, OR 3.333)were independent predictors of END in the multivariate logistic regression analysis.Furthermore, according to the analysis of ischemic distribution of 10 ASPECTS regions in patients with or without END, insular ribbon (P=0.006), M2 (P=0.003), M3 (P=0.001), M4(P=0.009),M5 (P=0.038),M6 (P=0.009) were correlated to END. Receiver Operating Curve(ROC) analysis demonstrated that AUC was 0.764. Cut-off value was 7.50 based on the Youden’s index of 0.500 (sensitivity 0.667. specificity (0.833).Conclusion:According to the characteristic of TCM syndrome evolution, inner-wind (neifeng),phlegm-dampness (tanshi), and blood stasis (xueyu) were the main TCM syndrome within 72 hours after stroke onset. Inner-wind decreased rapidly within 7 days, while all of the six TCM syndrome kept stable between day 7 and day 10. Day 7 after onset was a key inflection point,as a result, clinicians may pay more attention on syndrome evolution within 7 days.Univariate analysis demonstrated that age, hypertension, coronary heart disease, atrial fibrillation,complication, consciousness, baseline systolic blood pressure, and baseline NIHSS score were predictors of END. Among them, only atrial fibrillation and complication were independent predictors of END in the multivariate logistic regression analysis. Patients with older age, hypertension, coronary heart disease, atrial fibrillation, complication,consciousness,higher baseline systolic blood pressure,and higher NIHSS score were more likely to develop END within 7 days. DWI-ASPECTS was a good prognostic tool to predict END. DWI-ASPECTS<8 predicts high risk to develop END, which reminds clinicians to take more interventions to prevent END. Conclusively,DWI-ASPECTS is a valuable prognostic tool for END, and is helpful to better management for patients with acute ischemic stroke.Highlight of innovation:Previous researches of END after acute ischemic stroke mainly focused on investigating risk factors, mechanism, and effective interventions. To our knowledge, we first explored the prognostic tool for END based on both topographic mapping of brain and clinical characteristics. We first applied DWI-ASPECTS to predict END in patients with acute ischemic stroke, and developed a useful prognostic tool for END.