In patients with acute cerebral ischemia (ACI) and acute intracranial hemorrhage (ICH), neurological deterioration occurring within 3 to 4 hours of symptom onset is associated with reduced functional independence and increased mortality, according to a study published in JAMA Neurology. One in 8 patients with ACI experience ultra-early neurological deterioration during ambulance transport and initial evaluation at the emergency department, the researchers reported.

Data from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial were obtained for an exploratory analysis. Patients with suspected acute stroke who received ambulance transportation within a 2-hour period of stroke onset were consecutively enrolled in the trial (N=1690).

Neurological deterioration, or a worsening of ≥2 Glasgow Coma Scale (GCS) points, comprised the main outcome. Ischemic or hemorrhagic injury extent detected at the first brain imaging scan comprised the main imaging outcomes. Additionally, 3-month outcomes were disability level as assessed with the modified Rankin Scale (mRS) and mortality.

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At the final diagnosis, patients were categorized as having acute cerebral ischemia (n=1237), intracranial hemorrhage (n=386), and neurovascular mimic (n=67). Ultra-early neurological deterioration, or deterioration occurring within 3 to 4 hours of symptom onset, occurred in 11.8% of patients, with a significantly greater proportion occurring in patients with ICH vs ACI (30.8% vs 6.1%, respectively; P <.001).

Patients with ultra-early neurological deterioration had significantly worse 3-month outcomes, including reduced functional independence (mRS score 0-2, 16.0% vs 56.6%; P <.001), increased global disability (mRS score, 4.6 vs 2.4; P <.001), and increased mortality (43.5% vs 11.8%; P <.001).

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Limitations of the study include the lack of follow-up serial imaging and the nonstandardized collection of data on whether blood pressure medications were used in study participants.

The study investigators concluded that their findings indicate “the desirability of initiating stroke therapies as soon as possible after stroke onset, including in the prehospital setting, to avert the occurrence of ultra-early neurological deterioration.”


Shkirkova K, Saver JL, Starkman S, et al. Frequency, predictors, and outcomes of prehospital and early postarrival neurological deterioration in acute stroke: exploratory analysis of the FAST-MAG randomized clinical trial [published online July 23, 2018]. JAMA Neurol. doi: 10.1001/jamaneurol.2018.1893