Management Strategies for Early Neurological Deterioration in Noncardioembolic Ischemic Stroke

BACKGROUND: Early neurological deterioration (END) is a frequent complication of acute ischemic stroke. Although END worsens clinical outcomes, standardized treatment strategies remain undefined, resulting in variability in clinical practice. This study examines real-world treatment patterns for END and compares the effects of different strategies on neurological and functional outcomes. METHODS: This study analyzed data from a nationwide, prospective, multicenter stroke registry in South Korea, including patients with noncardioembolic stroke who developed END due to stroke progression between January 2019 and August 2024. END was defined as new or worsening neurological symptoms meeting National Institutes of Health Stroke Scale criteria (≥2-point total or ≥1 point in consciousness or motor subscores) with radiological confirmation. Patients were classified into conservative management, antithrombotics change, and induced hypertension (iHTN). The primary outcomes were neurological improvement, defined as a ≥2-point reduction in the National Institutes of Health Stroke Scale score, and 3-month functional outcome measured by modified Rankin Scale ordinal shift. Secondary outcomes included good functional recovery (modified Rankin Scale score, 0–2) and composite vascular events (death, stroke, and myocardial infarction). Multivariable analyses adjusted for age, sex, prestroke modified Rankin Scale, initial National Institutes of Health Stroke Scale score, vascular risk factors, the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification, acute thrombolysis, and laboratory covariates. RESULTS: Among 3067 patients with END due to stroke progression, 1840 (60.0%) received conservative management, 747 (24.4%) underwent antithrombotic changes, and 480 (15.7%) were treated with iHTN. Neurological improvement occurred in 34.2% of patients, with the highest in the iHTN group (41.5%) compared with the conservative (32.2%) and antithrombotics change groups (34.4%; P <0.001). In adjusted analyses, iHTN increased the odds of neurological improvement (adjusted odds ratio, 1.55 [95% CI, 1.25–1.92]) and a favorable 3-month modified Rankin Scale shift (adjusted odds ratio, 1.24 95% CI, 1.03–1.48]) compared with conservative management, particularly in patients with large artery atherosclerosis. Antithrombotics change showed no significant association with neurological or functional recovery. CONCLUSIONS: In patients with noncardioembolic ischemic stroke who developed END due to stroke progression, iHTN was associated with favorable clinical outcomes.