Early Neurological Deterioration in Acute Ischemic Stroke

Early neurological deterioration (END) represents a rapid worsening of neurological function within hours to days of acute ischaemic stroke onset. Affecting up to 15 per cent of patients undergoing reperfusion therapies and a similar proportion of untreated cases, END is a key determinant of long-term disability and mortality worldwide. Its pathogenesis is multifactorial, encompassing haemodynamic instability, extension of ischaemic injury, reperfusion injury, inflammatory cascades and coagulopathic processes. Clinically, END is most often gauged by an increment in National Institutes of Health Stroke Scale score, yet definitions vary across studies. Early recognition of individuals at risk has become a priority, given that prompt intervention—whether by optimisation of blood pressure and glucose levels, adjustment of anticoagulant or antiplatelet regimens, or consideration of endovascular approaches—may modify outcomes. Recent advances have emphasised the role of biomarkers, neuroimaging signatures and predictive algorithms in stratifying risk, while highlighting the interplay between stroke aetiology, therapeutic window and collateral circulation. Understanding the mechanisms and predictors of END not only informs individualised patient care but also guides the design of clinical trials targeting secondary deterioration.

Research from Nature Portfolio

Interpretable machine-learning approaches have been applied to atrial fibrillation-related stroke cohorts to predict END with improved accuracy. Using gradient-boosting models and Shapley additive explanations, researchers identified fasting glucose and admission stroke severity as the most influential predictors, enabling personalised risk profiles. Another large-scale analysis contrasted anterior and posterior circulation strokes following intravenous alteplase. Although the overall incidence of END was comparable between territories, distinct risk factors emerged: atrial fibrillation and stroke subtype in anterior circulation, and hypertension history with baseline severity in posterior circulation. Both studies confirmed that END strongly portends poorer functional recovery at three months, underscoring the need for territory-specific risk assessment and tailored monitoring protocols.

Early Neurological Deterioration in Acute Ischemic Stroke publication trend

The graph below shows the total number of articles in early neurological deterioration in acute ischemic stroke across all publications each year (not limited to Nature Index journals).

Technical terms

Acute ischaemic stroke (AIS): Sudden loss of brain function due to arterial occlusion.

Early neurological deterioration (END): Worsening of neurological status, often defined by a rise in NIHSS score, within hours or days of stroke onset.

National Institutes of Health Stroke Scale (NIHSS): A standardised tool for quantifying stroke severity based on consciousness, motor and sensory assessments.

Reperfusion therapy: Treatment strategies, including intravenous thrombolysis and endovascular recanalisation, aimed at restoring cerebral blood flow.

Atrial fibrillation (AF): An irregular cardiac rhythm that increases the risk of cardioembolic stroke and influences END risk profiles.

References

1. Inflammatory marker profiles and in‐hospital neurological deterioration in patients with acute minor ischemic stroke. CNS Neuroscience & Therapeutics (2024).
2. Interpretable machine learning for early neurological deterioration prediction in atrial fibrillation-related stroke. Scientific Reports (2021).
3. A Systematic Review of Body Fluids Biomarkers Associated With Early Neurological Deterioration Following Acute Ischemic Stroke. Frontiers in Aging Neuroscience (2022).
4. Early neurological deterioration after intravenous thrombolysis of anterior vs posterior circulation stroke: a secondary analysis of INTRECIS. Scientific Reports (2022).
5. Predictors of Early Neurological Deterioration Occurring within 24 h in Acute Ischemic Stroke following Reperfusion Therapy: A Systematic Review and Meta-Analysis. Journal of Integrative Neuroscience (2023).