Although classically stroke symptoms are maximal at onset and patients gradually recover over days, weeks, and months, patients can deteriorate. People have termed the phenomenon stroke progression, stroke in evolution, stroke deterioration, and symptom fluctuation. There is no consistent terminology. The phenomenon occurs from different causes and is incompletely understood. This chapter will discuss evaluation of potential causes, and approaches for treatment of each cause.

Probable causes

1. Stroke enlargement (e.g., arterial stenosis or occlusion with worsening perfusion).

2. Drop in perfusion pressure.

3. Recurrent stroke (not common).

4. Cerebral edema and mass effect.

5. Hemorrhagic transformation.

6. Metabolic disturbance (decreased O2 saturation, decreased cardiac output, increased glucose, decreased sodium, fever, sedative drugs, etc.).

7. Seizure, post-ictal.

8. Symptom fluctuation without good cause (due to inflammation?).

9. The patient is not feeling like cooperating (sleepy, drugs).

Initial evaluation of patients with neurologic deterioration

• Check airway–breathing–circulation, vital signs, laboratory tests. Is the patient hypotensive or hypoxic?

• Talk to and examine the patient. If the patient is sleepy, is it because it's 3 a.m. or because of mass effect? Is there a pattern of symptoms (global worsening vs. focal worsening)?

• Get an immediate non-contrast head CT (to evaluate for hemorrhage, new stroke, swelling, etc.).

• Review medications (antihypertensives, sedatives).

• Observe patient, and ask nurse, for subtle signs of seizure.

• Consider MRI for arterial imaging, new stroke, stroke enlargement, swelling; TCD or CT angiography for arterial imaging; EEG to diagnose subclinical seizures.

Stroke enlargement

This occurs when there is arterial stenosis or occlusion and the hemodynamics change for whatever reason.