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Original Investigation
September 2017

Recrudescence of Deficits After StrokeClinical and Imaging Phenotype, Triggers, and Risk Factors

Author Affiliations
  • 1Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
  • 2Neurology Department, Hacettepe University Hospitals, Ankara, Turkey
JAMA Neurol. 2017;74(9):1048-1055. doi:10.1001/jamaneurol.2017.1668
Key Points

Question  What are the clinical features, triggers, and risk factors of poststroke recrudescence?

Findings  This crossover cohort and case-control study of 153 patients admitted for poststroke recrudescence found that it occurs approximately 4 years after the index stroke and is characterized by mild worsening of poststroke deficits that usually resolve within 1 day. Infection, hypotension, hyponatremia, insomnia or stress, and benzodiazepine use are important precipitants; recrudescence is more common in women, African American individuals, and patients with vascular risk factors, severe deficits, or infarcts affecting deep white matter tracts within the middle cerebral artery territory.

Meaning  Results from this study should enable prompt diagnosis and help distinguish poststroke recrudescence from mimics.

Abstract

Importance  Reemergence of previous stroke-related deficits (or poststroke recrudescence [PSR]) is an underrecognized and inadequately characterized phenomenon.

Objective  To investigate the clinical features, triggers, and risk factors for PSR.

Design, Setting, and Participants  This retrospective study incorporated a crossover cohort study to identify triggers and a case-control study to identify risk factors. The study used the Massachusetts General Hospital Research Patient Data Repository to identify patients for the period January 1, 2000, to November 30, 2015, who had a primary or secondary diagnosis of cerebrovascular disease, who underwent magnetic resonance imaging of the brain at least once, and whose inpatient or outpatient clinician note or discharge summary stated the term recrudescence. In all, 153 patients met the preliminary diagnostic criteria for PSR: transient worsening of residual poststroke focal neurologic deficits or transient recurrence of prior stroke-related focal deficits, admission magnetic resonance imaging showing a chronic stroke but no acute infarct or hemorrhage, no evidence of transient ischemic attack or seizure, no acute lesion on diffusion-weighted imaging, and no clinical or electroencephalographic evidence of seizure around the time of the event.

Main Outcomes and Measures  Clinical and imaging features of PSR; triggers (identified by comparing PSR admissions with adjacent admissions without PSR); and risk factors (identified by comparing PSR cases with control cases from the Massachusetts General Hospital Stroke Registry).

Results  Of the 153 patients, 145 had prior infarct, 8 had hypertensive brain hemorrhage, and 164 admissions for PSR were identified. The patients’ mean (SD) age was 67 (16) years, and 92 (60%) were women. Recrudescence occurred a mean (SD) of 3.9 (0.6) years after the stroke, lasted 18.4 (20.4) hours, and was resolved on day 1 for 91 of the 131 episodes with documented resolution time (69%). Deficits were typically abrupt and mild and affected motor-sensory or language function. No patient had isolated gaze paresis, hemianopia, or neglect. During PSR, the National Institutes of Health Stroke Scale (NIHSS) score worsened by a mean (SD) 2.5 (1.9) points, and deficits were limited to a single NIHSS item in 62 episodes (38%). The underlying chronic strokes were variably sized, predominantly affected white matter tracts, and involved the middle cerebral artery territory for 112 patients (73%). Infection, hypotension, hyponatremia, insomnia or stress, and benzodiazepine use were higher during PSR admissions. Compared with the control group (patients who did not experience recrudescence), the PSR group (patients who were hospitalized for recrudescence) had more women, African American individuals, and those who self-identified as being from “other” race. The PSR group also had more diabetes, dyslipidemia, smoking, infarcts from small-vessel disease, and “other definite” causes and worse onset NIHSS scores. Six patients (4%) received intravenous tissue plasminogen activator without complications.

Conclusions and Relevance  The PSR features identified in the study should enable prompt diagnosis and distinguish recrudescence from mimics, such as transient ischemic attacks, migraine, Todd paralysis, and Uhthoff phenomenon. Prospective studies are required to validate the proposed diagnostic criteria and to decipher underlying mechanisms.

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