To clarify the associated factors and outcomes of very early neurological deterioration (VEND) after thrombolysis.

Early neurological deterioration (END) within 24 hours after thrombolysis for acute ischemic stroke was associated with high mortality and disability. However, no prior studies focused on END within 1 hour after thrombolysis. 

We retrospectively analyzed patients receiving intravenous thrombolysis for acute ischemic stroke at the National Taiwan University Hospital from January 2018 to December 2021. Relevant clinical and radiographical findings were reviewed. VEND was defined as a ≥ 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score within 1 hour after thrombolysis compared with initial score. A Modified Rankin Scale (mRS) score 0-2 at 3 months was defined as good functional outcome.

In the total of 347 patients (mean age 69.6 ± 13.7 years, 57% male) who received thrombolysis for acute ischemic stroke, 29 (8.4%) patients had VEND. Compared with non-VEND group, VEND group had higher NIHSS scores at 1 hour (19.2 ± 7.3 vs. 9.0 ± 7.1, p < 0.001) and 24 hours (14.1 ± 9.8 vs. 7.3 ± 7.5, p = 0.001), more likely to receive endovascular thrombectomy (EVT) (59% vs. 25%, p < 0.001), and less likely to achieve good functional outcome (24% vs. 58%, p < 0.001). VEND was inversely associated with good functional outcome after adjustment of other significant variables (adjusted odds ratio = 0.24, p = 0.006). In patients with initial NIHSS score ≤ 6 who were initially not regarded as candidates for EVT, VEND was significantly associated with intracranial atherosclerotic disease (ICAD), undergoing EVT after deterioration, and less likely to have good functional outcome. 

VEND was a negative predictor for good functional outcome after thrombolysis, which was especially important for patients with initial low NIHSS score and associated with ICAD.