Early neurological deterioration, usually defined as a rise of 2 or more NIHSS points in the first few days, affects a substantial minority of patients with ischaemic stroke and worsens outcome.
When it happens, work through the causes in a fixed order. Look for haemorrhagic transformation with urgent imaging. Look for stroke progression or recurrence, often in small perforator (lacunar) or large-artery disease. Check for oedema in large infarcts, seizures, and systemic causes: hypotension, hypoxia, fever, hypoglycaemia or hyperglycaemia, and hyponatraemia.
Regular NIHSS scoring by nurses, not just doctors, is what catches deterioration early enough to act.
- Score NIHSS regularly in the first 72 hours, including by nursing staff
- Image urgently for a rise of 2 or more points to exclude haemorrhage
- Check blood pressure, oxygen, glucose, temperature and sodium at every deterioration
- Consider seizures in a patient with fluctuating deficits
Why it matters
Many causes of early deterioration are correctable if caught within hours.
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