Previous stroke deficits can reemerge years later

By Will Boggs MD

NEW YORK (Reuters Health) - Previous stroke-related deficits can reemerge years after the original stroke, a phenomenon known as post-stroke recrudescence (PSR).

Dr. Aneesh B. Singhal from Massachusetts General Hospital and Harvard Medical School in Boston and colleagues describe the clinical features, triggers, and risk factors of PSR, according to their preliminary diagnostic criteria, in a paper online August 7 in JAMA Neurology.

Their six diagnostic criteria include: transient worsening of residual post-stroke focal neurologic deficits or transient recurrence of previous stroke-related focal neurologic deficits; chronic stroke on brain imaging; no acute lesion on diffusion-weighted imaging (DWI); cerebral ischemia considered unlikely; no clinical or electroencephalographic evidence of seizure around the time of the event.

Using these criteria, they identified 164 episodes of PSR in 153 patients, 145 with previous infarcts and eight with previous hypertensive brain hemorrhage.

Symptom onset appeared to be abrupt, but the mean duration of the deficits was only 18.4 hours, with 69.5% of episodes resolving on day 1, 17.5% on day 2, 6.1% on day 3, and 6.9% on day 4 or beyond. PSR occurred an average of 3.9 years after the index stroke.

NIH Stroke Scale scores increased by an average 2.5 points, with only 17.0% of episodes associated with a worsening of four or more points.

The distribution of neurologic deficits varied widely, but single deficits were predominantly localized to the motor-sensory and language pathways. Mental status appeared normal in three-quarters of patients; the rest had delirium or confusion, but none were comatose.

Common triggers of PSR episodes included infections, hypertension, hyponatremia, insomnia, stress, and benzodiazepine use.

PSR was more common in women, African Americans, and patients with vascular risk factors, severe deficits, or infarcts affecting the white-matter tracts within the middle cerebral artery territory.

“The incidence or prevalence of PSR is not known but, on the basis of our observation, appears to be relatively frequent and more common with ischemic stroke than hemorrhagic stroke,” the researchers conclude. “To our knowledge, recognition of PSR remains sporadic.”

“We envision that our diagnostic criteria and the results of this first attempt to characterize PSR will stimulate larger validation studies and ultimately enable prompt diagnosis and distinction from mimics in medical centers across the world,” they add.

Dr. Louis R. Caplan from Beth Israel Deaconess Medical Center, also in Boston, who wrote a linked editorial, told Reuters Health by email, "When the symptoms and signs match the original stroke and recrudescence is years after the stroke, seek an infectious-metabolic-toxic cause. The management is of the toxic-metabolic-infectious precipitant, not of the primary vascular disease."

“Many recurrent neurological symptoms are brief and recur depending on stimuli and the situation,” he said. “These are different than the recrudescence described in the report.”

Dr. Caplan describes several of these conditions in his editorial, and he makes it clear that these can only be recognized by talking to the patient rather than using electronic records, which suffer from shortcomings such as “lack of care continuity with the same stroke event, physicians’ rarely following up on the patients, and recipe-like care guidelines in the emergency department rather than thoughtful history-taking.”

Dr. Singhal did not respond to a request for comment.

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JAMA Neurol 2017.