Early neurological deterioration – a new mnemonic

So I love mnemonics. Sue me.

We really tend to have problems with the myriad of possibilities for a stroke patient to deteriorate in the first – say – 72 hours. Even worse and more problematic if he chooses to decline in the first hours after thrombolysis, where everyone only thinks hemorrhage.

After a decade of juggling the options in my head, I came up with a reasonably simple mnemonic for the etiology of END – HEMODYNAMICS:

  • H emorrhage – need a CT for this
  • E mbolism from a proximal stenosis – need ultrasound or CTA for this
  • M icroangiopathic: these tend to fluctuate a lot, but there is no proof. Think of it, if the same symptoms tend to progress or fluctuate from 100% to 0% and back
  • O edema: early edema can pose problems in large strokes or if a microangiopathic lesion occurs near the capsule and swells; need a CT for this, better even: MRI
  • D islocation: this is important in tPA patients – a well collateralized proximal embolus can shrink through thrombolysis and occlude a distal arterial segment where collateralization is not so good, thus increasing symptoms or even leading to new symptoms – need a CTA
  • Y namics: both occlusions and high grade stenoses can lead to fluctuations along with blood pressure instability. Need an ultrasound or CTA for that, but a better proof is orthostatic increase of symptoms. What I really like is: raising the blood pressure by 50 mmHg to see whether the patient improves.
  • M imics: think of migraine or encephalitis as the original cause of the stroke symptoms. As for diagnostics, probatory treatment with Metamizol+MCP and a spinal tap can help.
  • I ctal: another mimic, requiring EEG to rule out or – if not possible – 1g of Levetiracetam
  • C sf circulation problems – CT is enough
  • S preading depression: after ruling out everything else, this is what remains. No proper diagnostics for that, but try Topiramate.

So here is our diagnostic algorithm:

  • History – timecourse of deterioration, headache, other symptoms
  • Examination – vital signs, neurological and internal
  • Labs: routine labs + cTnI + EtOH
  • Imaging: preferrably MRI, but if that is not acutely available: CT + CTA
  • Ultrasound for hemodynamics
  • EEG to rule out status, or 1g LEV
  • Novalgin + MCP for Migraine
  • Spinal tap to rule out encephalitis
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