Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke
Authors: Romano Jose G. , Gardener Hannah , Smith Eric E. , Campo-Bustillo Iszet , Khan Yosef , Tai Sofie , Riley Nikesha , Sacco Ralph L. , Khatri Pooja , Alger Heather M. , Mac Grory Brian , Gulati Deepak , Sangha Navdeep S. , Olds Karin E. , Benesch Curtis G. , Kelly Adam G. , Brehaut Scott S. , Kansara Amit C. , Schwamm Lee H. , Moody Scott , Ye Weiping , Sobhawongse Vena , Craig Jeffrey M. , Pearson Heloisa , Summers Deborah , Boerman Christine , Rice Christy , Kintner Robin , Oka Mayumi , Baran Sarah , Roels Christina , Dosunmu Maureen , Chang Cherylee W. J. , Moran Jennifer , Ditrich Denise , Lanciano Nicholas , Mann Aimee , Romero Charles E. , Thiele Becky , Salvatore David , Taylor Annette , Shah Neel , Leacock Rodney , Rochester Angel , Guillerminet Fanny , Martin Jerry C. , Jones Johnny , Brandon Nicol , Grover Vikas , Gibson Maryika , Malik Maheen , Mechem Carol , Logan William R. , Cook Camilla , Khan Muhib A , Rood Christa , Babu Arun , Steinig Leah , Carlson Jestin , Henderson Melanie , Vidal Gabriel , Jennings Bethany , Lynch Jennifer , Ratcliff Jessica , Kirchoff Kathryn , Moncrieffe Khadean , Rasmussen-Winkler Jennifer , Allen Leigh , Thompson Gary , Firek Christopher , Martino Stephen , Georgy Baher , Gordon-Perue Gillian L. , Vekima Nina , Gildersleeve Kasey , Skewes Marian , Valdovinos Christina , Parsons Timothy C. , Marques Cynthia , Chen John W. , Lombardi David , Perez Brenda , Malik Amer , Hesse Kathy , Guzik Amy , Norona Sandra E. , Hoesch Robert , Anderson Jacki , Altschul Dorothea , Fermin Farah , Salgado Miran , Muller Jonathan , Acosta Indrani , Hartwell Brooke , Neill Terry A. , Hundley Carrie , Chowdhary Abhineet , Fortney Tina , Romero Jose Rafael , Finn Brandon , Assad Refat , Ellithorpe Maggie , Sugg Rebecca , Hetzel Susan , Alvi Muhammad M. , Sherman Jay , Hartman Jonathan , Orr Tashia , Garg Ankur , Turner Melissa , Given Curtis , Renfrow Sara , Hilburn Jeffrey , Looney Ellen , Commichau Christopher , Jarvis Paul , Hahm Changsoo , Mccaulley Melissa , Pulido Angel , Michel Sergio , Ramezan-Arab Nima , Toussaint- Jones Françoise , Khanna Anna , Olasoji Esther , Williams Armistead , Purrington Elizabeth , Reddy Ratna , Potter Renee , Desai Bhupat , Tse-Chang Karen , Ufford Laurence , Drager Leslie , Jones Keith O. , Ellebusch Teresa , Martino Stephen , Dobrzynski Michelle , Wise Elizabeth H. , Jerde Ann , Chaudhary Gauhar , McLean Robyn , Hanna Joseph , Cook Dana , Marden Franklin , Orde Jennifer , Arora Ajay , Miller Shawna , Reichwein Raymond , Hoffman Deborah , Matmati Kelly , Matmati Nabil , Owada Kumiko , Murphy Laura , Masih Ashish , Fife Bethany , Shepherd Larry , Holzmann Matthew , Gancher Stephen , Enoch Sabrina , Smith Matthew , Goings Denise , Mazzola Joseph , Plyler Edward , Landers Lisa , Napier James , Thoreson Laura , Alshekhlee Amer , Raymond Michelle , Ramachandran Tarakad , Jorolemon Michael , Padalino David , Maloney Collin , Mott Jenny Rae , Dhakal Laxmi P. , Murphy Cindy , Milling Truman J. , Lawrence Patrick , Shownkeen Harish , Hansen Kathy , Cullis Paul A. , Froehlich Lynne , Mueed Sajjad , Pavolka Ryan , Levine Steven R. , Gilles Nadege , Milling Truman J. , LaChance Laura , Nayyar Kanwal , Klein Karen , Dotson Rose , Rowe Kristopher , Coleman Elisheva , Sayles Emily , Gadhia Rajan , Lee Jason , Lewis Paul W. , Nunley Jenny , Sajjad Rehan , Halliday Carol , Katramados Angelos , Holmes Theresa , Kothari Rashmikant , Mader Linda , Chang Fen Lei , Western Kelly , Desai Kinjal , Kehr Colleen , Reese Gary , Jadhav Ashu , Steinbach Mackenzie , Saver Jeffrey , Avila Gilda , Miller Janice A. , Gneiting Alicia , Tenser Matthew S. , Burke Sarah 
Published: October 2021

Background and Purpose:
Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized.

Methods:
A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0–5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines–Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes.

Results:
Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations.

Conclusions:
Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment.

Registration:

URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT 02072681.