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Prehospital neurological deterioration in stroke
  1. Sabreena J Slavin1,
  2. Heidi Sucharew2,
  3. Kathleen Alwell3,
  4. Charles J Moomaw3,
  5. Daniel Woo3,
  6. Opeolu Adeoye4,
  7. Matthew L Flaherty3,
  8. Simona Ferioli3,
  9. Jason McMullan4,
  10. Jason Mackey5,
  11. Felipe De Los Rios La Rosa3,6,
  12. Sharyl Martini7,
  13. Brett M Kissela3,
  14. Dawn O Kleindorfer3
  1. 1 Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
  2. 2 Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  3. 3 Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
  4. 4 Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
  5. 5 Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
  6. 6 Baptist Health Neuroscience Center, Miami, Florida, USA
  7. 7 McNair Campus, Baylor College of Medicine Medical Center, Houston, Texas, USA
  1. Correspondence to Dr. Sabreena J Slavin, Department of Neurology, The University of Kansas Health System, Kansas City, KS 66160, USA; sslavin2{at}


Background and purpose Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND).

Methods Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals’ admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival.

Results Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61–83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND.

Conclusion Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND.

  • stroke
  • prehospital care
  • neurology

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  • Contributors All authors contributed to study design, interpretation of results, composition of the manuscript and revision of the manuscript. In addition, SJS, HS, KA and CJM contributed to statistical analysis. All authors approve of the final version and agree to be accountable for all aspects of the manuscript.

  • Funding This study has been funded by NIH grant RO1NS30678.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.