Box 32 Causes of deterioration after stroke

Neurological:

— Progression/completion of stroke

— Extension/early recurrence

— Haemorrhagic transformation of an infarct

— Developing cerebral oedema*

— Obstructive hydrocephalus*

— Epileptic seizures*

— Incorrect diagnosis*

Non-neurological:

— Metabolic derangement*

*Potentially reversible causes even decompressive craniectomy48 undoubtedly reduce intracranial pressure, it is unclear whether such aggressive interventions are associated with improved survival with acceptable quality of life. In selected patients who are deteriorating rapidly and who are judged to have some chance of a reasonable recovery, we do consider transfer to an intensive care unit for aggressive management of raised intracranial pressure. However, it is important to remember that early deteriorating conscious level is usually a very poor prognostic indicator, and such intensive treatment in an elderly patient with significant other neurological deficits is, in our view, rarely justified.

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